I have a terrible sense of direction. I always take getting lost in stride. I tell my wife that I am late because I am exploring new areas; she knows better and does not believe me. She says my brain is too clogged with knowledge about surgery and anatomy and that there was no room for information about the streets of New York. GPS has changed my life. I now have a device that helps me know where I am, where I am going, and how to connect the dots.

In surgery I do not get lost. I always know where I am, and what my goal is. The art of surgery is how to connect those dots. When doing hip replacement surgery we implant artificial parts to replace a damaged joint. There is a range of positions, a neighborhood of acceptable alignments that you can implant the parts in and expect an excellent result. We have found that with the newer materials we sometimes use the acceptable neighborhood is quite small. So small in fact that is difficult for surgeons to consistently achieve the level of precision needed to ensure an excellent result. In other words mere human surgeons cannot always put the implant in the best possible position. The problem is that it is very difficult to precisely asses the alignment of the body lying on the table. The visible anatomy does not lend itself to the new degree of precision needed.

Enter CAS or computer assisted surgery. This is a GPS system for the OR. Instead of satellites we use a special three dimensional camera and a series of infra-red trackers. The camera sees the trackers and sends their location to the computer. At the beginning of the procedure I place a pin in the pelvis and electronically mark a number of anatomical landmarks. The computer remembers this and during the procedure I input internal positions until the computer can generate an accurate model of the hip. This model is displayed on a screen.  My surgical instruments have trackers on them as well so that while I am working on the hip I see an Avatar of the hip and the instruments I am using. Thankfully we are not blue as in the movie.  As I move the instruments the images move in real time. Along with the images I see a numerical readout of the alignment and position of the implant. When I see the position and alignment numbers I want, I am done. Many scientific studies have validated the accuracy of the system I am now using. The majority of hip replacements are done using materials that do not demand this high degree of precision. However when using these materials CAS is extraordinarily helpful.

I have always enjoyed driving but was sometimes a little nervous when I had to go someplace new. I would have a nagging concern about finding the right place. GPS has alleviated that concern. Similarly, I enjoy performing surgery, but had some minor concern about being able to be accurate enough to do the best for my patients when using newer materials. CAS like GPS has completely alleviated that concern. With this technology I can offer the best to our patients, and find my way home quicker.

Jeffrey Passick, M.D.

Dr. Passick is the Director of Orthopedics at Coney Island Hospital. He can be contacted at 718-616-3440

 As quickly as winter came upon us, it has left. We have been blessed with the first hints of warmth and sun. People are emerging from their winter routines and the streets and parks are beginning to fill with sportsmen and women. As I observe this pleasant scene my mind always returns to the same thought, DID YOU STRETCH?

 Stretching is only one part of the regimen we should undertake when we transition from the relatively sedentary existence of winter to the renewed activeness of spring. Our bodies need to adjust gradually or we can become injured. What parts of our bodies? What injuries you say? I am glad you asked.

 All physical activities make use of the musculoskeletal system. This system is made up of the bones, muscles, ligaments and tendons that help us move. Here are some basic definitions:

 Bone: hard structure made primarily of calcium

• Muscle: tissue that by actively contracting and passively expanding make us move
• Tendon: Tissue that connects muscles to bone
• Ligament: Tissue that connects bone to bone

 What is common to these four tissue types is that they respond to use, or disuse. Muscles atrophy or shrivel when not used; bones get soft and brittle under the same conditions. Tendons and ligaments similarly get weak. This weakening process can be unfortunately rapid. If we go from hibernation to marathons our musculoskeletal system may not be able to tolerate the strain and an injury may occur. Some of these injuries are just annoying, but others can be catastrophic. Blogs in the near future will talk about these injuries and their treatment. For now let’s talk briefly about prevention.

 First, always gradually increase your activity level; especially when starting from a period of relative inactivity. Pain is a protective mechanism; it is there to stop us from doing stupid things. In general if something begins to hurt, STOP. You can rest a day and then come back to the same activity and find you can go a little farther before having discomfort again.

