Other Articles

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Endotec Beats FDA, Strikes Blow for Innovation
Endotec has struck a blow for every orthopedic surgeon who wants to develop a better device. See how the company’s founders took on the FDA and got a federal judge to charge the agency with “stymieing progress and technological advancement.” How did they do it? Read on.

From Obesity to Osteoarthritis, the Carpal Tunnel Connection
It’s certainly no surprise that Carpal Tunnel Syndrome (CTS) is an exceedingly common orthopedic malady. But, as PearlDiver’s data show, the linkage between obesity, osteoarthritis and other conditions to CTS is most surprising. Check it out.

Using DNA to Predict Scoliosis
Six million people (estimate from the National Scoliosis Foundation) have scoliosis in one form or another. The primary age for onset of idiopathic scoliosis is 10-15 years old. Finally, there is a test which can reliably predict scoliosis. Fewer X-rays. Lower cost. Better outcomes.

New Capital, New Science for Cartilage Repair
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Should I Become a Physician-Employee?
Large healthcare institutions are increasingly purchasing orthopedic practices. What does this mean for patient referrals? How beneficial can it be for orthopedists? The upside is more stability, among other things…and one of the downsides is loss of freedom.

Outrageous Whistleblower Lawsuit Challenged
Spine surgeons sued by whistleblowers in Boston are fighting back. Their lawyer is outraged and says the claimants are just shopping an old and settled case to another judge. Is this the proverbial lipstick on a pig? Find out.

Medical Education Under the Microscope – Is It Up to Today’s Challenges?
Where is the line drawn between what medical schools, residencies, and professors should provide to students and what doctors-in-training should reach for themselves? Here are the results of interviews with three senior surgeons, who opine on things such as attitudes, how people learn, and the possible effects on the field.

The Underlying Meaning of Zimmer’s Purchase of Abbott Spine
From the price paid to the timing, this transaction held an underlying meaning for the entire spinal implant industry. Zimmer, the $4.2 billion (revenue) diversified orthopedic company is now #5 in spine. More to come?

Resurging Lumbar and Cervical Total Disc Replacement Markets! New PearlDiver Estimates
Rumors of the TDA market’s demise were premature. Increasingly positive long term patient data is at the core of a resurging lumbar and cervical TDR market. Senior analyst Matt Menze tackles the TDA market and interviews one of the fathers of TDR, Dr. Scott Blumenthal from the Texas Back Institute. Where is this market actually heading? We think to the $2 billion range by 2015. All details here.

Six Days in June – Biomet and Zimmer Battle for Distributors in Kentucky
Documents filed recently in a Kentucky lawsuit pull the curtain back on an epic battle between Biomet and Zimmer. For six fevered days in June 2007, Biomet CEO Jeff Binder and founder Dane Miller went into the trenches to save one of their own. For all the details, read on.

Multicenter Clinical Trials: Do They Get the Respect They Deserve?
They’re not fast or sexy, but they are critical…large trials, that is. With multiple sites and principal investigators who donate their time, large trials are more complex—and normally yield more actionable data—than smaller, quicker studies. But large trials don’t always get the respect they deserve. And, says at least one physician-researcher, this could affect the future of the field.

Patent Wars: Medtronic Attacks NuVasive
MSD’s lawsuit came amid a period of declining spinal implant market share – from a peak of 60% in late 1998 (just prior to being acquired by Medtronic) to, we estimate, 36% currently – and a growing sense that MSD’s reign as the king of spine was coming to a close. What’s really behind Medtronic’s attack on its former senior exec? Read on.

“I type all day so my problem must be carpal tunnel syndrome (CTS),” says the common wisdom. Such is the insight that launched a thousand little industries and ultimately gave orthopedists everywhere a reason to pause. “Unfortunately,” says Dr. Alexander Blevens, an orthopedic surgeon with Bienville Orthopaedic Specialists in Ocean Spring, Mississippi, “over the years the waters have been muddied as far as what causes carpal tunnel syndrome and what does not. This has inevitably given rise to issues of who should pay for treatment.”

