Surf’s Up! - OrthoVirginia€™s Up! Multi-ligament Knee Reconstruction Helps DC Architect Ride the Waves ... Annunziata diagnosed a multi-ligament injury. In addition to the ACL

Spring 2012

Getting back to your life.www.c-o-r.com

Surf’s Up!Multi-ligament Knee Reconstruction Helps DC Architect Ride the Waves

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President Gordon L. Avery, MD

Chief Executive Officer William L. Harvey

Chief Operating Officer Maureen M.R. Cook

Chief Financial Officer Richard T. Givens

Director of Physical Therapy Jo-Anne Burton, PT

Director of Human Resources Michelle Melito

Directors of Marketing Suzanne M. Kelly

Deborah R. Martin

Editorial Mission: Commonwealth Orthopaedics magazine is an educational and informative resource for physicians, health care professionals, employer groups, and the general public. This publication provides a forum for communicating news and trends involving orthopaedic-related diseases, injuries, and treatments, as well as other health-related topics of interest.

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Medical

Surf’s Up ........................................................................................4

Living to Run Another Day .......................................................6

CME on Office Orthopaedics ..................................................8

Innovative Hamstring Repair Puts Athlete Back On Track .........9

On Call in the ER ..................................................................... 10

All-in-One Treatment .............................................................. 13

Enjoying Life After Traumatic Cervical Spine Injury .......... 14

Cartilage Restoration Gives Knee Patients More Options ................................................ 16

Turning Spine Surgery On Its Side ....................................... 19

Employee Spotlight: Jenni Fox ................................................ 20

The Kindest Cut: Shoulder Surgery Comes of Age.......... 22

On the cover:

Surfing fanatic Spiro returns

to his favorite sport following

multi-ligament knee injuries.

See story on page 4.

I am pleased to share with you the spring 2012 edition of Commonwealth Orthopaedics Magazine. In this issue, we take a close look at some of the unique and complex procedures that we perform here at Commonwealth Orthopaedics. From multi-ligament reconstruction of the knee to proximal hamstring repair to an advanced spine surgery technique

known as eXtreme Lateral Interbody Fusion, our team of fellowship-trained orthopaedic surgeons has the skills and expertise necessary to perform these cutting-edge therapies with outstanding results.

The patients profiled in this issue initially thought they had fairly common injuries. But our orthopaedic specialists quickly determined that they were suffering from unusual conditions that required sophisticated surgical intervention. With the help of our experienced team of physical therapists and orthopaedic technician experts, these patients were back on their feet, and back to their lives, swiftly and successfully.

Our Commonwealth physicians are committed to sharing their expertise with the greater community, and many serve as on-call trauma surgeons in local hospital emergency rooms. In this issue, you’ll read the dramatic stories of two patients who received lifesaving care from our surgeons in the ER. And in our Employee Spotlight, you’ll meet a long-time Commonwealth physical therapist who is devoted to restoring function and hope to the patients whose lives she touches every day.

I hope you enjoy this issue of the magazine. As always, it is our pleasure to work with you to provide excellent orthopaedic care and services to our Northern Virginia community.

Sincerely,

Gordon L. Avery, MD President Commonwealth Orthopaedics

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Surf ’s Up!

Spiro was determined to surf the beaches of Nicaragua after multi-ligament knee injuries, and he did!

Multi-ligament knee reconstruction Helps dC Architect ride the Waves

Surfing fanatic Spiro was looking forward to a trip to the world-class beaches of Nicaragua when disaster struck. Playing in a local football game, the 25-year-old architect took a hard hit and

felt a familiar pop and snap in his right knee. Thinking he’d suffered a repeat of an old anterior cruciate ligament (ACL) injury, he went home and put on a soft leg cast to immobilize his knee and keep it straight.

With the Nicaragua trip less than a year away, Spiro was determined to recover in time. His injury was worse than he thought, however. In the days that followed, his knee felt increasingly unstable and the pain did not let up. Spiro needed a specialist, but he wasn’t sure where to turn.

He got lucky in a Metro station. “I was waiting for the train and heard a familiar ‘clink, clink, clink’ on the platform,” Spiro recalls. “A young woman was coming toward me. She was on her crutches, I was on my crutches, and we started talking. It turned out she was a dancer with the Washington Ballet who just had knee surgery at Commonwealth Orthopaedics.”

Spiro got two phone numbers that day – one for the ballerina and one for Christopher Annunziata, MD, a Commonwealth surgeon with expertise in complex ligament and revision reconstruction. Dr. Annunziata diagnosed a multi-ligament injury. In addition to the ACL tear, Spiro had torn his medial collateral ligament (MCL) and damaged some cartilage. He would need a complex reconstruction procedure to fix all the injuries at once.

“Multi-ligament knee injuries are fairly rare and tend to occur in sports where people are struck or tackled, such as football, or from skiing or automobile accidents,” Dr. Annunziata explains. “This is not your typical weekend warrior with a hurt knee. It’s a complex injury pattern that includes pain, swelling and lack of control of the limb, and demands good clinical acumen to recognize.”

The sooner the injury is treated, the better the results. But it’s crucial the surgeon take the time to determine exactly what’s wrong before undertaking any repair procedure. “These injuries more than any

Commonwealth Orthopaedics | www.c-o-r.com 5

Surf ’s Up! Chris Annunziata, MD, earned a BS from Boston College before graduating with his medical degree from Georgetown University. He completed an orthopaedic surgery residency at Georgetown University Medical Center and went on to complete a fellowship in Sports Medicine/Knee and Shoulder Surgery at the University of Pittsburgh Sports Medicine Center.

