The human musculoskeletal system is a complex machine made of intricate moving parts. Although the bits and pieces may be composed of flesh and bone rather than steel and aluminum, the body is prone to breakdowns and wear-and-tear just as any man-made contraption is. When things get rusty, brittle or broken, it’s up to orthopedic specialists to get things moving again, replacing old parts and shoring up the weak spots.

What are the specialties of orthopedics?  Edward Stolarski, M.D., Kennedy-White Orthopedic Center:  Orthopedics is the treatment of muscular-skeletal diseases, including bone and joint, and is broken down into sub-specialties. You hear “general orthopedics,”that covers everything. I’m in adult reconstruction, so that just means hip and knee and hip and knee revisions. Dr. [Dan] Lamar is in sports medicine, and he does all of the athletes. Dr. [Avinash] Kumar does shoulder and elbow. Then you have foot-and-ankle, tumor and pediatrics. There are a lot of sub-specialties in the muscular-skeletal system.  

What are the most common issues you see? Sean Dingle. M.D., Kennedy-White Orthopedic Center: I see almost exclusively hip and knee complaints and the most common of those would be arthritis. Stolarski: Same, as well as hip and knee replacements that haven’t worked out well. Dan Lamar, M.D., Coastal Orthopedics and Sports Medicine: I see mostly younger patients, athletes with knee and shoulder injuries. Most of them have to do with ACL and meniscal pathology or injury and shoulder instability and labral tears. Avinash Kumar, M.D., Coastal Orthopedics and Sports Medicine: I treat mostly shoulder and elbow problems, so I’ll see a lot of degenerative conditions. My patients tend to be a bit older, but I see some pediatric patients. Often times it’s a wear-and-tear phenomenon such as the rotator cuff. Allen Boyce, M.D., Pinnacle Medical Group: I practice mostly adult orthopedics. The three most common complaints I see are shoulder pain, hip pain and knee pain. That’s probably 95 percent of the patients I see.

What’s going on when we experience joint pain?  Dingle: It’s dependent on the age of patients that you’re seeing.  Most of the things I see are degenerative. Dr. Kumar was talking about degenerative rotator cuff problems, where over time the rotator cuff gets worn or inflamed. The knee complaints and the hip complaints are mostly arthritic in nature, which means the articular surfaces are worn. Like the tread on a tire, they start to wear down the cartilage. As that cartilage wears down, the joint functions less optimally and causes pain. Stolarski:  The only thing I’d add to that is we have a huge population who comes down to retire and have had their joints replaced elsewhere. We’ll see joints that are worn out that have already been replaced. Lamar: For the most part, my injuries tend to be a little more acute —you can seasonally clump them depending on the sport of the moment. So my clinic is a little more fluid. I have to accept people at the last second. I probably add on five to seven people per day. Those tend to be sports-related injuries. 

What techniques do you use to treat these problems? Dingle: It depends on your specialty. In general with orthopedics, as with a lot of specialties, the techniques we’re using are less invasive—smaller surgeries, smaller incisions. The sports guys do a lot of arthroscopic work where you’re not making incisions but you’re working through a scope. The joint replacement guys are doing surgeries through smaller incisions with less trauma to the patient for faster recovery. As a general rule, that’s our goal. Lamar: As a specialty, we’re really in a privileged situation. We have a lot of intelligent people working to make our life easier. Technology is really applicable, both on the surgical front as well as the injury management front and the diagnostic front—we are fairly heavily technologically driven at this point and our skill set has to continually evolve to adapt to the new technologies that are brought to us.

