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3 Volume 1 Issue In this issue... Refinements, Research, and Innovation The History of Prosthetics Part Two Prosthetic history provides an understanding of our origins from which we may draw conclusions about the future. This article features the history of prosthetics from the 1600s to modern times. Replacement Technology Moves to the Spine Artificial Disc Offers Motion-Preserving Alternative to Spinal Fusion Artificial disc replacement (ADR) was developed as an alternative to fusion for the surgical treatment of degenerative disc disease of the lumbar spine. ADR was recently approved for use in the United States, and it represents a revolution in spine surgery. Putting Knowledge, Skill, and Dedication to Work Provider Directory The surgeons of Proliance Surgeons, Inc., P.S., have expert knowledge of orthopedic or general surgery and have additional specialized training. In Full Flow Reduce the Risk of Postoperative Venous Thrombosis Regardless of preventative measures, there is always a risk of venous thrombosis, which can result in pulmonary embolism. The goal is to keep that risk as low as possible without compromising the results of the surgical procedure. Bringing Images to Life PET-CT Gives Insight into Diagnosis, Treatment Options PET-CT provides radiologists with both the anatomy and metabolism of normal organs and cancerous tumors. PET-CT can show the size of a tumor and how far the cancer has spread, helping the physician and patient decide which treatment option would prove most beneficial. Directory 3

4 Opening Remarks As Proliance Surgeons Outlook wraps up its first year of publication, I would like to thank all its supporters and contributors. This includes not only our committed suppliers and article authors but you, the readers. The physicians and staff of Proliance Surgeons, Inc., P.S., take great pleasure in bringing you the information in this magazine. This issue is again an eclectic mix of well-written articles penned by our very own physicians as well as the conclusion to The History of Prosthetics, which appeared in the last issue and chronicles the historical background of prosthetics. Please continue to provide us with content suggestions for upcoming articles. This magazine s purpose is to help you gain greater insights into both Proliance Surgeons and the exciting world of surgery and its related fields. Two public initiatives are on the ballots in Washington State and are up for voting by the populace November 8. These initiatives I-330 and I-336 both concern professional liability, more commonly known as malpractice insurance. Physicians and hospitals as well as the majority of Washington businesses support I-330, which puts patients first by limiting the amount of noneconomic damages that are payable on a claim. It achieves this by limiting the amount of fees a personal-injury lawyer can collect based on the size of the award. By allowing arbitration rather than costly court battles and removing the joint and several burden of court awards to the actual damages from each defendant, the process is simplified. The state needs these reforms to stem the flow of physicians from the state. Plus, by not clogging the system with frivolous cases, true malpractice claims can be heard and awarded. I-336, a retaliatory initiative put forth by the personal-injury lawyers, is essentially a punitive measure to physicians that could undermine patient safety and physician-patient relationships. To protect our medical community, we urge you to vote yes on I-330 and no on I-336 November 8. A publication from Proliance Surgeons, Inc., P.S. Central Office 720 Olive Way, Suite 1505 Seattle, WA (206) (206) Fax President Jeffrey Remington, MD CEO David G. Fitzgerald CFO Gary Mayberry Proliance Surgeons Outlook, a publication from Proliance Surgeons, is an educational resource for health care professionals as well as the general public. The publication will feature Proliance physicians and facilities, communicate educational news and trends involving both orthopedic and general surgery topics, and contain various health-oriented articles of interest. Proliance Surgeons goal is to increase public awareness of surgical techniques and innovations and their significant roles in orthopedic and general health care. The information contained in this publication is not intended to replace a physician s professional consultation and assessment. Please consult your physician on matters related to your personal health. Thank you for allowing me to talk to you about this extremely critical situation. I hope you find this issue of Proliance Surgeons Outlook interesting and informative. See you at the polls November 8. Sincerely, David G. Fitzgerald, CEO Cover photo courtesy Washington State Tourism Proliance Surgeons Outlook is published by QuestCorp Media Group, Inc., 885 E. Collins Blvd., Ste. 102, Richardson, TX Phone (972) or (888) , fax (972) , QuestCorp specializes in creating and publishing corporate magazines for businesses. Inquiries: Victor Horne, Editorial comments: Brandi Hatley, Please call or fax for a new subscription, change of address, or single copy. Single copies: $5.95. This publication may not be reproduced in part or in whole without the express written permission of QuestCorp Media Group, Inc. QC Creative is a full-service graphic design studio, Creative services inquiries: Jalynn Turner, 4 PROLIANCE SURGEONS OUTLOOK

