Other Articles

AAOS Political Action Committee
Active players in the orthopedic field know the importance of the AAOS Political Action Committee (PAC). On the cusp of hot topics affecting physicians and patients, the AAOS PAC works diligently to provide data to members of Congress and improve the present and future of orthopedics.

Who ARE These Guys?
Every 60 seconds or so a surgeon tears the cover off an Integra LifeSciences package. Quietly, this company has become the seventh largest medical implant manufacturer serving orthopedic surgeons in the world. Where to now? Would you believe $1 billion in two years? How about $2 billion by 2015?

Redemption in a Mechanism of Failure: The TOPS™ Story
Impliant’s TOPS™ System had a “squeaker” in its clinical study. After a voluntary suspension of the study by the company and finding the mechanism of failure, the FDA has approved a resumption of the study. What insider lessons were learned? Class starts here.

Who is Numero Uno in the PearlDiver Database!! Are You Surprised?
The answer may surprise you. Is it sore backs, aching hips, sore knees, fingers? PearlDiver details 3.8 million spine related complaints—complete with demographic information and charging information. But that’s not #1. PearlDiver also lists 3.5 million large joint complaints. Sorry, still not #1. What could the most common orthopedic complaint possibly be? To get the surprising answer…read on.

What the Knees Need: Baby Boomers and Their Options
Knee patients often show up at the doctor’s office with recurrent mechanical symptoms. It is up to the orthopedist, says Dr. Giles R. Scuderi, Director and orthopedic surgeon with the Insall, Scott & Kelly Institute in Manhattan, to thoroughly assess the patient and then determine if nonoperative treatment will do, or if the person needs a unicompartmental or total knee procedure.

Physician: Report Thyself
The government says its healthcare anti-fraud efforts are working and it wants to encourage physicians to self-report possible fraud. How well did the government do in 2007 and what about those deferred-prosecution deals with undisclosed evidence? Read about it here.

Revising the Statistics
The word that orthopedic patients least want to hear is “revision.” Who, in the universe of large joint patients, do we expect to see on the receiving end of this news? If you guessed “the elderly” you would have been wrong. The reality of who is hearing “revision” may come as a surprise. Read what we found when probing PearlDiver’s database.

Where Is Ben Now? Trends in Venture Capital
What is being funded by VCs and why? First of all, spine is having to share the spotlight, says Gary Stevenson, Managing Partner at MB Venture Partners, LLC. Here Stevenson outlines what constitutes an attractive investment…he also highlights issues that are affecting the distribution of VC funding.

The Hounds of Wall Street
Conventional wisdom on Wall Street is that ArthroCare is in a bare-knuckle fight to the finish with short sellers. Which leaves us with the dominating question: If ArthroCare is essentially a “lame duck” growth stock, then why are sales, earnings, and the stock price contradicting the short seller’s dire predictions and even outperforming consensus analyst forecasts? We have the answer.

The Era of “Tell Me Right Now” Dawns at FDA
The FDA wants the next phase of post-market oversight to change from self reporting to proactive surveillance. How? Through the Sentinel Initiative. Read what it means to device manufacturers here.

The Day After Tomorrow: Complication Rates and Instrumentation Trends in Posterior Lumbar Fusion
Could PearlDiver be the Nostradamus of spinal instrumentation? This most commonly performed surgery on the lumbar region of the spine increases fusion rates and improves spinal stability—but what about complications? Using PearlDiver’s database we find the answers. Are you ready for some quatrains about what happens next?

You Try It. No You Try It First: New Technology Adoption
What are the forces working for and against new technology adoption? Youth versus age, risk taking versus conservatism, and the economic realities of the day, says Dr. Rick Guyer, President of the Texas Back Institute.

Cheaper, Thinner, Faster, Stronger
In this, the second of our series of three articles on innovation, we tackle the question: How do you measure medical technology innovation? While difficult, measuring innovation is NOT impossible. Why? Well to start, and in the immortal words of Supreme Court Justice Potter Stewart, “We know it when we see it.”