What factors go into the procedure of arthroscopy? Stolarski: Arthroscopy is a surgery. It’s just doing it without opening up the joint completely and looking in it. You’re using a camera that goes though a sheath about the diameter of a pencil and you do your work through that. Lamar: With arthroscopy, we apply video and use very small instruments that allow us access to tight spots, where formerly we’ve have to make large incisions to see very small structures and hope that we were dealing with the correct thing. We can now, and have been able to for quite some time, as technology continues to improve our ability to see those things with high-definition and smaller cameras and wider fields of view, really see the detail better, without us having to inflict surgical damage on the patient in order to get there. Sometimes just by getting there you change the environment and it’s harder to understand the problem by the time you’re looking at it. Kumar: It’s made surgery safer. As Dan was saying, when you make an incision, you’re altering the natural anatomy. When you’re doing a scope, you’re getting to the same location without having to disturb the natural anatomy, so you can actually observe the anatomy the way it’s supposed to exist. Then you can fix whatever the problem is. You may still need to make an incision but the diagnostic part has improved dramatically. And with the advancements in technology, we can now repair a lot of the damages that we were doing open surgeries on in the past with arthroscopic techniques. Stolarski: But we don’t want to lead people down the wrong path. You cannot replace a joint arthroscopically. You cannot do joint replacement through a portal. Even though the technology has gotten a lot less invasive, that is an open procedure. Kumar: That’s true. I do a lot of shoulder replacements and people ask me if I can do it through a scope. We still haven’t mastered that yet.

What makes someone a good candidate for surgery? Boyce: It all depends on the process. If someone has an arthritic joint, it depends on the phase of the arthritis. The majority of the people I see are early on in their disease. Patients who don’t have severe arthritis will respond to arthritis medications, injections and physical therapy. But once arthritis gets to a certain point, where there’s no cartilage left in the joint, non-surgical treatments are rarely successful. Once it gets to that point, patients are having pain where they can’t walk, they’re miserable and they don’t have a life. At that point and time, the most reasonable procedure is replacing either the knee or the hip, whichever is bothering them. But early on in the disease process, non-surgical treatments are very effective.

Tell us more about those non-surgical treatments.  Boyce: Specifically for hip and knee arthritis, standard treatments are arthritis medications, unless there’s a reason the patient can’t take them, and occasional cortisone injections. Cortisone injections have a drawback particularly in the knee, because if you get too many of them it can damage the remaining cartilage. Physical therapy is sometimes touted for arthritic knee joints, but I’ve rarely seen physical therapy help an arthritic knee. Dingle: As a general rule, surgery is usually the last resort. We try all non-operative measures first. When those things fail is when people would typically need surgery. Those are the people who typically do the best, as well—those who have tried all those conservative measures first. 

When patients come in for a joint replacement, what’s the likelihood you’ll be able to bring them back up to 100 percent? Stolarski: One-hundred percent means different things to different people. Really, you’re asking, “am I going to have a full recovery,” “am I going to be normal” and “when am I going to be normal?” It depends on what they’re having done, why they’re having it done and where they are in their life. If you have a young man who requires a hip replacement, I expect a higher level of return to function than I would from a grandmother who has diabetes and just wants to make it to her mailbox and her water aerobics class. The best they’re going to be is what they were like before they had the arthritic joint. As far as joint replacement, hips and knees, the vast majority of hip replacement people feel normal. A large percentage of knee replacement people are happy, but it does not go back to “God’s knee.” It’s all patient expectations and realistic expectations on what we can deliver with technology. Kumar: The main goal is pain relief. If you have someone who’s older, that’s goal number one—to give them 90-100 percent pain-relief. Function, at least in the shoulder arthroplasty, is as high as pain relief. Patients want to be able to reach to the top of their cupboards. They want to be able to do things they couldn’t do before. So generally I tell them they’re going to regain about 70 percent of the things they could not do prior to surgery. That’s not 100 percent, but 70 percent, for someone who’s not able to do a whole lot is a great deal. Lamar: With sporting injuries, the demands are much higher. I deal with a fair number of high-level athletes and their expectation is to be able to return and perform at that level and continue their career. We have improved our techniques a lot to get them very close. For instance, ACL surgery—if it comes along as an isolated injury, I can tell them I expect they’re going to be able to perform again at that same level. Realistically, it’s probably a year and a half to two years, because a lot of neuromuscular adaptation has to take place and recovery beyond just the injury healing. But if they have additional injuries to other structures in their knee—specifically the cartilage or the meniscus—those folks have a tougher time returning to their prior level. It really depends on the location of the injury, the health of the patient and expectations as to whether they become normal again.