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6 Refinements, Research, and Innovation The History of Prosthetics Part Two of a Two-Part Series Civil War Benefaction by the U.S. government that fueled competition by providing prostheses to veterans. This was a government s first commitment to supply prostheses to veterans and whose support plays a major role to this day. Prostheses Development: 1600 to 1800s From the 1600s to the early 1800s, great refinements of the prosthetic and surgical principles emerged. The invention of the tourniquet, anesthesia, analeptics, blood-clotting styptics, and disease-fighting drugs made amputation an accepted curative measure, rather than a last-ditch effort to save life. The surgeon had time to make residual limbs more functional and, therefore, allowed the prosthetist to improve prostheses. Many of the prostheses developed during the 1600s were merely refinements of earlier armor-type devices. In 1696, Pieter Andriannszoon Verduyn, a Dutch surgeon, introduced the first nonlocking, belowknee prosthesis. It bears a striking similarity to today s joint-and-corset prosthesis. Like the joint and corset, it was made of external hinges and a leather cuff that bore weight. The leg-cuff socket was lined with leather and had a copper shell and a wooden foot. James Potts of London designed a prosthesis in 1800 that consisted of a wooden shank and socket, a steel knee joint, and an articulated foot that was controlled by catgut tendons from the knee to the ankle. The Marquis of Anglesey used it after he lost his leg in the Battle of Waterloo, and it became known as the Anglesey leg. Flexion of the knee caused dorsiflexion of the foot, and extension of the knee caused plantar flexion of the foot. William Selpho then brought the Anglesey leg to the United States in And in 1846, Dr. Benjamin F. Palmer, a patient of Selpho, obtained a patent for a leg that improved on the Anglesey leg by adding an anterior spring and smooth appearance while concealing tendons. It was honored in 1851 at the London World s Fair. The Anglesey leg became known as the American leg in 1856, when A.A. Marks gave it knee, ankle, and toe movements and an adjustable articulation control. Dr. Douglas Bly of Rochester, New York, invented and patented Doctor Bly s anatomical leg in He is said to have first introduced the curved knee joint. The prosthesis also allowed for inversion and eversion through the use of an articulated ankle a polished ivory ball in a socket of vulcanized rubber. The Civil War and The Age of Entrepreneurship The American Civil War ( ) marked the first example of modern warfare, and the postwar industrial revolution began the age of entrepreneurship. It was fueled by the Great In 1862, the U.S. government guaranteed prostheses for Civil War veterans like this above-knee amputee, pictured here with his prosthetic leg in In 1862, the government guaranteed prostheses for veterans who lost limbs in the war. A southern soldier, J.E. Hanger, who lost his leg in 1861, replaced the catgut tendons of the American leg with rubber bumpers to control dorsiflexion and plantar flexion and used the plug fit wood socket. Hanger then opened a clinic in Richmond, Virginia. Later, the rubber foot, the forerunner of the SACH foot, came into use and eliminated the complicated articulated ankle of the Doctor Bly anatomic leg. Around 1912, with the budding of aviation technology, an English aviator named Marcel Desoutter, who lost his leg in an airplane accident, made the first aluminum prosthesis. Other inventions developed by Desoutter and Hanger, such as pelvic suspension rather than shoulder suspension, provided a more efficient and stable way of operating the prosthesis and direct knee control. This led to knee-control systems, such as the knee brake. As World War I began, prosthetists were at times less concerned about patients needs than their own greed and pride. This set the stage for leaps in technology from the two World Wars into the modern era. Modern Advancements: World War I, The Depression, and World War II As World War I ( ) began, American prosthetists remained an independent, competitive group, rarely working with surgeons let alone each other. Amputee casualties in the United States (4,403) were much fewer than the British (42,000) and European armies (100,000). This resulted in European prosthetists jumping ahead in experimentation of their American counterparts. 6 PROLIANCE SURGEONS OUTLOOK

7 Recognizing the lagging care for amputees in America, the Surgeon General of the Army invited the U.S. prosthetists to Washington, D.C., to discuss prosthetic technology and its development in this country. From this meeting arose the present-day American Orthotics and Prosthetics Association. Through this forum, prosthetists could develop ethical standards, scientific programs, and educational programs, as well as build better relationships with other health professionals. In 1918, Dr. Martin described the Belgian prosthesis, which emphasized the anatomy and physiology of the leg. This prosthesis was an improvement on the standard American leg. It could reproduce the natural static and aesthetic appearance of the lower limb and was made from measurements and a modified cast of sound and residual limb. Because of the relatively low number of amputees in World War I and the economic depression, prosthetics advanced very little by the beginning of World War II ( ). Many of the European advances had not yet reached America. As World War II waged on, the American amputee casualty list was much greater. These veterans found the current technology, which had not changed much since the 1800s, inadequate. In response, Normal Kirk, Surgeon General of the Army, requested that the National Academy of Sciences investigate the prosthetic state of the art. Originally, it was thought only a few designs and studies were necessary. But it soon became apparent that the United States lagged far behind. At this time, the orthotists joined the American Limb Manufacturers Association, making it the Orthopaedic Appliances and Limb Manufacturers Association. In 1950, the name was again changed to the American Orthotic and Prosthetic Association, or AOPA. Modern Era: Research and Development This research launched a quantum leap for prosthetic science. The Artificial Limb Program was sponsored by the Veterans Administration (VA), Today, technology affords patients more options than ever before to find properly fitted prostheses, which can significantly improve quality of life. HEW, and the Armed Services by establishing a number of research laboratories, such as the University of California at Los Angeles Laboratory for Upper Limb Study. Socket designs, such as the quadrilateral, were investigated and further refined at this time. Materials also improved. Northrup Aviation introduced the use of thermosetting resins to form custom-fit socket and structural components. This also led to the development of the SACH foot. Total contact now became possible along with clear check sockets. Prosthetic knees, such as the Mauch S-N-S system, were also developed. Educational seminars for these new techniques and components began in 1947, as well as pilot courses in prescription, fabrication, and alignment of above-knee prostheses. These courses were followed by workshops sponsored by the VA and the Orthopaedic Appliance and Limb Manufacturers (now AOPA). The American Board for Certification was created in 1949 to evaluate and certify prosthetists who met its standards. The 1950s continued this educational growth. The year 1956 marked the development of the SACH foot from the University of California (UC), and in 1959, the PTB prosthesis was created at UC Berkeley. In 1960, the Stewart- Vickers hydraulic leg became available and was improved with the Hensche-Mauch S-N-S systems. In 1968, the modern hydraulic Hensche-Mauch S-N-S knee was developed when it became apparent that hydraulic support in swing was not adequate. Different prosthetic procedures resulted when prosthetists began working with surgeons. Marian Weiss of Poland experimented with immediate postsurgical fittings in The next year, Dr. Burgess of Seattle brought prepatory fitting to the United States. In 1971, endoskeletal components became available with a soft-form cover. From 1974 to 1976, the STAR, Hosmer, and ROL rotational units were developed, and in 1980, the SAFE foot (one of the first energy-storing feet ) was developed. Many products and events are beyond the scope of this study. However, their development and prosthetic history as a whole provides an understanding of our origins from which we may draw conclusions about the future. Article reprinted with permission from Northwestern University s Prosthetics- Orthotics Center. 7