Ben W. Kittredge, IV, MD earned an undergraduate degree from the University of Virginia and a Masters degree in Physiology from Georgetown University, Dr. Kittredge returned to the University of Virginia to attain his medical degree. He then completed a general surgery internship at Roanoke Memorial Hospital and an orthopaedic residency at the University of Virginia. Additionally, Dr. Kittredge completed a fellowship in sports medicine at Jefferson Medical College and Pennsylvania Hospital in Philadelphia.

Following his surgery, Spiro took home several pieces of durable medical equipment (DME) to help with his recovery. Items included custom-fitted knee braces, a neoprene sleeve for compressive support, and a cold therapy unit.

Thanks to Commonwealth’s convenient on-site DME program, Spiro got everything he needed before he left the hospital. “It’s one-stop shopping for patients,” says Lisa Wallwork, Director of DME. “They don’t have to visit a medical supply store or worry about insurance reimbursement. We take care of all of that up front and in house – from providing the equipment and training to billing the insurance company.”

Commonwealth’s DME program is one of the strongest and most cohesive in the region. Highly qualified technicians ensure patients receive top quality equipment – from off-the-shelf items for common orthopaedic conditions such as carpal tunnel syndrome, arthritis and sports-related injuries, to custom-fitted braces, splints, and boots.

Most of these items are covered by insurance. But some, like Spiro’s cold therapy unit – which circulates ice water around the injury site via a motorized pump – are “luxury items” that patients choose to purchase.

Commonwealth’s thriving program continues to grow. Later this year, it will add a customized orthotics service. “We are definitely a leader in on-site DME,” Wallwork says. “Other organizations reach out to us for guidance in setting up their own programs.”

Here are three common DME products for knee injuries:

One-Stop Shopping for Medical Equipment

T-SCOPE: Post-op Range of Motion Brace

KODIAK: Cold Therapy Unit with Pad

FUSION: Brace for Activities of Daily Living

other require meticulous planning beforehand to know what you are getting into,” says Ben Kittredge, MD, a Commonwealth surgeon who performs multi-ligament repair and reconstruction. “From a very careful physical exam to reading the MRI properly to determining whether there is a vascular problem or arterial injury – it’s important to have a well thought-out plan, so there are no surprises during surgery.”

Following his reconstruction procedure, Spiro had just one goal in mind: to be able to surf again in seven months. He launched an all-out recovery effort, starting with physical therapy to regain flexibility, stability and strength, and gradually adding daily biking, weight training, and treadmill workouts. With the trip just six weeks away, he had regained 80% of his muscle strength and asked Dr. Annunziata to clear him for surfing. “He told me he’d never seen a faster recovery but warned that I was still fragile and shouldn’t risk it,” Spiro says. “I told him I would do whatever it takes – I was absolutely determined to go.”

That doggedness paid off and Spiro was able to make the trip to Nicaragua. Despite the stress on his knees, he surfed every wave he could and came back in one piece with no aches or pains. “Surfing is an unbelievably addictive feeling within the purest sport. It's just as physically challenging as mentally intensive, and adding the element of water and not being able to breathe when held under takes the reward to another level,” he says.

Dr. Annunziata, whom Spiro calls an “inspirational doctor,” says it’s Commonwealth’s team approach that ensures such exceptional care for complex multi-ligament injuries. “We have the resources and technical ability to provide truly coordinated care. From our fellowship-trained orthopaedic surgeons to our highly skilled physical therapists and bracing and orthotics experts, we treat these injuries as quickly as possible for the best results.”

For full biographies and a complete directory of physicians at Commonwealth Orthopaedics who perform these and other procedures visit our website at www.c-o-r.com.


Run Another Day

Ever since his glory days as a high school and college athlete, Wenners has dreamed of reliving those moments of triumph. The

56-year-old father of three from Manassas has always been active – jogging, swimming, cycling, and taking long walks with the dog. Last year, he decided the time was right to compete again and entered an Amateur Athletic Union (AAU) track meet in the over-50 age group. “I thought, ‘I can do this. I can run this race one more time,’” he says.

Wenners embarked on an ambitious training regimen. Even a pulled muscle in his left calf did not slow him down. But when the injury failed to improve after a few months, he suspected something else was wrong and consulted Kevin Lutta, MD, a foot and ankle specialist at Commonwealth Orthopaedics.

Dr. Lutta diagnosed a chronic Achilles tendon rupture, a flare-up of an old injury Wenners had suffered in college. Left untreated, the injury results in plantar flexion weakness of the ankle (the downward movement of the foot when pointing the toes away from the body) and gradual onset of progressive aching pain in the Achilles tendon that worsens over time.

“Tendon rupture from progressive tendon degeneration can take a dangerous course, so it’s important patients receive appropriate care,” Dr. Lutta says. “Non-surgical treatment includes a cam walker or boot, braces such as molded ankle-foot orthotics, and physical therapy. Surgical treatment includes end-to-end repair of the tendon if the defect is less than three centimeters and injury is within three months. For larger gaps, a tendon transfer augmentation with transfer of the flexor tendon of the great toe restores normal push off of the ankle.”

Wenners is back to his active lifestyle after

an Achilles Tendon Reconstruction.

living toAchilles Tendon Reconstruction Relieves Chronic Injury


Wenners was initially treated with immobilization in a boot but continued to have pain. Dr. Lutta performed an Achilles tendon reconstruction and transfer of the flexor tendon to the great toe. In this procedure, the tendon is harvested in the mid foot and passed through a drill hole in the heel bone. It is then woven through the tendon defect after all scar tissue and unhealthy tendon has been removed. Wenners was immobilized in a cast for six weeks and a walking boot for three months, followed by extensive physical therapy.

