Though spine surgery can be beneficial for people suffering from radiating leg pain caused by a herniated disc, the standard treatment, a microdiscectomy, often leaves patients with recurrent pain. Now, spine surgeons at Twin Cities Orthopedics (TCO) have introduced a new procedure — the annular disc repair, which is reducing patients’ time in the operating room and the chance of reherniation.

Typically, a microdiscectomy was performed to alleviate radiating leg pain. The surgery involved removing the portion of the disc that was applying pressure to the nerves. This procedure required the surgeon to make an incision in the annulus fibrosus, the outer layer of the disc, to access the nucleus pulposis, the herniated tissue. In other cases, a tear in the annulus allowed surgeons easy access to the herniated tissue. However, previously there has been no easy method to close the anulus following the removal of the tissue. Therefore, surgeons commonly left the anulus to heal on its own, which increased the risk of a recurrent herniation.

Many patients found relief with this procedure, but for others, the disc could reherniate through the annulus opening, resulting in the recurrence of pain and requiring additional surgery. Statistics show approximately 30 percent of patients have pain following a lumbar discectomy, and an estimated 15 percent of patients require a re-operation.

But now, with annular disc repair, the procedure provides a new method for treating the compromised tissue of the anulus fibrosus following a discectomy procedure. This innovative treatment is being performed by TCO spine surgeons, John Sherman, MD; David Holte, MD; and Jeffery Dick, MD. After removing the offending portion of the disc, the surgeons are able to re-approximate the soft tissue to facilitate the healing process of the anulus fibrosus. The device designed to re-approximate the soft tissue is the Xclose Tissue Repair System, developed by Anulex Technologies, Inc. For larger defects, a patch is also available, named Inclose.

“This makes a lot of sense,” Dr. Sherman said. “Previously, we have not had a reliable method of closing the anulus of the disc and when it is not repaired, the material inside may re-extrude, compress the nerve root, and result in recurrent pain and re-operation.”

“This annular disc repair procedure adds minimal time to the overall procedure and is easily completed,” Dr. Holte said. After the discectomy, the spine surgeons use the Xclose Tissue Repair System to re-approximate the soft tissue to facilitate the healing process. The surgery is typically done on an outpatient basis. With successful repair of the annulus, the patients can begin rehabilitation and resume their normal activities sooner.

The TCO spine surgeons were the first surgeons to introduce this procedure in Minnesota, and the procedure now is being performed at Fairview Southdale Hospital, Methodist Hospital, and the Centennial Lakes Surgery Center in Edina. For more information about this procedure, please call the Twin Cites Orthopedics’ Centennial Lakes Center at (952) 832-0076 or visit www.tcomn.com.

One in six Americans has some sort of foot disorder, and more than a third find the problem serious enough to see a doctor. You might be surprised to learn one of the major culprits is improper footwear. Many common aches and pains can be prevented or even corrected with a little extra care when shopping.

It’s no secret that wearing poorly fitting shoes or improper footwear for a particular sport can seriously damage your feet, causing painful bunions, corns, calluses, hammertoes, and other distressing maladies. It’s estimated that the cost of foot surgery to correct problems from tight fitting shoes is $2 billion a year or $3.5 billion, if you include time off from work for the surgery and recovery.

Who is at risk?
A woman’s risk of foot injury is a good deal higher than a man’s — and may increase with the heel height and tightness of her shoes. A study conducted by the American Orthopaedic Foot & Ankle Society found women are nine times more likely to develop a foot problem because of improperly fitting shoes than men. The report notes that nine out of 10 women wear shoes that are too small for their feet, eight out of 10 women say their shoes are painful, and more than seven out of 10 women have developed a bunion, hammertoe, or other painful foot deformity. Nine out of 10 women attribute their foot deformities to tight shoes, according to research.

The American Academy of Orthopaedic Surgeons recommends that women do not wear shoes with heels higher than 2 1/4 inches. They also recommend avoiding high-heeled shoes with pointed, narrow toe boxes that crowd the toes and force them into an unnatural,triangular shape. As heel height increases, the weight on the ball of the foot may double, placing greater pressure on the forefoot as it is forced into the pointed toe box.

Those individuals who participate in sports should keep in mind that proper-fitting sports shoes can enhance performance and prevent injuries. Shin splints — pain in the front of the tibia — is one injury typically caused by excess stress from over training, changing to a hard running surface, or wearing poorly fitting athletic shoes. If not taken care of, this injury can progress into a stress fracture, which is a more painful and debilitating injury.