8 Replacement Technology Moves to the Spine Artificial Disc Offers Motion- Preserving Alternative to Spinal Fusion By Jay B. Williams, MD, Seattle Spine Group/Orthopedic Physician Associates Spine Low back pain presents a common and costly health problem. Many feel that degenerated discs are a primary cause of low back pain, although this is still debated. Artificial disc replacement (ADR) was recently approved for the treatment of disc degeneration associated with persistent low back pain. Nonoperative treatment of low back pain associated with disc degeneration primarily consists of physical and cognitive therapy. Surgical treatment is generally considered for those who don t improve with extensive, appropriate nonoperative treatment. Discectomy with fusion remains the controversial gold standard for surgical treatment. (Results have been far from universally favorable, thus the controversy.) This and other factors led physicians and scientists to develop ADR as an alternative to fusion for the surgical treatment of degenerative disc disease of the lumbar spine. ADR has evolved significantly during the past 50 years. The Food and Drug Administration (FDA) approved the first lumbar artificial disc in October 2004 the CHARITE TM Artificial Disc by DePuy TM Spine, Raynham, Massachusetts. Early results appear comparable to fusion. As these devices become available, we must consider many variables, such as the durability of these implants over the years, if they will maintain motion, if they will slow or prevent adjacent-level degeneration, who the ideal candidates are, if arthroplasty is a better alternative to fusion, and if we should surgically intervene at all. ADR represents a revolution in spine surgery; we will discover the nature of that revolution in the years to come. Lumbar disc degeneration and discogenic low back pain present a tremendous medical problem in both the United States and worldwide. Low back pain represents one of the top health care expenditures in the United States and accounts for a tremendous number of office visits annually, time off work, and workers compensation claims. 8 PROLIANCE SURGEONS OUTLOOK

9 Debating the Options Nonoperative treatment options for degenerative disc disease and discogenic low back pain include rest and activity modification, bracing, physical and cognitive therapy, chiropractic care, anti-inflammatory medications, narcotic medications, injections, percutaneous sclerosing procedures, and other less traditional treatments. Cognitive and physical therapy are the primary modes of treatment. This reinforces to patients that the pain is not dangerous and they can physically work to become more functional with their discomfort, while hoping their pain will subside, as is often the case. Operative intervention is reserved for those who fail to gain satisfactory improvement with extensive, appropriate nonoperative treatment and primarily consists of discectomy and fusion. The rationale behind discectomy is that the periphery of the disc is innervated, and degeneration and tearing of the disc may stimulate pain fibers that transmit the painful stimuli to the central nervous system. Removing the disc might eliminate the painful stimuli. The rationale behind fusion is stabilization of the level following discectomy. When not performed correctly or performed on the wrong patient for the wrong reason, the procedure often results in a poor outcome. When performed well on the right patient for the right reason, the procedure often creates a good or excellent result, at least early on. However, even under optimal circumstances, results are not always favorable. Furthermore, even when results are good or excellent in the short term, adjacent-level degeneration could lead to problems years later, necessitating an extension of the previous fusion. Physicians still debate the cause of adjacent-level degeneration. Studies clearly demonstrate that motion loss at a fused level transfers stress to adjacent levels, possibly accelerating degeneration at those levels. Alternatively, the same degenerative disease process that affected the first disc may subsequently affect adjacent discs, irrespective of an adjacent fusion. Three-level disc degeneration in a patient never treated surgically who was known to have had only single-level degeneration 10 years prior is a perfect example. Ideal lateral placement of a CHARITÉ TM Artificial Disc at L5-S1 in a healthy 52-year-old male suffering from low back pain and L5-S1 disc degeneration Ideal anteroposterior placement in the same patient The ADR Advantage Compared to fusion, ADR offers the advantage of placing a motion-preserving implant into the void left by the resected disc, decreasing stress transfer to adjacent discs and, theoretically, decelerating or preventing the degeneration of adjacent discs. Deceleration or prevention of adjacent-level disc degeneration with arthroplasty is not yet proven and is considered theoretical at this time. ADR began in the 1950s with the insertion of metal spheres, cement, and silicone following discectomy and has evolved ever since. The first modern artificial disc was developed in East Germany in It underwent two major revisions in the mid- 1980s. The third-generation disc, developed in 1987, was accepted by the FDA for a prospective, randomized trial beginning in the late 1990s. This disc received FDA approval for commercial use in October A tremendous public interest preceded its approval and continues in association with abundant media coverage. A second disc was developed in the late 1980s in France, and that disc began its U.S. trial shortly after the first. The results are now under review by the FDA, and this disc will likely gain FDA approval before the end of Results with these two ADR models appear at least as good as with fusion. Two more total lumbar disc prostheses, as well as cervical disc prostheses, nuclear prostheses, and motion-preserving pedicle screw systems, are also undergoing studies. Indications and Contraindications Surgeons have implanted more than 12,000 artificial lumbar discs worldwide and more than 1,000 in the United States. While most of the non- U.S. investigational device exemption (IDE) studies are retrospective without controls and generally use poor methodology, authors report 50% to 90% good and excellent results. A paucity of studies present a greater than 10-year follow-up. The U.S. IDE study demonstrated a success rate of just under 60% using questionable outcome measures for success. General indications based on the inclusion criteria for the U.S. IDE studies include a primary diagnosis of discogenic low back pain related to one-level or two-level degenerative disc disease, an age between 18 and 65 years, and a minimum of six months of failed nonoperative treatment. 9