One year later, he’s returned to an active lifestyle that includes daily walking, cycling, and jogging on a treadmill. The pain is gone and he’s more conscious of his activities, avoiding any pounding pressure and taking care to stretch properly before and after exercise.

Wenners has high praise for Dr. Lutta and the care he received at Commonwealth Orthopaedics. “He’s the most fabulous doctor I’ve ever had and went way beyond simply treating my injury,” he says. “His staff is so kind and personable. They did everything they could to ensure my comfort. It was just a great experience.”

In addition, Dr. Lutta encouraged two of Wenners’ children to follow their dreams and pursue medical careers. His oldest son is now at Howard University Medical School, Dr. Lutta’s alma mater, and his youngest son is considering a career in medicine as well. “Dr. Lutta has been a wonderful inspiration and role model for my sons, and he cared for my wife when she broke her foot recently,” Wenners says. “We really consider him to be a part of our family.”

Kevin Lutta, MD, graduated with a BA in Biology from Clark University. He earned his medical degree from Howard University College of Medicine, where he was named to Alpha Omega Alpha Medical Honor

Society. He completed his residency in orthopaedic surgery at Howard University Hospital and went on to a fellowship in foot and ankle reconstruction at Pennsylvania Hospital, part of the University of Pennsylvania Health System.

Restoring function while protecting the surgery site is the goal of rehabilitation after Achilles tendon repair.

“Initially, we work on gentle, non-weight-bearing activities to improve strength and range of motion,” says Jennifer White, PT, DPT, a physical therapist in Commonwealth’s Reston clinic. “We try to avoid extreme foot flexion or contracting the calf because we don’t want to pull on the Achilles and jeopardize the repair.”

Following surgery, patients spend the first month in a cast and begin physical therapy five or six weeks later when they’ve graduated to a removable boot. In addition to stretching and strengthening exercises, therapy includes massage and elevation to reduce swelling, and ice and compression for the scar area.

When the boot comes off around the 12-week mark, patients begin working on gait and balance issues. “Patients usually will have a limp and they may have hip and back issues as well because they have been walking with one foot high, in the boot, and with this deviated gait,” White explains. “The slowest thing to come back is push off required during normal gait, due to weakness”

Generally, patients continue physical therapy until they are functional in their everyday lives – walking, using the stairs, wearing different kinds of shoes, performing job duties. Upon discharge, therapists might recommend a home exercise program or gym workout to further progress toward high level activities. If patients are unable to progress on their own, they may return to Commonwealth for more rehabilitation.

Did You Know?Commonwealth Orthopaedics has a new Online Store on our website offering our patients affordable and convenient access to over the counter medical products that our physicians recommend in our office. All of the products on the website are backed by an unconditional 30-day money-back guarantee. Most orders are mailed in 24 hours or less for just $6.95, shipping and handling. Express shipping is also available. Check out our Online Store at: www.c-o-r.com/onlinestore.

Protecting the Gains


Jennifer White, PT, DPT

www.c-o-r.com8 Commonwealth Orthopaedics | www.c-o-r.com

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More than 90 physicians, physician assistants, nurses and certified athletic trainers attended “Office Orthopaedics for the Primary Care Physician,” on March 3, 2012. The CME event co-sponsored by Commonwealth

Orthopaedics and Inova Health System coordinated a half day workshop on topics such as: What Not to Miss in a Pre-Participation Exam, Acute and Chronic Knee Pain, Shoulder Pain, Back Pain, Hand and Wrist Pain and the Ten Diagnoses Not to Miss. Attendees participated in hands on demonstrations on how to examine knees and shoulders, give steroid injections, and they learned proper splinting techniques.

Special thanks to DePuy Mitek, Inc. for their generous educational grant and to the following exhibitors: Covidien, Janessen, OrthoCare RN and Sterling Surgical for helping us make this CME program possible.

Commonwealth Orthopaedics Co-Sponsors CME Event

Chris Annunziata, MD demonstrates how to examine knees.

Wiemi Douoguih, MD demonstrates how to examine shoulders.

Kevin deWeber, MD, FAAFP, FACSM, COL discusses how to perform steroid injections.

Waterskiing at a friend’s lake house last summer, Melissa took a bad fall and landed hard on her right leg. Although she didn’t realize it at the time, the 47-year-

old from Vienna had suffered a proximal hamstring tear – a severe injury in which the tendon completely separated from the bone just under her pelvis.

“There was some pain and a bruise, but it didn’t hurt too badly, so I drove home, iced it down, and went to bed.” Melissa recalls. She took it easy for the next few weeks, avoiding her usual high velocity lifestyle of jogging, workouts, and mountain biking. Eventually she began running and swimming again, but when her strength had not returned after eight weeks, she knew something was seriously wrong.

An MRI revealed her hamstring was completely detached from the bone. She was referred to Andrew Parker, MD, an orthopaedic surgeon with experience in an advanced surgical technique to fix these types of injuries.

“A proximal hamstring repair is a procedure to attach a hamstring tendon when it has been traumatically torn from its normal insertion site,” Dr. Parker explains. “It’s typically performed in younger, athletic patients who wish to return to high levels of activity. Proximal hamstring rupture is relatively rare and has been traditionally treated non-surgically with inferior results. At Commonwealth, we have started repairing these injured tendons with great initial results.”

Ideally, proximal hamstring repairs should be performed within the first four to six weeks following an injury. But they can be performed later, too, with great success.

One of the biggest challenges patients face following this procedure is rehabilitation, which takes at least six months. Initially, patients must keep their leg elevated to protect the repair. In addition to using crutches, they may need a brace that keeps the hamstring in a relaxed position.