Shoe Shopping Guidelines

There are many things to consider when choosing the best-suited shoes for fit and the circumstance:

• Have both feet measured every time you purchase shoes. Your foot size increases as you get older.
• Try on new shoes at the end of the day. Your feet normally swell and become larger after standing or sitting during the day.
• Make sure your shoes are fitted to your heel and your toes. Try on both shoes, and make sure there is a half-inch space from the end of your longest toe to the front of each shoe.
• If one of your feet is considerably larger than the other, add an insole to the shoe on the smaller foot.
• When the shoe is on your foot, you should be able to wiggle all toes freely. If the shoes feel too tight, don’t buy them. There is no such thing as a “break-in” period.
• If you participate in a sport three or more times a week, you need a sports- specific shoe.

Follow these fitting suggestions when purchasing athletic shoes:

• Try on athletic shoes after a workout at the end of the day. Your feet will be at their largest.
• Wear the same type of sock you wear for that sport.
• When the shoe is on your foot, you should be able to wiggle all toes freely.
• The shoes should be comfortable as soon as you try them on. Again, there is no break-in period.
• Walk or run a few steps in your shoes. They should be comfortable.
• Always re-lace the shoes you are trying on. Begin at the farthest eyelets and apply even pressure in a crisscross lacing pattern to the top of the shoe.
• If you have foot orthotics, make sure you have them in the shoes you are trying on; they will dramatically alter the fit of your shoe.

Walk the walk
If you’re already experiencing regular foot or ankle pain, your doctor or therapist may recommend any of a variety of effective treatments. Most injuries are initially treated with the RICE method — rest, ice, compression, and elevation. Moderate and severe injuries often require some form of immobilization or protection with either a cast or splint. Strengthening exercises may be recommended in some cases, while other conditions may require surgery.

While there is no sure way to prevent all injuries, risk can significantly be reduced by participating in a conditioning program to build muscle strength (make sure to warm up before taking part in a sport or exercise program), improving agility (exercises that help improve your balance), performing stretching exercises to maintain range of motion specific to your activity, listening to your body (never run if you experience pain in the foot or ankle, for instance), replacing athletic shoes as soon as the tread or heel wears out, and wearing properly fitting athletic, dress, and casual shoes.

In the case of joint replacement surgery, the TCO staff has worked closely with the staff at the Ridgeview Medical Center, Center for Joint Replacement; the Joint Center at North Memorial Medical Hospital; and the Joint Replacement Center at Abbott Northwestern Hospital to develop an educational and therapeutic experience for patients that has proved to improve both patient outcomes and patient satisfaction.

The group experience
The experience begins with a pre-operative educational session filled with as little as four or as many as 20 patients; most of whom will also participate together in group physical therapy sessions following surgery.

While attending the pre-operative educational session, patients are given educational reference guides filled with answers to common questions such as: What does my new joint replacement look like? When will I be able to walk again? When will the pain go away? Sessions are guided by occupational and physical therapists who are also available to help answer additional questions and calm anxieties.

Patients are encouraged to bring a friend or family member to act as a coach. “We encourage the coach to come to all of the hospital visits including the pre-operative educational session, the therapy sessions, and the nursing education sessions,” said Katie Trent, a physical therapist and program coordinator at Ridgeview Medical Center,Center for Joint Replacement. “There is so much going on, it is helpful for the patient to have someone listening and learning with them. It also makes everyone more confident when it’s time to go home.”

Joint Replacement Education Program

In addition to Ridgeview Medical Center, North Memorial Medical Center and Abbott Northwestern Hospital, TCO physicians have also worked with the staff at Fairview Southdale Hospital to develop the Total Joint Replacement Education Program. This comprehensive and popular class prepares patients and their families for surgery, their hospital stay, rehabilitation, and long-range goals that might include returning to an active lifestyle.

“Our patients love the education they receive,” said Deb Smith, RN, a clinical nurse/educator at Fairview Southdale Hospital. “In fact, one total knee replacement patient comes to the class every Monday to tell others who are contemplating joint replacement how valuable the information is and how happy he is with his outcome.”

Pre- and postoperative physical therapy
Patients at Ridgeview Medical Center, North Memorial Medical Center, and Abbott Northwestern Hospital are encouraged to participate in a pre-operative physical therapy session. Exercise participation prior to total joint arthroplasty dramatically reduces the odds of requiring transfer to a swing bed or another inpatient facility, according to research noted in Arthritis & Rheumatism, the official monthly journal of the American College of Rheumatology.

Patients also participate in postoperative group physical therapy sessions prior to being discharged. Group physical therapy sessions give patients extra motivation and allow opportunity for greater support as they begin their road to recovery. Targeted postoperative care has resulted in more patients being discharged directly home after hip or knee arthroplasty, as indicated in research that appears in the Archives of Physical Medicine and Rehabilitation.

The results
Ridgeview Medical Center began offering this group approach to education and therapy when it opened its Center for Joint Replacement in April 2007.

“Prior to opening the Center for Joint Replacement, 65 percent of our patients went home after surgery and 35 percent required nursing home care,” Trent said. “Now, only 20 percent of patients are discharged to a nursing home and 80 percent return home.”