10 General contraindications based on exclusion criteria for the U.S. IDE studies include radiculopathy, previous fusion, stenosis, spondylolisthesis and instability, scoliosis, spinal tumor, systemic disease or infection, and obesity, to name a few. The ideal patient is a healthy adult with low back pain, no lower-extremity radiculopathy, no radiographic instability, and failure to improve with six or more months of physical therapy and other nonoperative treatment modalities. The procedure is performed in a fashion similar to an anterior lumbar interbody fusion. The approach is anterior and retroperitoneal (i.e., the abdominal cavity is not entered). Once the levels are identified, a thorough discectomy is performed. The disc space is then sized for an appropriate implant. Lastly, the implant is carefully placed in both the AP (anteroposterior) and lateral planes. A typical case would take two hours or less with 150 ml of blood loss or less. Patients are generally discharged on the third postoperative day. Materials Matter Despite the theoretical benefits of motion preservation and decreased stress transfer and adjacent-level degeneration, it is important to consider a few additional issues. To begin, artificial discs possess bearing surfaces that are subject to wear. The history of artificial hip and knee replacement provides abundant information regarding material wear. The polyethylene liners in the hip and knee wear at about 0.1 mm per year or 1 mm every 10 years. As the bearing surface wears, an inflammatory reaction occurs. Polyethylene in spinal implants wears at a much slower rate in laboratory tests, likely secondary to a much smaller arc of motion. As for the inflammatory reaction seen in hip and knee replacements, the same doesn t seem to appear in the spine. This is possibly due to the decreased wear rate of the spinal polyethylene, the lack of a synovial lining in the spine, which is present in the hip or knee, or some combination of the two. However, it may also simply take a longer time to occur. While the spinal polyethylene liners appear to wear at a slower rate, we are placing these devices in young people, and we do not have 40-year in vivo follow-up data. If an inflammatory reaction occurs in the lumbar spine, it would present adjacent to the great vessels anteriorly and the thecal sac containing nerve roots posteriorly. The results of such a reaction are largely unknown. When wear becomes significant in the hip or knee, a revision is often the solution. While this might prove quite difficult in some cases, it is usually possible without significant risk to the patient. Should the spinal polyethylene wear excessively or the implant fail, revision of an anterior spine procedure is much more imposing than revision of a hip or a knee, mainly due to scarring of the great vessels over the anterior spine. In most cases, it would prove impossible to perform safely, and a posterior fusion is the salvage procedure. As with hip and knee replacements, materials research continues on the spine, and two metal-on-metal prostheses have been introduced into U.S. IDE trials. Questions Remain Additional questions remain, such as who should consider ADR, what happens to adjacent-level discs and same-level facet joints, is arthroplasty better than fusion, and should we treat disc degeneration and discogenic low back pain operatively at all? While unanswered questions exist, no systematic complications have appeared to date. Sound research and years of evolution of design and materials have led to the development of the current models that have survived unprecedented critical review by the manufacturing companies and the FDA. Revolutionizing Spine Surgery Arthroplasty patients, within the first few years postoperatively, are doing as well as fusion patients, with the added benefit of shorter operating time, less blood loss, a shorter hospital stay, and a quicker return to work. The theoretical benefit of motion preservation and effects on adjacentlevel degeneration might prove significant in the future, but it is still theoretical at this time. ADR possesses the potential to revolutionize spine surgery, rivaling the accomplishments of the Harrington rod and pedicle screw instrumentation. It is important to anticipate this potential revolution with cautious optimism and profound respect. Ushered in properly, ADR might provide a viable alternative to fusion for operative treatment of lumbar degenerative disc disease and discogenic low back pain. 10 PROLIANCE SURGEONS OUTLOOK