Dr. Parker warned Melissa of these and other challenges, but she didn’t hesitate. “The moment the diagnosis was made, I knew I wanted it fixed as soon as possible,” she says. “I was very motivated to get back to all my activities and I didn’t want to run the risk of muscle weakness or sciatica in the future, which can happen if you don’t have surgery.”

Dr. Parker performed the procedure at Commonwealth’s Outpatient Surgery Center in Herndon, and Melissa spent the next few months in a grueling recuperation. “I’m pretty strong and it knocked me for a loop,” she says. “I spent the first weeks in bed with my leg in a brace at a 45-degree angle. I couldn’t walk. I couldn’t drive. I couldn’t work. All my muscles completely atrophied.”

But Melissa’s powerful motivation soon took over and she made rapid progress. Within four weeks, she was walking without a limp. At five weeks, she was jogging lightly around her neighborhood. She began stretching to

improve flexibility and range of motion earlier than expected, and returned to her beloved mountain biking this spring. She’s also back at work as an on-site office manager for a local construction firm. Throughout her rehabilitation, Dr. Parker has marveled at her fast recovery. “He calls me Superwoman and I call him God,” she jokes.

“Melissa’s case in particular is interesting, since she is somewhat older than the average person requiring proximal hamstring repair,” says Dr Parker. “However, she is a great example of someone who has responded well to the surgery and returned to a high level of activity following the procedure.”

Now fully recovered, Melissa is happy she opted to have the repair. “I am so glad I did it,” she says. “Dr. Parker is an amazing surgeon, the organic material he used will reduce the chance of any complications down the road, and I’m back to all the activities I love. My entire experience at Commonwealth was fantastic.”

Innovative Hamstring Repair

Puts Athlete Back on Track

D. Andrew Parker, MD earned a BS in Biology and Chemistry from Wake Forest University. Dr. Parker then graduated magna cum laude from medical school at the University of Louisville. He then moved to Chicago where he completed his internship and residency in orthopaedic surgery at Northwestern University. Dr. Parker concluded his formal medical education by completing a fellowship in sports

medicine at the Baylor Sports Medicine Institute in Houston, Texas.

Reattaching a hamstring tendon – a proximal hamstring repair

allowed Melissa to return to all the activities she loves.



On Call in the ER:Commonwealth Surgeons Treat Complex

Trauma Cases at Local Hospitals

Jim didn’t know what hit him. One minute, he was enjoying his weekly bike ride near his home in Clifton;

the next, he was lying in the middle of the road in excruciating pain. His friend who was riding behind him saw the whole thing. A huge buck had scaled a three-rung fence, gone airborne, and crashed down onto Jim as he rode by, sending him sprawling to the pavement.

“I woke up on the asphalt without a clue,” Jim, 52, recalls. “My bike helmet was crushed beside me, my head hurt, and I had a huge contusion on my right side – I felt like I’d broken my hip.” His friend drove him to the emergency room (ER) where doctors took X-rays and recommended that Jim consult an orthopaedic surgeon. He hobbled home on crutches and picked up the phone.

Jim knew just who to call: Brantley Vitek, MD, a Commonwealth surgeon who had first treated him in the ER 13 years earlier following a head-on car crash. At that time, Jim had suffered a calcaneus fracture – a severe foot injury that can lead to long-term disability and chronic pain. He also damaged his opposite knee severely, rupturing his patellar tendon. Dr. Vitek performed extremely complex heel reconstruction surgery, and surgery to repair the torn tendon. Jim made a full recovery, returning to an active lifestyle that included biking, skiing, and a busy job as the owner of Northern Virginia’s Spokes Etc. bicycle shops.

Dr. Vitek was the on-call trauma physician in the ER the day of Jim’s car accident. He and many of his fellow surgeons at Commonwealth Orthopaedics provide this service at the regions many emergency rooms and trauma centers. Inova Fair Oaks Hospital and Inova Fairfax Hospital’s Level 1 (highest level) Trauma Center. It is just one of the many ways Commonwealth physicians share their expertise with the greater community – treating severely injured people and helping them restore function and reclaim their lives.

“We are available to manage all kinds of different orthopaedic-related injuries in patients of all ages,” Dr. Vitek says. “Typically the ER calls us for fractured bones, but also for soft tissue injuries to the musculoskeletal system such as tendon ruptures.”

When Jim sought Dr. Vitek’s help most recently, the situation was far less critical. They met in his office, where Dr. Vitek determined that Jim had twisted his pelvis as a result of the deer collision. The pelvic bones were badly injured, separating apart in the front (out of alignment), but they were not broken. “Jim had a fairly minor version of what can be a horrendous injury,” Dr. Vitek says. “Experience in treating these kinds of injuries helps to avoid the pitfalls of a pelvis fracture that, if not treated and followed appropriately, can lead to long-term disability.”

Jim returned to Dr. Vitek’s office several times to be sure the bones were healing appropriately and had not shifted. Fortunately, he did not need surgery. He spent a month on crutches and was able to go back to work within two weeks. He’s now riding a recumbent bike in the gym at what he calls a “recreational pace,” but hopes to get back to his 200-mile weekly outdoor rides this summer.

He feels extremely fortunate that Dr. Vitek was on call in the ER that awful day of his car accident many years ago. “I got lucky,” he says. I am thankful that he could perform the type of complex heel reconstruction that I needed. He has tremendous knowledge and he tells it like it is. When my wife broke her hip several years ago, he performed her surgery and she was able to come with me on a bike trip to Hawaii two months later. My son went to see him recently for a lacrosse injury. He’s put everyone in our family back together again.”