What signs should people be looking out for to tell them they should go see a specialist and not just take painkillers and rest?  Boyce: Pain that doesn’t get better or progressively gets worse in spite of patients doing things that common sense would dictate. If after two or three weeks it doesn’t get better, or it gets worse, then it’d be a good time to consult a physician. A lot of the problems that I see are patients who would come in who’ve had pain for just a few days. A lot of the time, if you just give those things time to heal, nothing needs to be done. Certainly pain that persists beyond a few weeks or more or progressively gets worse, patients ought to go see their doctor and have it evaluated. 

People say, “bad backs run in my family” or “bad knees run in my family.” Is genetic predisposing something to be concerned about? Dingle: Certainly there’s a combination of both. When you’re talking about arthritic conditions, genetics plays a large role. There are people who, in their family have had their mother, brother, sister, etc. whose joints have worn down and there’s a genetic predisposition for the articular cartilage to wear down. Now if you’re overweight and you run marathons, you’re going to accelerate that degeneration, so there’s both the environmental and the genetic component to that. For arthritic conditions, there’s a fairly good combination of both genetic and environmental things. Stolarski: That’s true for wear-and-tear, but you also have the autoimmune and systemic diseases—lupus, rheumatoid arthritis, even people we see with psoriasis are predisposed to arthritic changes. There’s a systemic side of it, aside from just wear-and-tear, that makes up about 30 perent of joint replacements, maybe a little less than that. Lamar: From a slightly different angle, there certainly are genetic predispositions to things in the athletic realm as well, that can be modulated. The orthopedic community continues to look for ways to prevent injuries and prevent damage to joints. A perfect example is the young women in sports and athletic knee injuries—specifically the ACL. We’ve designed an entire program that helps target the potential movements and error in movement that contributes to the potential injury. Although you have genetic predisposition and you have environmental factors, the environmental factors often times can help avoid something that you’re predisposed to.

What are some bad habits for people to avoid in order to protect their joint system? Stolarski: Obesity is probably number one. Boyce: And not exercising. Patients frequently ask me, “Why did I get arthritis?” My common answer is, if you live long enough, almost everybody gets it. The fact of the matter is God didn’t design a perfect machine when he designed the human body and our parts wear out. Part of the aging process is our joints wearing out—particularly the shoulder. Rotator cuff disease is probably close to 100 percent in people over the age of 60-65. But things patients do to not help themselves—they eat too much and they don’t exercise. Exercise helps maintain healthy joints, keeps the muscles around the joints strong and helps maintain the health of the joints. Not getting regular exercise, having too much weight and of course bad habits like smoking, drinking too much, having an unhealthy lifestyle all contribute to the parts of the body breaking down. Kumar: I’ve also seen improper lifting technique in terms of injury to the spine or injury to the shoulder. If someone’s not bending their knees when they’re lifting and they’re reaching out with their arms being unsupported, they put a lot of strain on the rotator cuff as well as their spine. The spine is designed to take on a lot of force and it’s very good if the spine is in vertical alignment. If the spine is more horizontal, that tends to put more strain on the ligaments as well as more force on the shoulder ligament and the rotator cuff. Although I agree the rotator cuff is mostly a degenerative condition in people who are over the age of 60, in a lot of the workers injuries that I see it’s related to the actual lifting mechanics. If you can change the way you’re lifting loads, doing it more safely, these avoid a lot of the shoulder and spine injuries. Lamar: Allen mentioned the importance of exercise. In my office, it’s almost the opposite challenge, which is everyone can exercise too much. In this day and age, athletics has gone the way of sports specialization. They’re continuously doing the same thing over and over. A very important principle to the long-term success of any athlete and active individual is cross training. I’ve really pushed people in cross-training techniques and programs to keep them fit, keep their ability to compete up but preserve some of the movement patterns that will ultimately lead to their failure. Dingle: That’s also true with people with arthritic joint conditions. If you can take them from high-impact exercises to low-impact exercises such as biking or swimming, then you can preserve their joints longer and improve their symptoms by changing the types of exercises they do.