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12 Improving Patient Care with a Multidisciplinary Approach Proliance Surgeons Directory As one of the country s largest surgical practices, Proliance Surgeons, Inc., P.S., performs emergency and elective operations, treating illnesses and injuries that affect us all. With 30 care centers, six MRI centers, eight physical therapy clinics, and nine ambulatory surgery centers conveniently located throughout Washington s King, Snohomish, Pierce, Island, San Juan, and Skagit counties, Proliance s 210 physicians and its providers deliver the highest quality care available. For more information, including a list of physicians and directions to our clinics and centers, please visit our Web site at CARE CENTERS Ballard Orthopedic and Fracture Clinic (BOFC) 1801 N.W. Market St., Suite 403 Seattle, WA (206) Ballard Orthopedic and Fracture Clinic First Hill 1221 Madison St., Suite 1012 Seattle, WA (206) Ballard Orthopedic and Fracture Clinic Seattle Orthopedic Center 2409 N. 45th Street Seattle, WA (206) Bellevue Orthopaedic Associates (BOA) th Ave. N.E., Suite 100 Bellevue, WA (425) Cedar Surgical (CS) 2121 S. 19th St. Tacoma, WA (253) Everett Bone and Joint (EBJ) 1100 Pacific Ave., Suite 300 Everett, WA (425) Evergreen Orthopedic Clinic (EOC) th Ave. N.E., Suite H-210 Kirkland, WA (425) Evergreen Orthopedic Clinic Monroe th Ave. S.E., Suite 330 Monroe, WA (360) Evergreen Orthopedic Clinic Redmond st Ave. N.E., Suite 102 Redmond, WA (425) Evergreen Surgical Clinic (ESC) N.E. 130th Lane, Suite 420 Kirkland, WA (425) Northwest Orthopaedic Clinic (NWOC) Meridian Ave. N., Suite 250 Seattle, WA (206) Northwest Orthopaedic Clinic Seattle Orthopedic Center 2409 N. 45th Street Seattle, WA (206) Northwest Orthopaedic Physicians (NWOP) th Ave. N.E., Suite 510 Bellevue, WA (425) Northwest Orthopaedic Physicians Issaquah 600 N.W. Gilman Blvd., Suite E Issaquah, WA (425) Northwest Surgical Specialists (NWSS) 1560 N. 115th St., Suite 102 Seattle, WA (206) Orthopedic Physician Associates (OPA) 1229 Madison St., Suite 1600 Seattle, WA (206) Orthopedic Physician Associates Providence 1600 E. Jefferson St., Suite 600 Seattle, WA (206) Proliance Eastside Surgeons (PES) th Place S.E., Suite 101 Issaquah, WA (425) Proliance Eastside Surgeons Renton 1412 SW 43rd St., Suite 200 Renton, WA (425) Seattle Orthopaedic and Fracture Clinic (SOFC) 801 Broadway, Suite 1000 Seattle, WA (206) Seattle Orthopaedic and Fracture Clinic Seattle Orthopedic Center 2409 N. 45th St. Seattle, WA (206) Skagit Island Orthopedics (SIO) 1401 S. LaVenture Rd. Mt. Vernon, WA (360) Skagit Island Orthopedics Anacortes 2511 M Ave., Suite D Anacortes, WA (360) PROLIANCE SURGEONS OUTLOOK

13 Skagit Island Orthopedics Monroe th Ave. S.E. Monroe, WA (360) Stevens Orthopedic Group (SOG) th St. S.W., Suite 320 Edmonds, WA (425) Surgery Associates (SA) th Ave. S.W., Suite D-1 Burien, WA (206) Surgical Associates of Edmonds (SAE) th St. S.W., Suite 201 Edmonds, WA (425) Valley Orthopedic Associates (VOA) 4011 Talbot Rd. S., Suite 300 Renton, WA (425) Valley Orthopedic Associates Covington S.E. 272nd, Suite 210 Covington, WA (253) Washington Hand Surgery (WHS) th Ave. N.E., Suite H-10 Kirkland, WA (425) MRI CENTERS Eastside MRI th Ave. N.E., Suite H-120 Kirkland, WA (425) Everett Bone and Joint MRI 3102 Colby Ave. Everett, WA (425) Orthopedic Physician Associates MRI Center 900 Terry Ave., Suite 100 Seattle, WA (206) Seattle Orthopedic Center MRI 2409 N. 45th St. Seattle, WA (206) STAR MRI 8009 S. 180th St., Suite 105 Kent, WA (425) Stevens Orthopedic Group MRI th St. S.W., Suite 320 Edmonds, WA (425) PHYSICAL THERAPY CLINICS Everett Bone and Joint PT 3102 Colby Ave. Everett, WA (425) Evergreen Orthopedic PT th Ave. N.E., Suite H-220 Kirkland, WA (425) Proliance Sports Therapy and Rehabilitation of Bellevue th Ave. N.E., Suite 505 Bellevue, WA (425) Proliance Sports Therapy and Rehabilitation of Issaquah 600 N.W. Gilman Blvd., Suite A Issaquah, WA (425) Seattle Orthopedic Center PT 2409 N. 45th Street Seattle, WA (206) Skagit Island PT 1401 S. LaVenture Rd. Mt. Vernon, WA (360) STAR Sports Therapy and Athletic Rehabilitation 8009 S. 180th St., Suite 112 Kent, WA (425) Stevens Orthopedic PT th St. S.W., Suite 320 Edmonds, WA (425) SURGERY CENTERS Edmonds Center for Outpatient Surgery th St. S.W., Suite 140 Edmonds, WA (425) Everett Orthopedic Surgery Center 1100 Pacific Ave., Suite 100 Everett, WA (425) Evergreen Orthopedic Surgery Center th Ave. N.E., Suite H-110 Kirkland, WA (425) Anacortes 5 Edmonds Ballard Seattle Tacoma Burien Mount Vernon Kirkland Evergreen Surgical Clinic ASC N.E. 130th Lane, Suite 420 Kirkland, WA (425) Issaquah Surgery Center th Place S.E., Suite 102 Issaquah, WA (425) Seattle Orthopedic Surgery Center 2409 N. 45th Street Seattle, WA (206) Seattle Surgery Center 900 Terry Ave. Seattle, WA (206) Skagit Island Orthopedic Surgery Center 1401 S. LaVenture Rd. Mt. Vernon, WA (360) Valley Orthopedic Associates ASC 4033 Talbot Rd. S., Suite 270 Renton, WA (425) North Seattle Everett Mercer Island Kent Renton Federal Way Auburn Monroe Redmond Bellevue Covington 90 Issaquah 13