 Stretching if done correctly is also important. There is now some disagreement about the need for continual stretching into the active season. However at the beginning of the season slow gradual stretching can help regain motion we may have lost from disuse. When stretching it is best to use gradual rhythmic motions not one massive pull.

Think of the wisdom in fables of old when it comes to renewing physical activity after a period of hibernation – slow and steady wins the race.

Jeffrey Passick, M.D.

Dr. Passick is the Director of Orthopedics at Coney Island Hospital. He can be contacted at 718-616-3440

I have been on vacation this week visiting family and friends in Los Angeles.  We have family here with whom we remain close with despite the distance.  We have friends here as well because 20 years ago we lived here for over a year while I did a fellowship in Joint Replacement.  To become an Orthopedic Surgeon you spend 4 years in college, 4 years in medical school, 1 year of internship and 4 years of residency.  Many of us go on to study an additional year in an area of specialization; this year is called a Fellowship.  I spent mine in Los Angeles with Dr. Larry Dorr.

The teaching of medicine has changed somewhat over the years.  In medical school the first two years are still spent learning the basic medical sciences in books and labs.  Anatomy, physiology, biochemistry are the building blocks upon which further education is layered.  In the later clinical years, learning and teaching have become “evidence based”, rather than experience based, that is you have to be able to support your decisions and treatments with literature evidence.  In my educational days the ward attendings, the senior doctors who supervise the residents and students, would almost always start a discussion with the phrase “In my experience…” Now that statement can be “The Cochrane guidelines state…”.   This works well in Internal Medicine and to a degree in clinical surgery, however when it comes to the OR there is no substitute for hands on experience.  This where Larry Dorr made me the surgeon I am today.

Different people think in different ways.  In chess, some players analyze their moves by trying to figure all the possible outcomes of each possible move, and then choose the best alternative.  Others use pattern recognition.  That is they look at the board and think “I have seen this before” and base their decision on the known outcome of that previous similar situation.  The best players use a combination of both.  As novices play more games and study other games they recognize more patterns.  In speed chess there is a clock as well; you cannot spend forever pondering one move.  You must move on. Surgery is similar.  You start with basic book knowledge and memorized techniques. You then spend years assisting and observing and then you perform surgeries while being observed.,. Ultimately you need to be able to assess a situation and react quickly on your own.

That year in Los Angeles I assisted Dr Dorr with over 700 surgeries.  In the beginning I watched.  Then I began to do more and Dr. Dorr watched. When I got in trouble he would take over and bail us out. I would be lying to say that when he did take over Dr. Dorr was gracious or supportive.  Usually there was a look and a comment that made me feel two feet tall.  At the end of the day I was expecting to be told I should look for another profession, instead Dr. Dorr would invite my wife and I out to dinner on the spur of the moment.  We would talk with his wife about children and politics, but never surgery.  It was not until years later that I realized his annoyance was not entirely with me but with himself as well, for not preparing me better. Though he was probably at least a little annoyed with me too.

Dr Dorr also taught me about people. Surgery is a team sport. You cannot do it alone and if your think you can you are bound for failure. Just as he nurtured me and boosted my spirits when I was most dejected, he knew how to take care of his team. He expected nothing less than complete dedication and perfection from everyone he worked with, and led by his own example. In exchange for their dedication, those who worked with him were treated as family. Dr. Dorr hosted several events a year to thank his team for their hard work. When working for Larry Dorr you never felt unappreciated.

This is beginning to sound a bit like and obituary and it most certainly is not. The day I spent with Dr Dorr he did 5 surgeries. I saw that he did some things differently, some the same. He is developing a computer navigation system, not unlike a GPS for surgery. This system offers great promise in increasing the precision of joint replacement surgery.  I will incorporate some of the changes I saw into my technique, and hope to utilize the computer system here at Coney Island in the near future. I also saw the complete dedication of Dr Dorr to his patients,and the staff to Dr. Dorr.  Some things do not change.  