Brantley P. Vitek, MD, earned a BA in Philosophy from the University of Virginia before receiving his medical degree from the Medical College of Virginia. He then went on to complete

a general surgery internship at the University of Colorado followed by an orthopaedic surgery residency at the University of Texas Health Science Center in Houston.



Jim is back cycling after a traumatic injury to his pelvis.


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For patients with chronic back or neck pain, facet blocks can provide relief, help diagnose the source of pain, and even prevent the need for surgery.

The facet joints are small joints where the vertebrae come together along the spine. They provide stability and help guide motion. Facet joints can become painful from arthritis, or changes in the forces applied to them following a back injury or spine surgery.

Facet blocks inject local anesthesia and steroid medications either into the joints themselves or to the nerves supplying the joints to reduce inflammation and block the pain. The goal is to provide enough pain relief so patients can resume normal activities or better tolerate a physical therapy routine.

However, facet blocks do more than simply alleviate back pain. By placing numbing medicine into the joint, the amount of immediate pain relief experienced by the patient will help confirm or deny the joint as a source of pain. “Facet blocks help both in the diagnosis of facet joint disease as well as its treatment,” says Brett Robinson, MD, Pain Management Specialist at Commonwealth Orthopaedics. “Patients who are candidates for these blocks usually have radiographic evidence of facet joint disease (facet arthropathy), typically by MRI during the evaluation of their back pain.”

As with many spinal injections, facet joint injections are best performed using fluoroscopic (live X-ray) guidance to properly target and place the needle and avoid nerve injury.

The technique can provide significant, long-term pain relief in many cases. And for some patients with facet disease, the blocks can prevent the need for spinal fusion surgery.

While a facet block may quickly reduce a patient’s back pain, relief is not permanent and a repeat block may be necessary. If effective, the procedure can be performed up to three times per year.

Patients who are interested in Pain Management services should contact a Commonwealth Orthopaedics’ physician or their personal physician for a referral.

For more information about our Pain Management Program, please visit our website at http://www.c-o-r.com/orthopaedic_services_painmgt.asp.

Facet Blocks Both Diagnose and Relieve Back Pain

Brett M. Robinson, MD ,a native of New York city, earned a BA in Psychology from Yale University before going on to receive his medical degree from Tulane University. He then completed a rotational internship and an anesthesiology residency at the University of New Mexico, Department of Anesthesiology and Critical Care Medicine, in Albuquerque, New Mexico.

All-in-One Treatment


After a terrible fall, Catherine had spine surgery to relocate her spine.

Enjoying Life!


After Traumatic Cervical Spine Injury

When Catherine arrived in the Radiology department at Inova Fairfax Hospital, the pain in her

arms was so intense she couldn’t even sit up. The 64-year-old clinical psychologist had fallen in the bathroom of her McLean home one week earlier. Unbeknownst to her, the fall had fractured and dislocated her neck. By the time this was diagnosed, she had developed a kyphotic deformity (abnormal curve) in her cervical spine with dislocated and locked facet joints. This was putting pressure on her spinal cord and nerves and she was starting to lose arm strength.

Fortunately for Catherine, Commonwealth surgeon Thomas Mazahery, MD, was on call in the ER. Dr. Mazahery, whose specialties include cervical spine and neck surgery, and trauma and minimally invasive spine surgery, recommended an urgent procedure to correct the deformity, relocate the spine to its original alignment, and take pressure off the spinal cord and nerves. In order to safely do this, he initially took pressure off the spinal cord by removing one disc and realigning the spine into its proper position. Then he placed screws and rods in the back of her neck to give it more stability and hold the alignment.

“Spine deformity is any etiology that can cause an abnormal alignment of the spine,” Dr. Mazahery says. “This is most typically in the form of adolescent scoliosis or acquired degenerative scoliosis of the thoracolumbar spine. However, it can also be caused by trauma, as in Catherine’s case, or tumor, infection, congenital malformations, previous surgery, or inflammatory conditions such as ankylosing spondylitis or rheumatoid arthritis.”

Patients characteristically have symptoms of improper posture and, in some cases, increasing pain. Depending on the cause, some may have years of progressive deformity, while others present early on with debilitating pain and neurologic compromise. On the positive side, most patients who have such deformities are asymptomatic and non-progressive, so no intervention is needed.

Commonwealth offers the latest cutting-edge techniques to manage the full spectrum of spine deformity conditions. “Procedures range from major reconstructions that may involve staged operations to minimally invasive techniques to correct the deformity,” Dr. Mazahery says. “Every patient has different needs, and we are able to provide the complete range of surgical and non-surgical care.”

Restoring quality of life is the number one priority, according to Commonwealth spine surgeon Tushar Patel, MD, whose areas of specialization include cervical spine and neck surgery and minimally invasive spine surgery. “We have just one overriding goal in mind, to help our patients return to the activities they love. Our practice is at the forefront with ever-changing technologies and treatments that allow us to restore performance and function to peoples’ lives.”

Following her emergency surgery, Catherine felt a marked improvement. Her pain had diminished and her arm strength improved. After a short hospital stay, she returned home in a neck collar. Soon, she was able to drive the short distance to her office and begin a physical therapy program to regain strength and range of motion in her arms. In a relatively short period of time, she resumed her favorite activities, including cross-country skiing and walking in the wooded parkland behind her home. Most happily of all, she returned to her beloved piano, practicing scales even though her arms were still a bit sore.

Now on the road to recovery, Catherine is grateful that Dr. Mazahery was there when she needed him. “He had an excellent bedside manner and his staff took good care of me, too,” she says. “I particularly liked his faith in the team at the hospital who would be looking after me following my surgery. He was very positive about their work supporting his work.”