SAS Crosses the Rubicon in Miami Beach
The SAS 8th Annual Global Symposium in Miami Beach may have crossed the Rubicon. How? Read about the Society’s opportunities for growth and collaboration as its new President lays out a vision for the future.

Arthroscopic Treatment for Tennis Elbow: Coming on Strong
“Tennis elbow” or lateral epicondylitis is, according to our PearlDiver database, one of the most reported diagnosis for problems with the elbow. Lately clinical evidence has shown that arthroscopic treatment for tennis elbow can provide long-term stability and, in most cases, return of the elbow to its optimal function. Check out the data from PearlDiver.

Do Republicans Make Better Orthopedic Surgeons?
A recent Nature Neuroscience journal study of the decision making differences between liberals and conservatives appears to argue in favor of Republican surgeons! Which, frankly, explains a lot—to BOTH sides and, to stretch an analogy almost to its breaking point, it may also explain why McCain’s health care plan is different from Obama’s. Read OUR take here.

"Sound of Music" Turns to Greek Tragedy for Smith & Nephew
Smith & Nephew’s Swiss (mis)adventure with Plus Orthopaedics is turning into a Greek Tragedy. The company’s whole acquisition strategy is being called into question. Read how CEO Illingworth explained it to the brutal British press.

“Dear John Letter” for Hip Resurfacing?
“Dear John H. Resurfacing: I hope this little note finds you well. We certainly have had some great times and, gosh, I’ll never forget those wonderful moments when the FDA approved your PMA. We’ve just celebrated our second anniversary together and, well, I’m just not feeling the magic anymore….” Two years after FDA approval, how happy are orthopedists with hip resurfacing? Read our analysis here.

In the Beginning, There Was the End: Manuscripts 101
Dr. Paul Manske, Professor of Orthopaedic Surgery at Washington University School of Medicine in St. Louis and Editor-in-Chief of The Journal of Hand Surgery, shares his thoughts and experience on the details of shepherding a manuscript through publication.

Did ConMed Get Re-Wired?
Ever hear about the neurosurgeon who used an $80 Bosch power drill to do brain surgery? It really happened. Surgeons like their power tools. Increasingly they also like a particular line of sterilizeable power tools from ConMed’s Linvatec unit. Did ConMed get re-wired? We have the details here.

Thanks to Dr. Evan Flatow, shoulder surgeon and Chair of the Department of Orthopaedic Surgery at Mount Sinai Medical Center, more New Yorkers can comfortably express themselves with body language. (Think of the multiple meanings of a shoulder shrug.)

A die-hard New Yorker, Dr. Flatow lives two blocks from where he was born and has made an exciting life in “the city.” Evan Flatow: “I was raised in a very intellectually stimulating environment. My mother was in the public eye quite a bit as a politician and urban planner. My father was a professor of mathematics and my grandfather, a banker, wanted me to develop a career in business. Through my friend’s father, a rheumatologist, I was exposed to the world of medicine. I have always had a penchant for science and since the age of six have known that I wanted to become a physician. And yes, even though I’ve been all around the world, for me, the center of the universe is New York City.”

Before embarking on a journey through scapulas and clavicles, however, Dr. Flatow would spend time journeying through history and philosophy. “Despite knowing that I would enter the medical field,” says Dr. Flatow, “I used a significant part of my undergraduate time at Princeton to study the offerings of history and philosophy. I will never regret this decision as it widened my worldview and routinely informs my daily life. In 1977 I began medical school at Columbia College of Physicians and Surgeons and developed an interest in orthopedics. Influencing me during my medical school years was Dr. Ashby Grantham, a very erudite professor who showed me the intellectual side of orthopedics. The picture of an old-school professor, Dr. Grantham smoked a pipe and would lecture for four solid hours. Then there was Dr. Howard Kiernan, a superlative knee surgeon who taught me the humanistic side of orthopedics. I recall Howard seeing a patient with prostate cancer, normally a situation where an orthopedist might not have much to say. But Howard spent about 30 minutes talking with him about things such as the stress his illness put on his marriage. I try to follow in his footsteps and give patients the same kind of time and empathy; once you’ve seen excellence it is hard to let it go.”