            Luckily I will have the chance to see Larry Dorr soon at a national meeting next month. We have an alumni group of former fellows that will be gathering a day prior to the meeting to teach and learn from each other and Dr. Dorr. We had our first such meeting 19 years ago. It was a much smaller group then, and some us got together and purchased a bottle of fine wine to give to Dr. Dorr in appreciation.  As I left him this week he mentioned that he has kept that bottle all this time and will bring it to the meeting for us to drink and enjoy.  He thinks it may have gotten better with age, I know it has.

Jeffrey Passick, M.D.

Dr. Passick is the Director of Orthopedics at Coney Island Hospital. He can be contacted at 718-616-3440

An Orthopedic Success Story

I along with over 100 million other people watched the triumph of Drew Brees and the New Orleans Saints in the Super Bowl this past Sunday.  I am a long suffering New York Jets fan and usually root for the AFC.  This year I broke with my tradition for two reasons.  First my oldest daughter attends Tulane University in New Orleans; the Saints have really lifted the spirits of that city in ways you must live in NOLA for a while to appreciate. Second, Drew Brees came back from a potentially devastating injury and I always love an Orthopedic Happy Ending.

In December 2005 Mr. Brees dislocated his shoulder while attempting to recover his own fumble in the last game of the regular season.  In the process of that dislocation he tore his labrum and partially tore his rotator cuff.  The shoulder is an amazing joint capable of an extraordinary range of motion.  That flexibility however makes it inherently unstable.  The labrum is a rim of firm tissue that helps hold the shoulder ball in the socket.  When the shoulder dislocates that rim of tissue frequently tears making the joint prone to more dislocations.  The rotator cuff is made of the tendons of four muscles and is also often injured in dislocations.  The cuff muscles and tendons are responsible for maintaining the strength and motion of the arm.  For any throwing athlete stability, motion and strength are essential.

In the general population the incidence of shoulder dislocation is 2%.  This means that at some point in their lives 1 out of 50 people will suffer a shoulder dislocation, usually related to injury.  Even regular people  (i.e. non- professional atheletes) can have problems with their shoulders after a dislocation.  Often the shoulder will “pop out” without significant trauma, sometimes even during sleep.  The younger you are when the first dislocation occurs the more likely you are to have problems with your shoulder in the future. When this happens you may have to consider the treatment that Drew Brees did.

In January 2006 Drew underwent arthroscopic repair of his labrum and rotator cuff.  This surgery involves using an Arthroscope, a small television camera to see inside the joint, as well as specialized anchors and sutures to repair the torn tissues.  Specific instruments are used to perform the repair through 3 or 4 small incisions called portals.  The surgery can take between one to two hours to perform.  At Coney Island Hospital we have the ability and the technology to perform these procedures and do so frequently.  In fact we use the same equipment that is used in specialty hospitals in Manhattan.  The rehab afterwards is just as important as the surgery, and it can take 4 to 6 months to get full mobility and strength back.

The inspiring thing about Drew Brees’s story is his perseverance in the face of adversity.  He was released by the Chargers after his injury.  Several teams declined to hire him because they did not feel a quarterback could recover sufficiently after this type of injury to be competitive.  The Saints, a then ‘down on their luck’ team, hired a then ‘down on his luck’ quarterback.  The rest, as they say, is history.  Modern orthopedic reconstructive surgery enables us to repair and rebuild damaged joints.  To fully recover though, the patient must actively participate in their recovery.   Hopefully the victory of Drew Brees and the Saints will inspire the people of New Orleans to continue to actively participate in their recovery as well.

Jeffrey Passick, M.D.

Dr. Passick is the Director of Orthopedics at Coney Island Hospital. He can be contacted at 718-616-3440

Keeping pace with change
Hospitals are special places for those of us who have spent the majority of our adult working lives in one, and for those who visit one episodically for care. To those of us who work here in Coney Island Hospital, this is a place where we find fulfillment, where we see our friends, where we get to experience the highs and lows of life on a daily basis. The hospitals of popular culture sensationalize these things. Seattle Grace, the hospital setting of the television show “Gray’s Anatomy” does capture the essence of being part of a hospital community (except with much more promiscuity). Most of us feel blessed to be part of an organization that’s primary purpose is to do good. From what I can tell St. Vincent’s hospital in Greenwich Village is such a place, but unfortunately it may not be around much longer.

