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Dem Bones

How orthopedic surgery has changed

By CORY FRANKLIN M.D.
“A physician is obligated to consider more than a diseased organ, more even than the whole man—he must view the man in his world.”—Dr. Harvey Cushing, the top American surgeon of the first half of the 20th Century

   What’s the best way to find a good surgeon? Using those magazine ratings of “Best Doctors” is a hit or miss proposition. My experience is that 50 percent of the doctors are really good and the other 50 percent are really good self-promoters. Celebrity endorsements have about the same reliability. Celebrities get some of the best medical care; they also get some of the worst. I’ve found there are two ways to locate a good surgeon. If you’re lucky enough to know an operating room nurse ask him or her. They know who’s good and who’s not and usually aren’t shy in letting you know. The other way is to find out which surgeons doctors send their own families to. Although not a surgeon, I can tell you when I was practicing critical care, there was no higher compliment than when a physician asked me to consult on a relative.
   That’s why when I wanted to interview a top orthopedic surgeon about how the field has changed in the past generation, I selected Ira Kornblatt, a North Shore surgeon who specializes in sports medicine and reconstructive surgery of the knee and shoulder. Ira, who has been in practice since 1982, did orthopedic work for the Chicago Bulls in their glory years, but what was more significant to me was his impeccable reputation among his colleagues and the nurses who work with him. I have referred many patients to him over the years, and they have returned to my care after surgery, uniformly satisfied. He has performed surgery on my wife and two of my children and the results and follow-up could not have been better. I sat down with him recently to discuss how orthopedics has changed since he started practicing over 25 years ago.
   Kornblatt began with a broad overview. “Orthopedics has had more changes than almost any subspecialty…orthopedic surgeons are a lot more subspecialized. Orthopedics has grown so much that you can’t be an expert in all areas of orthopedics. When I came out, there were a lot of guys doing everything, from spine surgery to complex hand cases. That is no longer the case, at least in metropolitan areas. That’s why we have large groups with all sorts of subspecialty coverage for different types of cases. There is no question patients get better outcomes this way.”
    It is no surprise that as Baby Boomers age, the patient population and surgical procedures have changed also. “Over the past 25 years, there certainly has been an increase in the number of older people who are active,” Kornblatt says. “Our generation doesn’t want to slow down. There are many more joint replacements done in people in their late 40s and 50s than in the past. The prostheses are better and people have higher expectations. People want to keep active. After a total knee replacement, they shouldn’t be jumping and running, but they can play golf, they can play doubles tennis, they can ride bicycles and walk distances.” To illustrate his point, he describes one patient he is especially proud of, “I have one 70-year-old man who plays in an over-65 baseball league. I have operated on his shoulder, and he is back throwing.”
   This surgical progress has been facilitated by the development of arthroscopic surgery. The arthroscope, a long, flexible fiberoptic scope introduced into the joint, precludes the need for a large open incision, as was done in the past. This usually means shorter operative and anesthesia time, less tissue disruption, shorter recovery and fewer complications.
   “Look at sports medicine today, almost everything is done with the arthroscope,” explains Kornblatt. “We used to do all these open shoulder procedures where now we can do minimally invasive procedures on condi-tions like labrum (shoulder capsule) tear”.        Kornblatt cites advances in technology. “There is better technology. We’ve had MRI scans since I started, but they weren’t routinely available. Now they are, and they’ve made arthrograms (dye injections into a joint) virtually obsolete, except for certain conditions. The newer generation of CT scans are also much better in demonstrating difficult fractures and helping out in preoperative planning.”
   Like any good surgeon, Kornblatt works with his support team and he emphasizes the advances in rehabilitation medicine. “Rehabilitation has become much more specialized,” he says. “We’ve always used rehab, but rehab has grown tremendously. It’s become a specialty in itself.”
   He notes that there is a nationwide shortage of physical therapists (college students take note). “People with orthopedic problems need rehabilitation therapy whether or not they have surgery. There are many things that rehabilitation can cure without surgery.” That last comment is particularly telling—some surgeons are reluctant to consider alternatives to surgery. Kornblatt’s attitude supports a well-known medical axiom that the best surgeon is the one who knows when not to operate.
   But he is candid about some of the serious problems that have arisen in the past generation, including the depersonalization of medicine, declining reimbursement, increasing corporatization and waste. He explained how reimbursement for common procedures such as total hip replacements is far below what it was in 1982 when calculated in 2009 adjusted dollars. This diminished reimbursement, along with the higher overhead it takes to run a practice, has had major consequences for the delivery of care.
   “Surgeons will naturally do whatever they can to see more patients,” Kornblatt says. “That’s why orthopedic groups hire physician assistants (and other ancillary care providers). Not too many surgeons had physician assistants in 1982. Care (between the surgeon and patient) was more personalized back then.”
   Hospitals have also changed the practice of orthopedics in the current environment. “Hospitals are all corporate now. If you look at Chicago, there are very few independent hospitals left. So there is greater emphasis on the bottom line. In 1982, you could pretty much decide what prosthesis or special equipment you wanted to use. That is being dictated much more by hospitals today. But even hospitals are having difficulty running profitably. If you have preexisting problems, if you’re ‘expensive’, the insurance companies are not going to want to cover you.”
   Even the technology that has advanced the field so dramatically has not been an unalloyed benefit since it contributes to the billions of dollars wasted annually.
   “There are a lot of unnecessary tests done. Many of the patients referred to our group have had unnecessary MRIs. This happens across the country hundreds of thousands of times a year.”      Kornblatt explains that in some cases an MRI is not warranted because the clinical situation is obvious or because a patient needs arthroscopy anyway and the MRI will not change management. Since the cost of a routine MRI runs over $1500, the annual cost of unnecessary MRIs alone may be over one hundred million dollars.       While physician-ordering habits are responsible for much of this waste, Kornblatt says that in the contemporary medical culture, patients are also partly culpable. He explained that when he tells some patients they don’t need an MRI before arthroscopic surgery, they simply won’t accept it.    
   “In some patients, you know they need arthroscopy, so you do the procedure and fix whatever you find. The MRI doesn’t change anything in those patients. Yet patients’ expectations are that ‘if I have this problem, I’m going to have an MRI scan.’ They say, ‘What do you mean you want to do surgery on me without an MRI?’ They expect certain tests that may not be absolutely medically necessary. That is one of the many reasons costs are so high, and it’s one place we could really save money.’”                           
   I asked him to look into the future of orthopedic surgery. He believes it’s spelled robotics. “I just went down to Florida and saw a company that is involved in developing computerized robotic devices to assist the surgeon. You won’t be replaced by it, but the robot keeps you from making mistakes. The computer program gives you more information and the robot makes sure you don’t make a bad cut. The robots have a navigation system built into them, and that way you are not estimating where in space you are. You know exactly what direction to cut from. Robots will definitely have a place in the operating suite. It was the most fun day I’ve had in I don’t know how long.”

Published: August 09, 2009
Issue: Fall 2009 Water Issue