Her Commonwealth experience was excellent and she appreciates the patient-centered amenities the practice has to offer. “It was great to visit the office in Reston and have valet parking available,” she says. “Not just for patients like me who are physically injured but able to walk, but also for those with mobility problems due to hip or knee surgery. The service is extremely helpful and just another example of how Commonwealth puts the patient first.”

Thomas Mazahery, MD, received a BA in Biology from the University of Virginia and earned his medical degree from the Medical College of Virginia. He then completed a general surgery internship and an orthopaedic surgery residency at Northwestern University.

Additionally, Dr. Mazahery completed a spine fellowship at Case Western Reserve University.

Tushar Ch. Patel, MD, earned his medical degree from the University of Pennsylvania in Philadelphia and completed his orthopaedic surgery residency at George Washington University Medical Center. He then went on to do a fellowship in Spinal

Surgery at the Cleveland Clinic Foundation in Cleveland, Ohio.




Cartilage Restoration Gives Knee Patients More Options

Many young, active adults suffer articular cartilage damage in the joints, most commonly the knee. Articular cartilage is the smooth tissue that covers

the ends of the long bones, allowing them to glide over each other with very little friction. Damage occurs due to injury or normal wear and tear. Because articular cartilage does not heal itself well, physicians have developed surgical techniques to stimulate the growth of new cartilage to relieve pain and improve function. Patients are able to get back to their lives and activities, including recreational sports. Most importantly, articular cartilage restoration can delay or prevent the onset of arthritis.

Commonwealth Orthopaedics offers its patients state-of-the-art procedures to repair or replace damaged cartilage. Options include:

Microfracture

Microfracture is an effective first-line treatment with good clinical outcomes. In this minimally invasive procedure, the surgeon drills holes into patches of bone where the cartilage has

worn away. The goal is to stimulate the growth of new cartilage by creating a blood supply that brings cells to the surface. Coupled with modifying activities, the results work well for several years.

Resurfacing

Resurfacing is an option for patients whose cartilage damage is more severe, or when microfracture fails to alleviate symptoms. Osteochondral transfer (OATS) resurfaces the defect with cylinders of bone and cartilage from other normal areas of the joint. DeNovo® grafting involves resurfacing with donor pediatric cartilage or a donor osteochondral graft.

Autologous Chondrocyte Implantation

In this two-part procedure, healthy cartilage is harvested from the patient and sent to the lab where new cartilage cells are grown and returned for implantation into the damaged joint. “Implantation is one of the newer techniques to come along, but it’s not for everyone,” explains Frank Pettrone, MD, a Commonwealth surgeon with expertise in cartilage restoration.

Microfracture Cross section of Patella exposing bonePatellar articular cartilage

Trochlear articular cartilage

Cartilage & bone defect of Medial Femoral Condyle (after contouring)

Articular cartilageCortical boneCancellous bone

Cadaver donor graft

PatellaOsteochondral

Allograft (Transplant)


Keith W. Lawhorn, MD, graduated with a BA in Chemistry from the University of Virginia and continued his education at the University of Virginia School of Medicine, where

he earned his medical degree. He completed a general surgery internship and orthopaedic residency at the Medical College of Virginia. Dr. Lawhorn served on active duty in the U.S. Air Force for eight years, reaching the rank of Lt. Colonel.

Frank A. Pettrone, MD, earned a BA from Brown University and a medical degree from Georgetown University. Dr. Pettrone completed both his internship and residency

program at Georgetown University Medical Center. Then, before joining Commonwealth Orthopaedics, he served a tour in the United States Navy as an orthopaedic surgeon.

Kevin D. Sumida, MD, graduated with a BA from DePauw University in Greencastle, Indiana. Dr. Sumida earned a medical degree from the University of Kentucky College of

Medicine in Lexington. He completed his orthopaedic surgery training in Lexington before completing a fellowship in Sports Medicine at the University of North Carolina at Chapel Hill. In addition to his orthopaedic practice, he is also a clinical assistant professor at Georgetown University.


“It’s a complex and time-consuming procedure that involves both harvesting and transplanting cells. Patients must be carefully chosen. The optimal candidate needs to have a well-aligned, stable knee with no other major problems in the joint.”

Commonwealth surgeons consider many factors when determining the best treatment for each individual patient. “The location and size of the lesion coupled with age and activity level help to guide us,” says Keith Lawhorn, MD, who specializes in knee cartilage resurfacing procedures. “The use of biological techniques for articular cartilage repair gives surgeons the option in repairing damaged cartilage surfaces with living biological tissue similar to normal hyaline cartilage in an effort to preserve the integrity of the joint surface and maintain joint function.”

Current research is focused on new ways to make the body grow healthy cartilage tissue and Commonwealth is at the forefront in this area, as well. “Although candidates for cartilage restoration are typically younger, active adults with isolated lesions, promising new options are on the horizon for older patients,” says Kevin Sumida, MD, a Commonwealth sports medicine specialist with expertise in cartilage resurfacing. “Not only do we perform the latest techniques for younger patients with traumatic defects, but our practice is participating in a research study in which the hope is that stem cells may be able to replace worn out cartilage in an older age group.”

Cultured Chondrocyte Cells injected under patch

Chondrocyte or Cartilage Construct Implantation

Subchondrial Bone Plate

Healthy articular cartilage

Healthy articular cartilage

Subchondrial Bone Plate

Bioscaffold (with or without cells) or Bioengineered cartilage implants

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EXtreme Lateral Interbody Fusion (XLIF) offers a less disruptive surgical option for patients with chronic back pain. Commonwealth Orthopaedics was the first large

practice in the area to perform this advanced, minimally invasive procedure in which surgeons access the spine from the side of the patient, avoiding the major muscles of the back.