14 Putting Knowledge, Skill, and Dedication to Work Provider Directory The orthopedic surgeons of Proliance Surgeons, Inc., P.S., have expert knowledge of general orthopedics and additional specialized training in sports medicine, joint reconstruction, arthroscopic surgery, spine surgery, hand surgery, foot surgery, fracture care, and major orthopedic trauma. Its general surgeons have further specialized training in thoracic, vascular, bariatric, and colorectal surgery. Randolph Anderson, DPM, SIO James Alberts, MD, SOG Michael Allison, MD, VOA Richard Angelo, MD, EOC Craig Arntz, MD, VOA M. Kevin Auld, MD, OPA Howard Barker, MD, EBJ William Barrett, MD, VOA Traci Barthel, MD, VOA Mark Brakstad, MD, NWSS Clayton Brandes, MD, BOA James Bruckner, MD, BOA Michael Burke, MD, PES Brian Cameron, MD, SOG Robert Cancro, MD, VOA Thomas Castle Jr., MD, BOA Susan Cero, MD, VOA James Champoux, MD, EOC Thomas Chi, MD, NWOP B. David Chilczuk, MD, VOA Gary Clancey, MD, SIO Herbert Clark, MD, NWOC Robert Clawson, MD, NWOC Kelly Clinch, MD, ESC Carol Cornejo, MD, SAE James Crutcher, MD, OPA Jimmy Cui, MD, SIO Timothy Daly, MD, NWOC Leaza Dierwechter, MD, CS Philip Downer, MD, BOFC John Ebisu, MD, ESC Michelle Eden, MD, PES Alexis Falicov, MD, SOFC Gary Forster, MD, SOG Lawrence Fowler, MD, SOG Jonathan Franklin, MD, BOFC I. Edward Freimanis, MD, PES Robin Fuchs, MD, EOC K. Elizabeth Garr, MD, OPA Jeffrey Garr, MD, OPA V. Joyce Gauthier, MD, VOA Paul Gott, MD, SA James Green, MD, EOC Ralph Haller, MD, EBJ Daniel Hanesworth, MD, SIO Andrew Haputa, MD, SA Kurt Harmon, MD, SAE Kaya Hasanoglu, MD, VOA Todd Havener, MD, EBJ John Hendrickson, MD, VOA Lawrence Holland, MD, OPA Scott Hormel, MD, OPA Fredrick Huang, MD, VOA George Huang, MD, NWSS Allen Jackson, MD, NWOC Marion Johnson, MD, ESC W. Michael Johnson, MD, CS Thomas Jurich, MD, SAE Michael Kennelly, MD, SA E. Edward Khalfayan, MD, OPA Helen Kim, MD, PES Peter Kinahan, MD, EBJ Richard Kirby, MD, OPA Leonard Kolodychuk, MD, SIO Gregory Komenda, MD, NWOP Walter Krengel, MD, BOA Kenneth Leung, MD, OPA Timothy Locknane, MD, EOC Steven MacFarlane, MD, SAE Peter Mandt, MD, NWOP Martin Mankey, MD, OPA Jeff Mason, MD, EBJ Michael McAdam, MD, OPA Craig McAllister, MD, EOC John McCormick, MD, EOC James Mhyre, MD, ESC Patrick Moore, MD, NWSS Andres Munk, MD, EOC St. Elmo Newton III, MD, SOFC Gregory Norling, MD, EOC Edward North, MD, WHS Ashit Patel, MD, NWOP Alison Perrin, MD, NWSS Charles Peterson, MD, SOFC Charles Peterson II, MD, SOFC Brian Plaskon, MD, PES J. Scott Price, MD, EOC Terence Quigley, MD, NWSS Steven Ratcliffe, MD, NWOP Steven Reed, MD, WHS Jeffrey Remington, MD, SOG Mark Remington, MD, VOA James Robbins, MD, EOC John Robertson, MD, OPA Curtis Rodin, MD, SIO James Russo, MD, VOA Michael Sailer, MD, NWOP Vincent Santoro, MD, BOA James Schopp, MD, CS Todd Seidner, MD, OPA Richard Semon, MD, EBJ Joel Shapiro, MD, BOFC Michelle Sinnett, MD, SAE Jeffrey Stickney, MD, EOC Virginia Stowell, MD, CS Steven Sun, MD, WHS James Swenson, MD, EOC John Thayer, MD, NWOP Jason Thompson, MD, VOA Sean Toomey, MD, OPA E. Pepper Toomey, MD, OPA Michael Towbin, MD, ESC Martin Tullus, MD, VOA Robert Veith, MD, VOA J. Michael Watt, MD, BOFC Wayne Weil, MD, BOFC Loryn Weinstein, MD, WHS Clay Wertheimer, MD, EBJ Jay Williams, MD, OPA Richard Williamson, MD, SIO William Wilson, MD, SOFC Robert Winquist, MD, OPA Michael Zammit, MD, SAE Richard Zorn, MD, OPA 14 PROLIANCE SURGEONS OUTLOOK