On the whole, diagnosing carpal tunnel syndrome is fairly straightforward. Says Dr. Blevens, “The carpal tunnel is a closed space between the carpal bones and the transverse carpal ligament through which the flexor tendons and median nerve pass. In carpal tunnel syndrome we have a situation where something has gone awry with the nerve such that there is increased pressure, which results in numbness of the thumb, index finger, long finger, and half of the ring finger. Patients usually notice intermittent numbness and tingling, which may wake them up at night. Although it eventually progresses to constant numbness, most people have sought medical attention by then. If it is early, mild CTS, treatment would begin with a night splint to keep the wrist from flexing down for long periods of time. As the syndrome progresses, however, this has less of an effect. A steroid injection may give temporary relief of the symptoms. If these measures fail, a nerve conduction velocity test can confirm the diagnosis prior to performing a carpal tunnel release.”

Adds Dr. David Ring, Director of Research in the Hand Surgery Service at Massachusetts General Hospital, “The vast majority of carpal tunnel syndrome is idiopathic, meaning that we don’t know the cause. The pathophysiology is also incompletely understood. While we know that increased pressure in the carpal tunnel (e.g., from wrist flexion) brings out the symptoms, and that release of the transverse carpal ligament stops progression of the disease, we do not completely understand why this is so. People have looked for inflammation around the tendons, other anatomical problems, and vitamin B6 deficiency but none of this panned out. The typical patient with carpal tunnel syndrome complains of numbness with bending of the wrist during activities such as driving or blow drying hair. Night symptoms are classic because people tend to sleep with their wrists bent. It is a myth that carpal tunnel syndrome involves pain when typing. Pain in carpal tunnel is accompanied by numbness. If someone has pain without numbness, it is either not carpal tunnel syndrome or it’s not carpal tunnel syndrome alone. You can experience pain in CTS when the numbness is so intense that it is perceived as pain. While numbness is fairly easy for doctors to work out, pain is often more puzzling and imprecise and the complaints and physical exam are often vague and nonspecific. For numbness, we can verify specific diagnoses using electrophysiological testing. Unfortunately, we just don’t have definitive diagnostic tests to work out pain.”

An issue important to big business, the little guy, and insurers alike, the cause of carpal tunnel syndrome is a hot potato. “In the ‘80s and ‘90s there was more of an acceptance in the medical and business community that CTS is a work-related injury,” says Dr. Blevens. “There were always skeptics, however, and today the orthopedic community is trying to roll back the tide of this set-in-stone public perception. In fact, most work activities do not cause CTS and at most they only aggravate the symptoms. High pressure, high vibration activities such as using a handheld grinder or drill are associated with an increased incidence of CTS, but this association probably occurs just because of an increased awareness of symptoms rather than as a result of an actual causal relationship. In my practice I see a significant number of shipyard workers, some of whom use those types of tools. But as you can imagine, it is hard to tell a shipworker, ‘The tool that makes your hand go numb at work is not causing your problem.’”

According to Dr. Ring, “Much of the confusion regarding carpal tunnel syndrome can be resolved by abandoning a biomedical (find it and fix it) approach to illness for the more comprehensive and accurate biopsychosocial behavioral model of illness. We need to distinguish between disease (the objective impairment caused by the pathophysiological process) and the illness, which involves one’s beliefs, reactions, and behaviors with respect to the disease. For instance, many patients start their description of the problem with a proposed cause. When I say, ‘What brings you in?’ the patient may start with, ‘Well, I’ve been typing at work for 20 years.’ This is just the way the human brain works—it’s psychology. Our minds are excellent at pattern forming and rationalizing. We also have a strong desire to control our environment, and part of feeling in control is to know the cause. It can be unsettling to have a condition that is idiopathic, as carpal tunnel seems to be.”

Continuing his thoughts on the psychosocial aspects of CTS, Dr. Ring notes, “Another important and well-recognized aspect of illness behavior is secondary gain. We have to examine the extent to which it benefits someone to be ill. Are they in the midst of a personal injury lawsuit, a disability claim, or a workers’ compensation dispute? Are they receiving more attention at home or feeding a narcotic addiction because of the illness? Perhaps less well appreciated is the influence of ineffective coping skills, health anxiety, and depressed mood. Unfortunately, as a society we are reluctant to discuss these normal aspects of human existence because they are stigmatized, meaning that they are seen as flaws or weaknesses and people feel ashamed and demeaned to acknowledge them. Ignoring these aspects of illness will not help us make progress, however. It does matter if you don’t like your job or your boss, if you are having marital or financial difficulties, if a loved one is sick or recently died. It also matters if you tend to think the worst and over interpret or ruminate about symptoms. These things all create more pain and disability in the context of a given illness, and they all represent important opportunities for increasing health and wellness.”