In addition to the improvement of discharge status, the average hospital stay following joint replacement has decreased from 3.8 days to 3.15 days. In 2007, the center achieved a zero percent infection rate for all knee replacement surgeries and a 0.77 percent infection rate on all hip replacement surgeries. At North Memorial Medical Center, the improvements are similar. “The results of our program have been amazing,” said Chuck Lister, program coordinator at the Joint Center at North Memorial Medical Hospital. Since starting the program, the North Memorial Joint Replacement Center has seen a zero percent infection rate and the average hospital stays have decrease from 3.5 days to 3.1 days.

Abbott Northwestern Hospital is just starting their Joint Replacement Center but they are optimistic they will have similar results.

In addition to outcome statistics, patients are also more satisfied with the care they receive. “Today’s patient wants to take an active role in the treatment and recovery process,” Lister said. “Since implementing joint replacement classes, patients have been more satisfied with their ability to be involved and expedite the recovery process.”

Constant improvement

While the results of improvement in patient education and pre- and post-operative physical therapy have helped improve patient recovery and patient satisfaction, TCO and the hospitals it is affiliated with are continuously researching and looking for new ways to improve care.

For more information about TCO physicians, locations, and services offered, visit www.tcomn.com.

With 30 locations in the greater Minneapolis area and more than 79 highly trained physicians, TCO is the largest, most comprehensive and prestigious orthopedic practice in Minnesota and the Midwest, and is one of the largest in the United States. The practice provides conservative, top-quality care and research and uses state-of-the-art technology and procedures to help return each patient to an active, pain-free lifestyle.

TCO was formed between 1996 and 2003 when five orthopedic practices, each of which began nearly 60 years ago, combined. TCO has three goals: 1) To provide worldclass, compassionate care to individuals of all ages with musculoskeletal injuries and conditions; 2) improve the musculoskeletal health of our communities through research and education; and 3) be the orthopedic provider and employer of choice for Twin Cities residents.

New Physicians
Joining the practice in 2008 are Jay Johnson, MD, Christie Heikes, MD, and Erik Wetter, MD. Dr. Wetter specializes in general orthopedics and sports medicine, while Dr. Heikes’ emphasis is in women’s orthopedics and sports medicine. The addition of Dr. Heikes will be of particular benefit to those who prefer to be seen by a female physician. Dr. Johnson, who has been practicing in the Twin Cities for several years, specializes in total joints and general orthopedics.

Additional locations
TCO also is in the midst of an ambitious expansion program in the following locations:

Maple Grove: To meet the demands of a growing market (with a 90-bed hospital that is expected to open its doors in February 2009), TCO has opened a full-service clinic that includes physical therapy, orthotics and prosthetics.

Waconia: TCO is expanding its presence in the Waconia market by providing physical therapy, orthotics, and prosthetics programs and by adding a spine specialist and MedX, a back pain rehabilitation program. The
goal of MedX is to strengthen the back using preventive-type medicine to help the patient avoid undergoing invasive spinal surgery. The new Waconia location has additional space to accommodate the possibility of adding future orthopedic surgeons.

Coon Rapids and Burnsville: Expansions similar to Waconia have already taken place in these two communities. In Coon Rapids, one of TCO’s two offices has moved into a larger building that also houses a clinic, a physical therapy center, magnetic resonance imaging (MRI), and MedX. In Burnsville, the new building houses a surgery center, physical and hand therapy centers, an MRI, and orthotics and prosthetics services.

Edina: With a long-standing presence of four sites in this city, TCO plans to consolidate them into one orthopedic “Center of Excellence” during the next two years, said Troy Simonson, TCO administrator. To enhance the continuity of care for patients it will include every orthopedic specialty and sub-specialty at one convenient location. Plans for the Edina center also include a surgery center, physical therapy, hand therapy, MRI, orthotics, prosthetics, and MedX. Once the center is complete, patients will be able to have all their orthopedic needs met at one central location housing as many as 30 physicians. “We’ve been there (Edina) for many years, but we’ve been fragmented,” Simonson said. “Now, we’re looking to provide improved customer service to our patients and provide those services more efficiently.”

The common goal driving much of the expansion is improving patient satisfaction. “For example, to improve the convenience and continuity of care we are striving to provide the full spectrum of orthopedic care patients desire at one convenient location,” Simonson said.

Patient satisfaction
To better gauge patient service, TCO has begun a patient satisfaction campaign. Patients were asked to complete questionnaires and, to date, more than 1,600 responses have been obtained. Survey feedback indicates that 96 percent of patients either agreed or strongly agreed that “I would rate my overall care at TCO as excellent.” On a second question — “Was staff helpful, courteous and did staff treat me respectfully?” — 97 percent either agreed or strongly agreed. “We are looking to gather this data continually,” Simonson said. “We are constantly going to measure and maintain that high level of service.”