15 Rainier Surgical Inc. Routinely stocking thousands of orthopedic products Distributor for Wright Medical Technology and BREG Representing most major manufacturers, in addition to several value-priced alternative product lines Our Solution Specialty Areas Include Orthopedic Implants and Biologics CPM Function Bracing Custom Cold Therapy Bone Stimulation Stock and Bill Programs for Clinics Physician Offices Emergency Rooms IDN Clinics Ambulatory Surgery Centers Third Party Billing th Street NW Auburn, WA (888) WA OR ID AK 15

16 surgery, the body is generally immobile static. The body s response to any injury is to increase its ability to clot hypercoagulability. Thus, surgical procedures are good models for inducing venous thrombosis, and the surgeon s goal is to allow blood to clot at the surgical site and prevent it from clotting in remote veins. Superficial Venous Thrombosis In Full Flow Reduce the Risk of Postoperative Venous Thrombosis By Terence M. Quigley, MD, FACS, Vascular Surgeon, Proliance Surgeons, Northwest Surgical Specialists Venous thrombosis (clot in vein) is at best an annoying problem that causes aching and swelling. At worst, it is a potentially fatal event resulting from a vein clot breaking off and traveling to the lungs (pulmonary embolism), making venous thrombosis an important topic for discussion and prevention. There is much medical and surgical literature devoted to venous thrombosis due to the potential serious consequences of clots in the leg or pelvic veins. An estimated 600,000 people per year die with pulmonary embolus listed as either causative or contributing to their deaths. The following paragraphs briefly explain the problems associated with postoperative venous thrombosis, primarily deep venous thrombosis (DVT), identify those patients at risk, and describe various treatments and procedures that can reduce the incidence of postoperative venous thrombosis. It is important to note the word reduce. Regardless of preventative measures, there is always a risk of venous thrombosis. The goal is to keep that risk as low as possible without compromising the results of the surgical procedure. Veins are thin-walled blood vessels that carry unoxygenated blood to the heart through the lungs. (Arteries are thicker, muscular vessels that carry blood to various parts of the body away from the heart.) The deep veins of the body lie next to the major arteries and are not visible. The superficial veins lie just under the skin and are easily visible on the back of the hands or top of the feet, among other places. The superficial veins connect to the deep veins, and both types of veins have one-way valves allowing blood to return to the lungs and restricting backflow or pooling. The great 19th-century pathologist Rudolph Virchow described the classic triad of conditions allowing for vein clotting injury, stasis, and hypercoagulability. A surgical procedure is a controlled injury. During Superficial thrombosis is the formation of a clot(s) in the superficial veins. This occasionally results from the placement of an intravenous (IV) catheter to deliver fluids and medications. The symptoms typically include a painful red lump near the IV site. Superficial venous thrombosis is an annoying problem, but with the application of heat and anti-inflammatory medication, the swelling and pain gradually improve although it may take a few weeks. Superficial venous thrombosis does not result in clots that can travel to the lungs and is not a dangerous problem unless the clotting progresses into the deep veins. Deep Venous Thrombosis DVT is a potentially serious problem because of the risk for pulmonary embolism, which essentially blocks the blood supply to part of the lung, preventing re-oxygenation of the blood and resulting in total body oxygen lack or, in the most severe circumstances, death. DVT most commonly occurs in the veins of the legs or pelvis. Pelvic vein clotting may occur without symptoms unless the entire vein is blocked, in which case the leg(s) will swell significantly. Leg vein clotting Quick Fact Deep vein thrombosis resulting in pulmonary embolism is one of the leading causes of preventable in-hospital mortality in the United States, making risk reduction of utmost importance to health care providers. 16 PROLIANCE SURGEONS OUTLOOK

17 Anterior view of the major veins in the pelvic and leg regions generally causes an aching pain, leg swelling, and, occasionally, a redpurple skin hue. Once DVT has occurred, the treatment is with IV heparin, a medication that prevents blood clotting, and coumadin, an oral medication that also prevents blood clotting. To some extent, the body gradually dissolves most clots over time, but some patients have permanent leg swelling and achiness a condition known as postphlebetic syndrome. DVT is a potentially serious problem because of the risk for pulmonary embolism, which essentially blocks the blood supply to part of the lung, preventing reoxygenation of the blood and resulting in total body oxygen lack or, in the most severe circumstances, death. Some surgical procedures are more likely to result in DVT, and some patients are more prone to DVT. Surgical procedures that last more than an hour, require the patient s legs to sit in stirrups (gynecologic, urologic, orthopedic, and colorectal procedures), or require manipulation of the veins (some orthopedic, back, and vascular procedures) have increased incidences of postoperative venous thrombosis. Patients who are older than 40 years of age, are obese, use tobacco, have cancer, are taking certain medications, have an identified clotting abnormality, or have a previous history of vein clotting are at a higher risk for postoperative venous thrombosis. If the patient or the planned surgical procedure falls into any of the categories mentioned above, particular attention is directed to try and prevent venous thrombosis. Preventing Postoperative Venous Thrombosis Postoperative venous thrombosis is not completely preventable, but the incidence can be significantly reduced. The routine use of intermittent compression of the legs with either calf or foot pumps during and after an operation has shown to reduce postoperative DVT. Placing compression stockings on the patient s legs and having him or her get out of bed early and often is also helpful, although this may not be possible depending on the procedure and patient. Administering anticoagulants before, during, and/or after the surgical procedure (such as aspirin, heparin, or coumadin) in low doses has also shown to reduce the incidence of postoperative DVT. The timing and dosages of the various blood thinners and types of surgical procedures to which these measures may apply are still under discussion at medical meetings and are the ongoing subjects of much research. Your surgeon can discuss the specifics as they relate to your individual case, but keep in mind that there is no exact right way to approach this issue. In conclusion, postoperative venous thrombosis is a potentially serious problem for which various preventative measures are available. Surgeons assess patients individual circumstances regarding these preventative measures, recognizing that in preventing clot formation, postoperative bleeding is also a potentially serious problem. Patients can act proactively by avoiding tobacco products, keeping their legs moving, and following their physicians advice regarding activity and positioning. Patients should also make sure to tell their surgeons whether they or any family members have had problems with vein clotting. 17