In this “see, hear, and speak no evil situation,” most people point the finger of responsibility toward the workplace. Dr. Blevens: “Workers think it’s job related, employers think it’s job related, and insurance companies think it’s job related…we surgeons have an uphill PR battle. If an orthopedic surgeon declares that someone’s condition is not work related, the patient may choose not to get a carpal tunnel release because he or she can’t afford to take time off from work without workers’ compensation benefits. And many times it’s an ambiguous situation and one could make an argument either way. In this issue of who pays for treatment, it is important to distinguish between causation and aggravation. Who pays will vary from state to state depending on a particular state’s workers’ comp laws and how much proof is required to link the disease to the work activity―either by causation or aggravation―and whether this effect is permanent or transient. In the state of Mississippi, the laws are employee-friendly such that a condition is compensable if it is aggravated by work. So if you have CTS and use your hand in nearly any type of activity, your symptoms could very likely get worse. In other states where the law specifically says that a condition is covered only if work was actively the cause of the problem, it is easier to say that the work activity didn’t cause it.”

Giving a bit of historical perspective, Dr. Blevens notes, “In the 1980s there was a push to identify cumulative trauma disorders. A hot topic of debate and essentially an unverifiable social construct, these disorders were seen by many as originating from doing the same activity over and over again. Once the government got involved in order to protect workers, they legitimized things. From there it grew feet before the medical community could evaluate it. If it were not connected to work, however, this never would have happened. There is much to be learned from what happened in Australia, where for several years there was a condition known as repetitive strain injury [RSI]. It was so widespread that the government published pamphlets telling workers and employers how to prevent it. There were a substantial number of government workers on disability for this, in some areas up to 30% of the workforce. The medical community got together and informed the public that this was a psychosocial problem as much as it was a physical problem. In fact, it was related to dissatisfaction with work and other similar issues. It was not long before the problem went away entirely. Then Americans started to develop cumulative trauma disorders. Obviously, we had not learned from the Australian experience.”

Dr. Ring and his colleagues examined the amount, quality, strength and consistency of scientific evidence regarding the etiology of carpal tunnel syndrome. They examined 117 studies that provided original epidemiological data regarding the etiology of carpal tunnel syndrome. Dr. Ring: “We used a quantitative system based on the Bradford Hill criteria for assessing an etiological relationship. We found stronger and more consistent evidence for structural or genetic factors than for environmental or occupational exposures. Even the data for inherent biological factors was graded as only moderate in strength. It is very difficult to show a causal relationship between one thing and another. Anyone who confidently says that environmental things like typing cause CTS is going beyond the existing scientific evidence. Since it is our obligation to provide the most positive, optimistic, enabling, reassuring, resourceful, and practical illness concepts consistent with the scientific data, we need to be careful with what we say and avoid overstatement. If we are going to be pessimistic and create concern about something, we had better be right, because negative illness concepts create more illness. For examples of this one can look at the Australian epidemic of RSI, the hysteria that surrounded silicone breast implants, and the hullabaloo created by speculation that proximity to power lines increases the risk of cancer. A confident belief or statement that carpal tunnel syndrome is caused by work activities is inappropriate based on both the existing scientific data as well as our responsibility to maximize health and wellness.”

And the final word goes to…science. Dr. Ring: “It can be difficult to address these issues because one may appear insensitive. Nonetheless, we as a society should insist on solid scientific evidence as science is a tool to overcome weaknesses in our thought processes. As for health providers, politicians, and journalists, we are obligated to choose the most positive, practical, enabling interpretation consistent with the best available scientific evidence. If I advise a patient to stop doing a certain activity, I disable them with my words, so I’d better be right. We should strongly consider the implications of our words and actions. Regarding the general public and the media, when someone says something like, ‘Typing causes carpal tunnel syndrome’ or ‘Repetitive use causes injury,’ the initial reaction should be skepticism. If it’s negative or disabling, insist on solid proof. Assume you are healthy until proved otherwise!”