For the community that is served by a hospital, that hospital should be an essential part of that neighborhood. Particularly in areas that have an abundance of the poor or disenfranchised the hospital is a place where people go for comfort and care. St. Vincent’s has a long history of caring for some of New York’s poorest and sickest through epidemics from Cholera to HIV. Greenwich Village without St. Vincent’s will be a very different place.

Unfortunately being a ‘caring community’ caring for a community is not enough anymore. A hospital is a business. Whether a voluntary hospital or not, at the end of the day you must be able to make your payroll and pay your bills. In 2010 it is not possible to expect others to make up the difference. Neither the Church nor the State has the resources to subsidize hospitals anymore. It appears St.Vincent’s got caught behind the times. In order to fulfill its mission it had to do more than good work, it had to adapt to a fast changing environment.

At Coney Island Hospital we are lucky. We have an extraordinarily caring community who work and volunteer here. We have a diverse community that we care for as well. In addition, we have seen the future and are actively preparing for it. I have been fortunate to be part of the “Breakthrough” initiative here. This program, launched by our parent, the New York City Health and Hospitals Corporation, has us look at essential processes and reengineer them for greater efficiency and quality. It a system-wide priority and is supported by the entire hospital community. What is unique to this approach is that it involves staff at every level and empowers them to make real changes in areas that they understand because they do the work every day. These changes are immediate and are monitored for efficacy.

We are evolving and adapting to meet the needs of our community and expanding the community we serve. Plans are in place to expand our ER; we are involving community physicians and facilities and connecting them to our information system to allow for better continuity of care. My department, Orthopedic Surgery, is developing a Center of Excellence in Joint Replacement to serve our immediate community as well as surrounding areas.

The story of St. Vincent’s Hospital is truly sad. I feel badly for the hospital staff and people they serve. I hope we will not have to witness the closing of other great institutions that are part of the City’s fabric. Coney Island Hospital is making necessary changes so that we can continue to survive and provide even more services to our community. Stay tuned and see.

Jeffrey Passick, M.D.

Dr. Passick is the Director of Orthopedics at Coney Island Hospital. He can be contacted at 718-616-3440.

There was a story reported in this week’s New York Times and elsewhere about a rare disorder called chondrolysis that has been seen to occur after certain surgeries. Chondrolysis is the unexpected deterioration of cartilage in the joint. These particular procedures have employed a “pain pump” – a recently developed device used to slowly inject local anesthetic into the joint after surgery. In theory this technology should decrease post-op pain and increase the patient’s comfort. Unfortunately, it turns out that the anesthetic drugs we routinely use all over the body can actually be toxic to the joint if injected consistently over a period of days. These new devices were never tested for this specific application but were approved for similar uses throughout the body; no one expected these results when the pumps were used directly in joints.

My daughter desperately wants an IPad. It seems soooo cool she has told me on multiple occasions since its announcement 48-hours ago. I told her “it is never a good idea to be the first one to get something new, remember all the problems with the first generation IPhones and Blackberry Storms.” I told her to let someone else be the guinea pig, and once the kinks were worked out we would reassess and consider buying one. The downside of this philosophy is not being the coolest kid in school right away; you can’t tell your friends about your new device and attract the eye of that cute boy or girl before anybody else.

In medicine there are real pressures to be that cool kid. To compete you often have to distinguish yourself from your colleagues. Being the first to offer some new technology that decreases post operative pain can make you more popular, like the kid with the first IPad. I have succumbed to this type of temptation in the past with other new technologies – those devices were approved for my applications. I have not implanted any pain pumps into joints and none of my patients have chondrolysis.

For now my daughter will not be the first in her school to get an IPad. I will also not be the first surgeon to try some new technology. I will watch carefully and when technology is proven safe and offers a real advantage for my patients I will be all over it. I am sure when IPad 2.0 is released I will be all over that too.

Jeffrey Passick, M.D.

Dr. Passick is the Director of Orthopedics at Coney Island Hospital. He can be contacted at 718-616-3440.