A lateral approach has many advantages that lead to a faster recovery, including:

Reduced operative time – The XLIF procedure can be successfully completed in as little as one hour, reducing the amount of time spent under anesthesia.

Reduced blood loss and post-operative pain – The procedure allows a much smaller entry through sensitive back muscles, bones, or ligaments, resulting in less tissue damage, blood loss, and post-operative pain.

Minimal scarring – The minimally invasive technique uses a much smaller incision, promoting a quicker recovery.

Reduced hospital stay – Patients are typically walking soon after surgery and require only an overnight stay in the hospital, compared to several days of immobility and hospitalization typical of traditional open approaches.

Rapid return to normal activity – Recovery is usually about six weeks, compared to six months or more for some spine surgeries.

XLIF is a type of interbody fusion. The disc in the front of the spine is removed and replaced with a stabilizing implant containing a bone graft. The two vertebrae are then fused together through the disc space. “Potential candidates for this procedure are patients with instability in the lumbar spine from disc degeneration, spondylolisthesis (where one vertebra has slipped forward over another), degenerative scoliosis (spine misalignment), or recurrent herniated disc,” says Steven Hughes, MD, a Commonwealth spine specialist who has been

performing XLIF for several years. “However, it is for a very select group of patients and the final determination should be conducted by a qualified orthopaedic surgeon.” XLIF cannot be used to treat conditions at the lowest level of the spine (L5-S1) because the pelvis prevents access.

The procedure is performed under neurologic monitoring called electromyography (EMG) to prevent damaging spinal column nerves. “With EMG, we run a current through the instruments we are using to detect the position of the nerves and avoid disturbing them during surgery,” explains Ron Childs, MD, a Commonwealth spine specialist who first performed XLIF five years ago and now instructs other physicians in the technique. “The current will alert us if we are too close to a nerve and we can adjust our position and move away.”

Commonwealth’s specialists are among an elite group of spine surgeons nationally who perform XLIF on their patients. Only about 20% use the technique in the lumbar spine and fewer still use it in the thoracic spine for conditions such as thoracic disc herniation.

Dr. Childs helped develop the lateral access system now in use and has lectured nationally on this topic. He performed the first lateral access surgery in the DC Metro area. Dr. Childs and Dr. Hughes are members of the Society of Lateral Access Surgeons (SOLAS).

Turning Spine Surgery on its Side

Ronald C. Childs, MD, a Major in the United States Army Medical Corp, Dr. Childs earned a BA in Psychobiology from Boston University before going on to complete his medical degree and orthopaedic surgery residency at Howard University. Dr. Childs then pursued additional training in Chicago where he completed a spine surgery fellowship program at Rush-Presbyterian—St. Luke’s Medical Center.

Steven S. Hughes, MD, graduated summa cum laude from the University of Rochester and completed his medical degree with honors from the University of Rochester School of Medicine. Dr. Hughes worked as a surgical intern at Bethesda Naval Hospital and was later honorably discharged after serving as a Commander in the United States Navy. Following his internship, he completed an orthopaedic surgery

residency at Strong Memorial Hospital in Rochester and a fellowship in spinal surgery at Case Western Reserve Hospital.

Commonwealth Specialists are among an elite group of spine surgeons nationally who perform XLIF on their patients.

Video Extra!Dr. Childs explains XLIF Spine Surgery in a video featured on our website: www.c-o-r.com/videos



Easing pain, restoring function, and helping patients put their lives back together is what motivates

Jenni Fox, LPTA, MS at Commonwealth Orthopaedics. Jenni has been part of the Commonwealth family for more than 24 years. She began as a volunteer with Alexandria Orthopaedics and Associates in 1988 – folding towels, answering phones, and filling in wherever needed. She moved on to PT aide in 1989 and began her practice in 1994. Five years later, Alexandria Orthopaedics merged with

Commonwealth Orthopaedics, and Jenni has been a valued employee ever since.

Her interest in the field dates back to her teenage years when she spent many difficult months recovering from a severe ankle fracture. “There were many complications and it turned into a long-term rehabilitation in which I had to learn to walk again,” she recalls. “Thanks to excellent care from two wonderful physical therapists, I had a really good outcome. The work was hands-on and rewarding

and I decided then and there I wanted to

make people functional again.”

Now clinical manager of Commonwealth’s

Fairfax physical therapy clinic, Jenni

brings unique professional training to her

job. In addition to undergraduate degrees

in physical therapy, she holds a master’s

in Health Fitness and Performance from

Marymount University. Health fitness and

performance takes a holistic approach to

rehabilitation. No two people are in the

same place following injury or surgery,

Employee Spotlight:Hometown Girl Gives Patients Courage, Strength, and Hope


and health fitness and performance helps the therapist identify specific, individualized factors that influence or hinder recovery.

Jenni is a hometown girl who grew up cheering for the Washington Redskins and Baltimore Orioles. The 41-year-old Alexandria native shares some proud history with her 12-year-old son, Jeremiah. Both were born in the same room at Inova Alexandria Hospital. These days, she can’t walk down the street without running into someone she knows, or someone she’s treated.

One of the most amazing aspects of her job is having the opportunity to help many of the people who helped her get to where she is today. “I’ve treated the doctor who delivered me, teachers who taught me in high school, and my mentor in physical therapy,” she says. “Without these people I wouldn’t be helping other people. Every one of them has touched my life in some positive way, and it is always such a prized moment when I can show them how their contribution turned out.”

The rehabilitation field has changed considerably since Jenni first volunteered to fold towels back in 1988. One of the biggest improvements she’s witnessed is the growing recognition of the importance of physical therapy to health, wellness, and performance. Surgeons are quicker to acknowledge its role in the recovery process, trainers and athletes apply it as an injury-prevention tool, and the workplace has embraced ergonomics for healthier, more productive employees.