18 Bringing Images to Life PET-CT Gives Insight into Diagnosis, Treatment Options Lung cancer staging showing the primary tumor Diagnostic radiology has come a long way since x-rays were invented in Today s diagnostic radiologists play a central role in health care. With computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET), radiologists can look inside the body and diagnose many diseases without invasive tests or surgery. If a biopsy or surgery is needed, however, the radiologist can guide the surgeon to the affected part of the body. One of the newest radiology procedures is called fusion imaging, the result of marrying PET and CT (PET- CT). CT, a process patented in 1975, uses x-rays to make clear, cross-sectional pictures of the body s anatomy, precisely locating abnormal masses that may represent cancer. PET uses a special sugar solution (FDG) injected into the body to highlight the cancer, creating a metabolic map of the body. A computer combines these images to provide the radiologist with both the anatomy and metabolism of normal organs and cancerous tumors. A relatively new diagnostic tool, PET- CT was named the Invention of the Year by Time magazine in Aiding in Disease Detection According to Lloyd Stambaugh, MD, Medical Director of Evergreen Radia Imaging, Combining CT and PET allows for earlier and more accurate detection of disease, particularly for cancers of the lung, colon, lymph nodes, and neck. PET-CT Combining CT and PET allows for earlier and more accurate detection of disease, particularly for cancers of the lung, colon, lymph nodes, and neck. Lloyd Stambaugh, MD, Medical Director of Evergreen Radia Imaging can show the size of a tumor and how far the cancer has spread, helping the physician and patient decide which treatment option would prove most beneficial. In addition, once therapy has begun, PET-CT can measure tumor shrinkage and the patient s response to treatment and guide the physician in modifying or continuing the treatment. Recently, PET-CT has proven successful in distinguishing Alzheimer s disease from other dementia earlier than physical and neurological assessments. Patients with memory loss or symptoms of abnormal brain functioning can obtain an accurate diagnosis of Alzheimer s disease, enabling them to access new drugs that are proving highly effective in slowing the course of this disabling disease. Enhancing Quality of Life Additionally, the U.S. Centers for Medicare and Medicaid Services has already expanded Medicare coverage of PET to evaluate for Alzheimer s disease. This decision will enhance the quality of life for many patients and their families by helping the medical community obtain earlier diagnoses, says Stambaugh. We re excited to offer PET-CT at Evergreen Radia and to work with physicians throughout the Puget Sound in advancing its unique capabilities to provide image fusion for diagnosis and therapy planning. Information and images courtesy Radia (www.radia.net) Lung cancer staging showing the abnormal lymph nodes 18 PROLIANCE SURGEONS OUTLOOK

19 Ambulatory Care Distribution Serving your physician offices, surgery centers and other sites of care. Working together for life. TM 19

20 Reducing Documentation Costs Local Clinics Integrate Technology and Transcription By Ellen Russell Increasing regulatory and financial pressures are causing many clinics to scrutinize their cost for documentation, particularly the cost of transcription. Despite the dizzying array of vendors offering voice-recognition, templatebased programs, and other tools to ease transcription costs, many clinics simply don t know where to turn. There are more claims of an easy solution than I can possibly track mostly from vendors I ve never heard of, says Sandy Ziegler, Manager of two Proliance clinics. And they almost always require a significant investment. PAID ADVERTISEMENT Ziegler is not alone; the landscape is baffling for many. In a recent Internet search, Google found more than two million possibilities for medical transcription and more than 40,000 for voice-recognition vendors. The results are not surprising considering more than $16 billion is spent per year in the U.S. alone for medical transcriptions, according to the Medical Transcription Industry Association. In addition to saving money, the integration, effective implementation, and ongoing support are key for us.that s why we selected Pro-Scribe as a partner. Dave Fitzgerald, CEO, Proliance Surgeons However, many of the so-called solutions don t integrate with existing practice-management systems, requiring stand-alone implementation and unique ongoing support, actually requiring additional steps and costs for managers and physicians. Serving local clinics since 1990, Pro- Scribe embarked on a major technologyimplementation program in We digitized workflow and mastered integration with our clients practice- management systems and electronic medical records (EMR). Now we are unrolling automatic, electronic-document distribution, says Jonathan Solomon, Co-Owner and Vice President of Engineering at Pro-Scribe. Solomon is especially expectant about Pro-Scribe s development work with tablet PCs and template systems, including the incorporation of voicerecognition technology. We strive for innovative solutions that streamline documentation processes for doctors and reduce the total cost for clinics. Employing local transcriptionists and building tools for precise and efficient document processing makes Pro- Scribe s approach unique. Our lower costs result from the reduction in labor required to create and manage documents not from outsourcing to the cheapest labor. We are proud to say transcribed in America, says Tom Albro, Co-Owner and President of Pro- Scribe. Our transcriptionists are the best in the business and a large factor in our growth and success. For more information about Pro-Scribe, Ellen Russell at or call her at (206) PROLIANCE SURGEONS OUTLOOK

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