Other Articles

Oxiplex® – “Not Approvable”
The FDA’s Orthopaedic and Rehabilitation Devices Advisory Panel said FzioMed’s Oxiplex gel was safe but not proven to be effective, and therefore, not approvable. Did statistics get in the way of something that’s needed, works for some and is safe? Decide for yourself.

Tiger’s Knee and the Cruel Twist to the Sport of Golf
At the U.S. Open in June, Tiger Woods played through intense knee pain to stay on the leader board. His next appointment is with an orthopedic surgeon. Last year there were 103,000 golfing related orthopedic injuries reported. That’s $2.4 billion in medical care. For more on this important and growing market segment read on.

Carpal Tunnel Syndrome: The Causal Controversy
An issue important to big business, the little guy, and insurers alike, the cause of carpal tunnel syndrome (CTS) is a hot potato. According to two orthopedic surgeons familiar with the issue, CTS is largely idiopathic. Here we examine the medical, sociological, biopsychosocial, and behavioral issues related to the problem.

Transitioning to Post-Graduate Year Two: Residents Speak
Going from PGY1 to PGY2 is like going from being robotic to being a decision maker. So say two PGY2 residents, whose experiences transitioning to their second year are telling and instructive for those designing curricula.

Chiropractic: When BS Becomes Rx
Increasingly, spine centers are incorporating chiropractic services as part of their “one-stop-shop” market positioning. This is an interesting issue for surgeons—particularly if the surgeons have a financial interest in the center. Should $30 billion BS become Rx? Maybe.

Off-Label BMP Warning Fallout
FDA’s warning last week about off-label use of rhBMP products should be fair warning to companies developing a new biologic product to be prepared to go through the regulatory ringer. What happened and what’s next? Read on.

Tissue Engineering: The View From Cincinnati
David Butler, Ph.D., a Professor of Biomedical Engineering at the University of Cincinnati, is working to shift the field of tissue engineering. He and his colleagues have set out to determine how much force a given tissue experiences and what the patterns of those forces are. The answers would then provide information for designing new products. And they’re up to much more….

Breaking the Rules to Success
On January 10, 1994, Kyphon became a corporation. That was a defining moment in corporate medical history—not because the company would sell 13 years later for $3.9 billion—but because Kyphon would eventually break almost every rule of medical technology company success. Kyphon was, we now realize, an All-American rebel and its influence is spreading to Medtronic and other companies.

U.S. Senate Fails to Stop Physician Pay Cuts; CMS Stops Processing All Claims
Congress goes on recess leaving physicians with a 10.6% pay cut from Medicare. In response, CMS halts all claims processing for two weeks. Congressional Physician’s Caucus Founder Phil Gingrey, M.D., tells us what happened and what will come next. Read here.

Biologics for Spine: Where We Are Now
Dr. Jeffrey Wang, Chief of the UCLA Spine Service and Director of the UCLA Spine Surgery Fellowship, discusses the exciting happenings in spine biologics, including growth factors, the use of different genes, and injecting stem cells into the disc. And then there are the challenges, namely the disc environment and the funding environment.

Physician Medicare Payments: Grandma vs. Docs
The fight over Medicare physician payments in Congress has been reduced to a fight over limited public dollars between Grandma and her physician. Is this a prelude to how public health care policy will be decided in the future? Read about the tussle here.

Spine Niche! Opportunity in the Spinal Deformity Market
Given the myriad of start-up companies pursuing the same patients, product differentiation and solutions for specific target markets could be the key in the future. Using the PearlDiver Patient Records Database we estimate procedure volumes for posterior fusion as a treatment for scoliosis—followed by the results of a study identifying complications associated with instrumented posterior thoracic fusion in treating scoliosis.

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.

While most orthopedic surgeons are found in the office or the OR, Dr. Tandy Freeman, orthopedic surgeon and the Medical Director for the Professional Bull Riders, Inc. (PBR) Sports Medicine Program and for the Professional Rodeo Cowboy Association’s (PRCA) Justin Sports Medicine Team, can be seen alongside the flying dust, hooves, and horns of the rodeo arena.

Says Dr. Freeman, “I was born in Dallas and attended high school in Junction, Texas, a small hill country town best known for Bear Bryant of Aggie fame. My dad (also Tandy) worked in highway construction so he, my mom (Beth), my two brothers (Terry and Tim) and I moved around a lot. My dad, whose education stopped just short of an engineering degree, didn’t want any of his sons to be road hands and provided us with the education that only experience brings. In my case that meant giving me summer and holiday jobs in highway construction from the age of 15 until I actually started medical school. As he predicted, it was good motivation to attend college.”