What is your top advice for our active Boomers and retirees? Stolarski: People who’ve already had their joints replaced but not looked at within 5-10 years should come in for an exam and an X-ray because we can see something that’s potentially failing before they can feel it. The only other thing about Sarasota is that people can be fanatics, running everyday 5-6 miles. They’re going to have overuse injuries. Cross training is important, as is avoiding sporadic exercises. Be consistent. Run a half an hour a day rather than be a “weekend warrior,” which is going to exacerbate arthritis or create an Achilles tendon rupture caused by doing high-intensity exercise two days a week and doing nothing the rest of the week. Consistency and common sense when it comes to cross-training and low-impact exercises. Kumar: Someone who hasn’t exercised in a while needs to have a gradual ramp-up period. You don’t want to just go out and run five miles the first day. You might want to walk a half mile the first day, gradually build up to one mile and every other week increase your distance. There should be a gradual build-up of exercise. Once you get to that point, you want to maintain that program. 

Are there any advancements in your fields that make you excited for the future of treatment? Boyce: I’m going to speak to that because I’m the old guy here. I’ve been practicing since ‘79 and the technology in orthopedics in 35 years is astounding. When I was in training, arthroscopy was in its infancy. Initially, we did diagnostic arthroscopy. We used something called a needle scope that was a 1.7mm scope. We didn’t have video, we had to look through the scope physically, and we didn’t have the technology to do arthroscopic surgery. I started doing arthroscopic meniscectomy in ‘80 or ‘81. We still didn’t have video and it was very difficult. Our instruments were archaic by today’s standards. I did my first ACL reconstruction in ‘83 or ‘84, and I remember taking about three to four hours. The younger guys don’t appreciate what we went through 30 years ago. The technology has been explosive. Stolarski: Not only has technology changed, but also patient expectations have changed. They used to expect that it would last them five years and they could walk. Now they come in and ask when they can play pickle ball, handball, racquetball, basketball. Can they run 5ks? That’s where expectations come in, because a lot of them feel like they can and we don’t know how quickly they’re going to wear that joint out. Boyce: When I first started practicing, patients would ask me how long their knees would last and I’d tell them five years. That’s about how long you’d get out of them. The materials have improved drastically, the surgical technique has improved drastically and our ability to put in joints properly has gotten much better. Patients now ask me how long they can expect their joints to last and I don’t know. A well-done hip replacement in this day and time—we don’t know how long they’ll last. The majority of joints that have to be redone are either due to the patient abusing their body, doing things they shouldn’t do on a total joint, or perhaps things weren’t exactly perfectly put in and they had abnormal wear.

From what materials are replacement joints fabricated? Dingle: It’s a combination of metal and plastic. There is typically a plastic bearing, which is the surface that will wear out over time. The basic design hasn’t changed dramatically in the last 40 years but the materials that we’re using have. A plastic bushing that would wear out in 10-15 years will probably get decades of use now. As a general rule, there is a metal portion of the joint, which is attached to the bone, and then there is an articular surface, which has a piece of plastic against either a piece of metal or ceramic, which forms the articulation of that joint. Lamar: We’ve talked a lot about giving people artificial joints and the holy grail of orthopedics is being able to give them back what they originally had, which is a biologic solution to cartilage injury. All these conversations about joint replacement deal directly with the damaged surface in the joint. That smooth, white surface, which is very complex. It’s built on many different layers and going many different directions with cells that are very poorly vascularized and have a very difficult time healing. That’s made it exceptionally challenging for us to recreate that surface. A lot of attention is paid these days to developing ways to put back cartilage that’s almost identical to what we have. Currently the technology in that area can help us address discrete defects in cartilage and we do a really good job of recreating that surface already, but expanding that to include the entire surface of the joint is a significant jump and we’re still searching for that. Ultimately, the goal is to get to a biologic solution that doesn’t require metal and plastic.