Going forward Dr. Flatow would encounter excellence at every turn. “In 1981 I began an internship at St. Luke’s-Roosevelt Hospital Center, followed by a year of residency at the same institution. It was a popular place to learn surgery, which was understandable given the quality of the instructors. Dr. Andrew Patterson, the Chief of Orthopedics, was a legendary teacher who was like a father to his charges. If you made a mistake he was personally disappointed. If you missed something on an X-ray he would look at you and shake his head. It was enough to make us work extra hard. A humble man, Dr. Patterson spent as much time with his clinic patients as he did with those from Park Avenue. I also learned quite a bit from Dr. Bill Hamilton, a famous foot and ankle surgeon who works with all the major ballet companies in New York City. He gave me tremendous insight into how to care for patients and is probably the smartest orthopedist I’ve ever known.”

Equipped with additional surgical skills, Dr. Flatow would now hone his processes and learn the beauty of being thorough...and he would learn from a superstar craftsman. “When I did my orthopedic residency at Columbia-Presbyterian Medical Center, Hal Dick was the Chair, with Frank Stinchfield as Emeritus Chair and Bob Carroll as Chief of Hand Surgery. I was so fortunate that Charlie Neer, the father of modern shoulder surgery, was my mentor. I guess you could say that I fell under his spell. Dr. Neer was the most famous shoulder surgeon in the world, and patients, including royalty and movie stars, flew in from all over to see him. He was an amazing leader who taught us to do whatever it took to get a great result. Dr. Neer would spend hours with a patient and made sure that we, his trainees, understood that we were violin makers, not carpenters. Orthopedics is one of the last feudal guilds where one learns directly at the hand of the masters. Under his tutelage I learned to pay close attention to patients, and to listen and learn. Dr. Neer often quoted his old chief from when he was in the military, who said, ‘Don’t brag about how quickly you fixed a hip—brag about how well the patient walks.’”

Inspired by the high levels of excellence at Columbia, Dr. Flatow remained on faculty there from 1987 until 1998. “It was at Columbia that I began my research, teaching, and practice career. I worked with Van Mow, the Chair of Biomedical Engineering, along with Lou Bigliani and Charlie Neer. Most of my research has been in the basic science arena where I’ve studied rotator cuff tendon damage. Dr. Mow and I used cadavers and studied the way the rotator cuff moves and gets contacted in the shoulder. Using stereophotogrammetry we projected a grid onto tissue and then took pictures from two angles with a computer doing 3D mapping. Then we articulated a joint with similar muscle forces, mapped all the surfaces, and could tell which parts were squeezed together. With Lou Bigliani I did a study of shoulder mechanics and rotator cuff contact where we found that the rotator cuff could be compressed in an area where it often tears, and that this could explain tendon damage. We also looked at how the tendon gets stretched by putting load on tissues in cadavers and using optical systems of measurement. It’s like looking at Silly Putty getting pulled and watching how as you pull, the picture gets stretched and changed.”

In 1998 Dr. Flatow himself would learn what it’s like to be pulled in different directions. “Despite the myriad of responsibilities involved, I very much wanted my own service,” says Evan Flatow. “In 1998 Dempsey Springfield, a well-known tumor surgeon, called and asked me to establish a shoulder service at Mount Sinai. I thought it would be fun because he was the new Chair and I was coming from a familiar, established department to set up an untested department. While a bit scary, it was also exciting. It was then that I learned the value of investing in quality talent. I hired a skilled junior partner, Brad Parsons, and we sent him to train with Gerry Williams and Matt Ramsey at the University of Pennsylvania. Following that I sent him to Europe, Harvard, and the Mayo Clinic.”