And good motivation to excel in high school. “I always enjoyed high school chemistry, physics, math, biology, and physiology. Entering Baylor University in 1976, I had no idea what I wanted to do when I graduated. The physical sciences were a draw, but all of the physicists I knew about worked for the government or large institutions and I didn’t think that would be a good fit for me. I liked the fact that, at least at the time, most doctors worked for themselves, so I chose to major in biology as a premed student. When it came time to take the MCAT and apply for medical school I hadn’t found anything I liked more, so I continued to pursue a degree in medicine.”

The trial and error approach would pay off. Explains Dr. Freeman, “I entered medical school at the University of Texas Southwestern in 1980. It was in my third year, when starting to care for patients and ‘learning’ to be a doctor that I realized medicine was truly something I wanted to do. I found the process of sorting out what was wrong with people to be very interesting. Both the detective work aspect of it and being able to correct things in some cases was quite rewarding. It became evident to me that in medicine I could provide a tangible benefit to people. I knew after my first few rotations that I liked the surgical specialties more than the medical specialties. Orthopedics was enjoyable, but I began a general surgery program and took a look at cardiac surgery.”

So it was off to the colorful panoramas of Utah. “When I went to The University of Utah’s general surgery residency one of my roommates was a thoracic fellow and one was an orthopedic resident. I noticed that whenever I would come home they usually weren’t around. One was often out skiing, riding a bike, or doing something else interesting and fun, many times with his bosses; my other roommate was usually in the hospital, often with his bosses. I didn’t want to be the guy who was living at the hospital all the time. Besides, I liked the scope, so to speak, of orthopedics, the physical nature of the surgery, and the tools. Additionally, orthopedic surgery often provides the sense of satisfaction that comes from actually effecting a cure or helping a patient be truly healed rather than just managing a disease or delaying its effects.”

After three years at The University of Utah, Dr. Freeman returned to Dallas for an orthopedic residency at The University of Texas Southwestern. “It was fairly rigorous, including the time I spent at Parkland Hospital, one of the busiest county hospitals in the country, and my year at the VA hospital in Dallas. I had two six-week elective rotations during my residency, one of which I spent with Dr. J. Pat Evans. Dr. Evans was the first orthopedic surgeon in this part of the country to focus his practice on sports medicine at a time when it wasn’t a recognized subspecialty. He was the team physician for both the NFL’s Dallas Cowboys (19 years) and the NBA’s Dallas Mavericks (10 years) when I rotated with him, although I never saw any of those players as patients during that time. I did, however, observe him with patients in the office and during Saturday morning high school football clinics. Seeing how he related to patients and how his practice was managed made an impression on me. At that point he had a mature practice and was traditional in his approach. He spent time listening to and talking to his patients rather than having a physician’s assistant or other provider do so. In him I found a true role model: I wanted to have relationships with my patients like he did with his. I still wasn’t sure if I would head toward joints or general orthopedics, but at least I now knew what I wanted my practice to look like.”

Continues Dr. Freeman, “From 1991 to 1992 I did a fellowship at the American Sports Medicine Institute in Birmingham, Alabama. There I had the opportunity to see two masters at work—masters who came from two different directions. Drs. Bill Clancy and Jimmy Andrews were both extremely smart and gave me the chance to get a balanced view of sports medicine. Dr. Andrews took an arthroscopically based approach to orthopedic problems, with a lot of upper extremity work that was cutting edge. Dr. Clancy had been around longer and did more knee-based, open surgical procedures, although early on he advocated arthroscopically assisted ACL reconstructions. They often approached the same problem in distinctly different ways. For example, if you’re dealing with a knee dislocation, Dr. Clancy used a staged approach, while Dr. Andrews did everything at once. It was very helpful to be able to see the differences in outcomes.”

After a brief stint in a Dallas orthopedic practice, Dr. Tandy would find the rodeo world opening up to him. “One day Dr. Evans called me and said, ‘I hear you are looking for a change. Do you want to take care of my old patients?’ Over the next year and a half, I spent time in the office with him where we basically divided up his patients. I discovered that the real reason he called me that day was because in 1981 he had started a sports medicine program for professional rodeo athletes, the first of its kind in the country…and was hoping that I would want to work with rodeo patients. After about a year he started taking me to events and getting me involved in caring for the athletes. It turned out that I fit the program and the program fit me. I came to learn that treating rodeo cowboys and bull riders is different than treating ‘regular’ patients. Their experiences with healthcare professionals are often tainted by the fact that a lot of people don’t understand what they do. A physician’s response to a rodeo athlete with an injury is often to say ‘quit,’ something they won’t and/or can’t do. I think I fit with the athletes in part because of my background growing up in a small West Texas community and also because of my practice style being in some ways similar to the traditional country doctor. I don’t have or want a high-volume practice and only do 200-250 cases per year. I often spend an hour with a new patient who has a surgical problem, educating them regarding their diagnosis, treatment options, and likely outcome. For me, that means better care, but smaller volume. In 1995, two years after I became involved with the PRCA’s Justin Sports Medicine Program, the fledgling PBR asked the Justin Boot Company to provide the program’s services at their events saying, ‘We want Drs. Evans or Freeman at our events.’ Since Dr. Evans was retiring, I elected to take over this work and have been doing it ever since.”