At Commonwealth, these changes add up to seamless care and a smoother recovery process. “There is definitely more interaction between PTs and physicians these days and the protocols are better as a result,” Jenni says. “What’s unique about Commonwealth is that we can pick up the phone and talk to the physician whenever we need to, which helps with continuity and quality of care for our patients.”

Jenni loves being with people and credits her team of fellow therapists, aides, and front office coordinators for making Commonwealth such a great place to work. As for her patients, Jenni’s motto is Commonwealth’s motto. “It’s all about ‘getting back to your life,’” she says. “Being able to do simple things like reach up to a cupboard to get your coffee, or walk up and down the stairs, or hold your child. These are everyday things most people take for granted. But for those who are hurting or have lost the ability to function because of an injury, accident, or wear and tear, regaining independence is the most important thing in the world. And we help them recover with courage, strength, and hope.”

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Arthroscopic techniques have revolutionized shoulder surgery at Commonwealth Orthopaedics. Historically, physicians had to cut through connective tissue and disrupt the normal

anatomy to find and correct the problem. Now, shoulder procedures are performed through tiny incisions using a camera to visualize the inside of a joint. Guided by the camera’s images, surgeons use miniature instruments to carry out the operation.

“This tendon-preserving method allows us to access all areas of the shoulder joint, so we can see and address problems better than in traditional, open surgery,” says Daniel Weingold, MD, a Commonwealth surgeon whose areas of specialization include arthroscopic shoulder procedures. “And because it is minimally invasive, it is much easier on patients. They experience far less pain and blood loss, fewer complications, and in many cases, a faster recovery.”

Commonwealth offers the latest arthroscopic techniques for a wide variety of shoulder problems, including:

Rotator cuff tears. Rotator cuff muscles and tendons, which cover the shoulder joint and help it move, can tear when they are overused or injured. During rotator cuff repair, the edges of the muscles are brought together and the tendon is attached to the bone using small rivets called suture anchors. The anchors do not need to be removed after surgery. “Rotator cuff disorders come in a variety of degrees and the complexity of the tear usually dictates the repair approach,” Dr. Weingold explains. “In general, we tend to fix smaller, less complicated tears arthroscopically. Larger tears are more challenging and sometimes have to be performed with an open incision.”

Bankart/SLAP injuries. Common in overhead athletes, Bankhart/SLAP injuries involve tears to both the lower and uppermost parts of the labrum (the cartilage that surrounds and cushions the shoulder joint). “Arthroscopic repair for Bankhart/SLAP injuries allows surgeons a full view of the shoulder so they can reattach the torn tissue without having to cut through nerves or muscles,” says Edward Lane, MD, who performs these and other orthopaedic procedures at Commonwealth. “The result is a more balanced, stable repair that helps most patients return to full function.”

Frozen shoulder. In a small percentage of patients, pain and stiffness can make the shoulder hard to move over time. For those who fail to respond to non-operative treatments, surgical options include manipulation under anesthesia to loosen the shoulder and improve motion, or an arthroscopic procedure to cut through tight portions of the joint capsule. Manipulation and arthroscopy are often used together for maximum results.

Arthritis. “We perform arthroscopic surgery for severe arthritis of the acromioclavicular (AC) joint,” Dr. Lane explains. “This simple procedure involves removing the end of the damaged collarbone. It usually provides significant pain relief with minimum recovery time.”

Arthroscopic shoulder procedures are performed on an outpatient basis either in one of Commonwealth’s surgery centers or in the hospital. Patients go home with a brace on their shoulder and often opt for a cold therapy unit to keep the injury site cool and promote healing. Physical therapy begins within a week or two, and patients are able to return to basic activities soon after that. Resumption of sports or physical labor may require additional recovery time.

As arthroscopic techniques continue to evolve, Commonwealth is at the forefront, offering patients more options to address their conditions. “Our physicians are highly skilled specialists who have many years of experience in these types of shoulder surgeries and can handle very complex procedures,” says Dr. Weingold. “This level of expertise, coupled with newer instruments and the latest therapies, ensure our patients are receiving the most advanced care possible for their shoulder issues.”

The Kindest Cut: Shoulder Surgery Comes of Age

H. Edward Lane, III, MD, earned his medical degree from Georgetown University School of Medicine in Washington, DC. He then completed his internship and orthopaedic surgery residency at Georgetown University Medical Center.

Daniel E. Weingold, MD, earned an undergraduate degree at Duke University in Durham, North Carolina. He completed his medical degree at the University of Maryland School of Medicine and finished his surgical internship and orthopaedic residency training at George Washington University Medical Center in Washington, DC.

The Latest in Arthroscopic Techniques for Shoulder Problems

Video Extra!Watch our physician videos on seven different shoulder topics on our website: www.c-o-r.com/videos For full biographies and a complete directory of physicians at

Commonwealth Orthopaedics who perform these and other procedures visit our website at www.c-o-r.com.

The Kindest Cut: Shoulder Surgery Comes of Age


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Our orthopedic surgeons have performed thousands of joint replacements. But more important than quantity is the quality of care we provide. Our patients recover at rates that far exceed national averages. Meaning they get on with life faster. And we’ve been recognized by the Joint Commission for these quality practices and outcomes. It’s how we put you first. Learn more at restonhospital.com.

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Surf’s Up! - OrthoVirginia€™s Up! Multi-ligament Knee Reconstruction Helps DC Architect Ride the Waves ... Annunziata diagnosed a multi-ligament injury. In addition to the ACL