Along with his junior partner and others, Dr. Flatow set about laying the foundations for a new laboratory. “Much of my work has involved understanding tendon tears. I have used a rat model to examine injuries in the infrapatellar tendon. This work is important given that tendon tears occur in approximately one-third of the population. It’s not well understood why they fail, so we are trying to look at the biology, mechanics, and histology of early tissue damage. Working under an R01 grant I secured from the NIH, we found that very early on if you take a living rat and pull the tissue you can image it. My postdoc, David Fung, developed a technique where we used a laser beam to look inside the tissue and were able to see the first evidence of tissue damage. You could see how certain fibers get overstretched. It was startling to see that when we looked at the molecular biology, the RNA expression, we found a profile that is totally different from laceration. If you cut healthy tissue you get a different biological response. In the past we modeled tears by cutting, but rotator cuff tears are common in patients in their 40s, 50s, and 60s and are associated with tendon damage. Thus I thought that cutting healthy tissue would be a poor model. We also found that early tissue damage didn’t heal quickly, making us think that this is how damage accumulates over time.”

Dr. Flatow, who has also been awarded career development and prospective clinical grants from the Orthopaedic Research and Education Foundation, has found that his basic science research has been very relevant to his clinical work. “Both have been in the area of tendon damage,” says Dr. Flatow. “At Columbia I collaborated with a research group on the study of rotator cuff outcomes. We did a cost-benefit analysis of rotator cuff repair and found that it was more cost-efficient than other procedures, including heart surgery. I have continued such work at Mount Sinai where I have looked at new technology for rotator cuff arthroscopic repair, comparing open and arthroscopic repair. I am proud to say that this work won the Neer Award from the American Shoulder and Elbow Surgeons. It is very fulfilling to see that all of my research can be brought to bear on the problems and concerns of my patients.”

Not one to miss out on the latest in orthopedics, Dr. Flatow spends part of his lab time on the minimally invasive world. “I am investigating the MI treatment of shoulder fractures and working to improve the technique of percutaneous fixation of fractures. I collaborated with researchers from the University of Pennsylvania and Washington University in St. Louis on a related study; we presented our results last year. While the findings are positive and the patients achieved good motion, we have to follow them for two or three years because we’re dealing with avascular necrosis.”

Years ago, the 6-year-old with the little black bag didn’t know that one day he would have a shoulder named after him. Says Dr. Flatow, “Lou Bigliani and I designed a shoulder replacement system that is used the world over. Manufactured by Zimmer, the Bigliani/Flatow® Shoulder includes innovative features such as precise and reproducible instruments. Our goal was to design something that can be used not only by shoulder experts but by the surgeon who does shoulder replacements only occasionally. We set out to do this because research shows that most shoulder replacements are in fact done by people who do only a few a year.”

Acknowledging the unusual nature of his work, Dr. Flatow notes, “Shoulder work is particularly fun because it is not as recognized a specialty. In some hospitals sports medicine people do shoulders, in some hospitals fractures are done by trauma experts. In rheumatoid hospitals where you have arthritis patients, large joint specialists do hips, knees, and shoulders. That is just fine as you have to go with the needs of the hospital. Shoulder work is fun and stimulating because you work with all types of patients: children, athletes, the elderly, and people who do all types of jobs. I love the variety.”

As for the future of his work, Dr. Flatow projects, “From basic science research we can develop biologic and genetic healing therapies. Ten years from now we will have gene therapies and growth factors which will enable us to grow tendons in the lab. It will be artificial, but living, tissue. We’ll be able to grow it in a rat or test tube and use it to repair tendons.”

On occasion and under duress, Dr. Flatow finds a bit of time away from the lab rats and the rat race. ”I never leave the city voluntarily…my wife has to drag me to the Long Island beach every summer. The family goes in June and returns on Labor Day, and I commute back and forth during that time. These summer excursions do give me a chance to relax and enjoy sipping some wine, listening to opera, and reading some good history and philosophy books, however.”

Dr. Evan Flatow…shouldering significant responsibility and having a good time along the way.