Patient expectations have come up a lot in this discussion. How much attention is paid to managing expectations and how important is that? Boyce: It’s the most important thing and it’s the job of the surgeon to tell the patient what they can expect. I personally will not allow my knee and hips to return to high-impact activities—running, playing tennis—things like that. That puts excessive wear on the joint. Particularly if they’re young, it increases their risk of wearing out their joint and having to have a revision. I’m very firm with my patients. You cannot go back to high-impact activities. The job of the surgeon is to tell the patient, “OK, this is what you can reasonably expect. This is what you’re going to be able to do.” Once patients understand what they can expect, then they are able to live with their limitations. Dingle:  I don’t disagree with anything you say. However, whatever activities you should return to after is somewhat of a judgment and there are different surgeons who have different opinions on that. As a general rule, I do not restrict any of my patients’ activities after joint replacements. I give them the information to know that if they do things that are high-impact, they have a higher chance of having difficulties later on. But I do not necessarily restrict them as you do. Boyce:  I don’t tell them “absolutely not,” I just tell them if they do that, they’re probably at risk for wearing out the joint. My official stance to patients—I don’t want you running; I don’t want you playing tennis. Stolarski:  It all goes back to expectations. A dissatisfied patient with a great surgery is often because we didn’t educate them enough. I tell people, if an average person does a million cycles per year on a joint just living life, then if they run marathons, it’s going to be a significantly more number of cycles. And I’ll tell you that your primary hip or knee, if you run or long distance running, probably will wear out sooner. Then if I revise you, you have significant limitations. Your first joint is your best joint with the least limitations, then it’s all downhill. All your revisions will be limited because it’s more of a salvage procedure. Although the technology has gotten immensely better with that, we’re working with less bone stalk. Kumar:  Shoulder replacements work a little differently than hip or knee replacements. Generally, I don’t limit my patients with any activities except repetitive loading. I tell them not to go to the gym, not to lift 200-300 pounds repetitively. They can go back to all the activities they did prior to their surgery. They’re playing tennis, swimming, playing golf. Since the shoulder is not a load-bearing joint, there aren’t the same limitations put on it.

Sean Dingle M.D. Kennedy-White Orthopedic Center, Hip & Knee Joint Replacement Surgeon: A South Florida native and Board Certified Orthopedic Surgeon, Dingle attended the University of Florida for undergrad before going to the University of South Florida College of Medicine for his medical degree, where he was elected to the Alpha Omega Alpha Honor Medical Society. Dingle completed his orthopedic residency at Orlando Regional Healthcare System. He is currently also a member of the American Association of Hip and Knee Surgeons.

Edward Stolarski M.D. Kennedy-White Orthopedic Center, Adult Reconstruction Surgeon: A Board Certified Orthopedic Surgeon specializing in minimally invasive hip and knee replacements as well as complex revisions, Stolarski attended the Hahnemann University School of Medicine in Maryland before completing his internship and residency at Temple University and his Adult Reconstruction Fellowship at the University of Pennsylvania. A published researcher, Stolarski was appointed to a two-year term with the American Academy of Orthopaedic Surgeons Adult Reconstruction-Hip Program Subcommittee.

Dan Lamar, Coastal Orthopedics and Sports Medicine, Sports Medicine Specialist and Orthopedic Surgeon: Specializing in sports medicine, total joint replacement, cartilage rejuvenation and arthroscopy, Lamar has served as physician to the Tampa Bay Buccaneers, Pittsburgh Pirates, the U.S. Soccer Team and IMG Academy. Lamar completed his residency at the University of Pennsylvania Hospital and Children’s Hospital of Philadelphia before moving on to a fellowship in Orthopaedic Sports Medicine at the University of Miami. 

Avinash Kumar, M.D. Coastal Orthopedics & Sports Medicine, Shoulder and Elbow Specialist: A graduate of the Emory University School of Medicine in Atlanta, Kumar was a Whitehead Surgery Scholar and Hughes Research Scholar. He completed his orthopedic residency at Tufts University and his fellowship in shoulder and elbow surgery at the Florida Orthopaedic Institute. Board certified and one of Vitals Top 10 Orthopedic Surgeons of 2013, Kumar is one of the few Florida physicians that performs Reverse Total Shoulder Replacements.

Allen Boyce, M.D. Pinnacle Medical Orthopedics: Boyce received his medical degree from the Virginia Commonwealth University School of Medicine, where he also completed his internship and residency in Orthopedic Surgery. Board certified in Orthopaedic Surgery, in addition to working with Pinnacle Medical Group, Boyce is associated with Blake Medical Center and Manatee Memorial Hospital.