And he loves it. But sometimes, he’s got to do a bit of roping himself…of the patients. “The biggest challenge with rodeo athletes is keeping them out of the arena until they have healed enough for a safe return. They tend to have complex high-energy types of injuries; yet, they seem to be exceptionally tolerant of pain and will often compete with injuries that would sideline many of us from much more mundane employment. There are several factors that contribute to the fact that these are the toughest athletes I have worked with. There is the very real issue of them earning a living. They don’t have guaranteed contracts, so if they’re not competing they’re not eating. From a social standpoint, there is a western mentality that says, ‘Cowboy up,’ i.e., no whining if you’re hurt…just get out there and do your job. At the elite levels of competition, there is a Darwinian aspect in that to get to the upper levels of the sport, one has already had to compete with pain and injury. The message is that wimps don’t make it to the top of the ladder. Finally, there is the physiologic aspect that some of these athletes simply do not feel pain the same way that most of us do. The advantage I had early on was that Dr. Evans brought me in, thus giving me a measure of instant credibility. Now that I have established a reputation in the community, if, for example, I tell a bull rider or other rodeo athlete that he or she needs to be out six months to let a reconstructed shoulder heal, most will listen to me.”

Definitely branded as a member of the rodeo family, Dr. Freeman’s other challenge is the same as the cowboys and bull riders. “In addition to covering PRCA events in the Dallas-Ft. Worth area throughout the year, I am on the road in excess of 30 weekends a year covering PBR events. I typically leave on a Friday and return on a Sunday evening or Monday, thus squeezing my work week down to four days. A couple of times a year I go to Las Vegas for the PBR Finals and the PRCA’s National Finals Rodeo, both of which are 10-day events late in the year so that I end up spending 24 days in Vegas during a 45-day stretch. There are casino bells in my head for days after that!”

Continues Dr. Freeman, “The PBR had a 31-city tour in 2006—I was present at all of those events. I am helped greatly by the fact that our team includes three athletic trainers, Rich Blyn, Peter Wang, and Tony Marek, who do the real work. We see the entire gamut of trauma, from typical sports injuries like sprained ankles and muscle strains to injuries similar to those found in motor vehicle accidents or falls from a height, such as cervical spine fractures, blunt chest and abdominal injuries with rib fractures, spleen injuries, liver lacerations, long bone fractures, and open fractures. The most frequent injuries in bull riding are concussions from head to head or head to ground contact, or getting kicked by a bull or hitting a post. The most common surgical procedure is shoulder reconstruction for shoulder instability. Second on the list is surgery to fix facial fractures. Many of these athletes are able to compete with an ACL-deficient knee so they often don’t undergo reconstruction until the injury interferes with their riding or is really problematic in their daily life. We have had three catastrophic injuries since 1995. One athlete, Glen Keely, was stepped on and died of a transected inferior vena cava. Two other athletes, Jerome Davis and Beau Lindley, sustained cervical spine fractures and were left with quadriplegia. Fortunately, more than anything, there are a lot of near misses. Having seen as much arena action as I have, I don’t wince as much as I used to.”

But he still doesn’t think the best place for him is in the arena. “Although I’ve been to steer wrestling school, I’ve never been on a bull and I don’t handle a rope. Roping is one of the events where there’s a lot less risk of injury, but you can lose fingers and thumbs. Since they don’t make surgical gloves with four fingers, I figure I’ll leave roping to the professionals.”

“My wife, Maureen, and I are so pleased to be part of this wonderful community,” says Dr. Freeman. “In many respects I am their small town doctor. I get calls from patients and people I don’t know seeking advice, for example, as to where they should take their dad to get treated for cancer. Some guys, when they fill out a form somewhere that asks for their doctor’s name, list me. A few have even asked me to deliver their babies, a request that their wives and I were able to agree was best left unfulfilled. This is exactly the kind of medical life/environment I wanted. As for my wife, she is a flight attendant who attends as many events as she can with me. She always joins me in Las Vegas and has taken real pleasure in getting to know the sport, the athletes, and their families.”

Dr. Tandy Freeman…creating and sustaining community and bucking tradition.