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Orthopedic Surgery: A Mosaic of Skilled Work by Superspecialists

When one of their bones or joints needs surgical work, patients quickly find that they can't call just any orthopedic physician. In today's medical universe, patients need to connect with the correct medical superspecialist who will treat the specific problem interrupting their lives.

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healthbeatThis article appears in the July-August 2010 edition of HealthBeat, John C. Lincoln's free health newsletter.

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Virtually no orthopedic surgeon will do all varieties of bone and joint surgeries. These physicians specialize in backs or shoulders or hips or knees. Have a hand problem? Find a different surgical specialist.

Part of this is because so much more is known today about human anatomy, its problems and how to fix them, and it takes a lot of training to learn everything a surgeon needs to know about fixing any specific bone or joint.

So once a surgeon finds a superspecialty that "speaks" to him — or her — it makes sense to focus on that area to the exclusion of everything else.

Trauma Orthopedics: Equally Challenging and Rewarding

You might not suspect "fun" as the factor that would motivate someone to choose trauma orthopedics. Yet that's the hook that caught Laura Prokuski, MD, during her surgical residency.

Orthopedic Surgery Superspecialists
Orthopedic trauma patient Sean Moore and the doctor who put him back together after a motorcycle crash, orthopedic surgeon Laura Prokuski, MD.

She started her clinical rotations with no clue what she wanted to choose as a specialty and found her first couple of experiences less than thrilling. But next up was orthopedics, and it started with a trauma patient who was not likely to survive. Yet the next day, Dr. Prokuski saw the patient up and walking.

"It was an epiphany," she said. "Seeing this kind of amazing patient progress is the most fun you can have in medicine."

She likes being part of the Sonoran Orthopedic Trauma Surgeons, Arizona's only medical group that specializes in trauma orthopedics. "It's mentally and physically challenging," she said. "No two surgeries are ever the same."

Patients who are having the worst day of their lives when they come to you in the Level I Trauma Center at North Mountain Hospital can only get better, Dr. Prokuski said, "and they're really appreciative of whatever you do for them."

Ready for Patients Who Have the "Worst Day of Their Lives"

Certainly Sean Moore was having the worst day of his young life when Dr. Prokuski met him. And that's saying a lot, because his "worst-day" title had serious competition. "I have history," he said. "I blew up my car on my 19th birthday; I had my first motorcycle accident on my 20th birthday, and I spent my 21st birthday last year in the ICU.

"I think maybe this year I'll just reserve a room at the hospital and check in early, before I get hurt!" he said with a laugh.

Explaining his most recent hospital stay, Moore said, "I really don't remember what happened. They told me I was going through an intersection in the West Valley when a white pickup truck turned right in front of me. I must have seen it and tried to brake; police said there was a 40-foot skid mark behind my bike. My bike and my helmet were trashed."

A Multidisciplinary Approach

Moore was airlifted to John C. Lincoln's Level I Trauma Center with a ruptured abdominal aorta and small intestine. John C. Lincoln trauma surgeon Kara Villareal, MD, repaired his aorta and removed about eight inches of his shredded intestine in order to stitch it back together.

Only after his lifethreatening injuries were stabilized could Dr. Prokuski do her part. Trauma care is multidisciplinary.

"I like that aspect," she said. "You can do other kinds of orthopedic surgery as a solo practitioner," she said, "but in trauma you need lots of other people working with you. You need specialty-trained trauma general surgeons, plastic surgeons, neurosurgeons and vascular surgeons. I like being part of the team."

She repaired Moore's shattered pelvis, his fractured right femur, a cracked bone in his ankle and three broken foot bones. Moore thinks he spent several weeks in intensive care before spending the remainder of his two months in the hospital in a medical/surgical unit. But he's not sure, because most of his ICU time was spent in a medically induced coma.

Orthopedic Surgery Specialists
Orthopedic trauma surgeon Laura Prokuski, MD, shows her patient, Sean Moore, an X-ray of some of the hardware she installed to hold his shattered pelvis in place.

Back at Home, Looking Forward

Youth is an advantage, and, after an extended stay in a skilled nursing facility, Moore was healthy enough to return home, where he's planning to spend his 22nd birthday anywhere but in a hospital.

Moore's experiences with hospital care have inspired him to work toward a career in the hospital. "I just started school, a program to become a medical laboratory technician," he said. "I was really inspired by my medical experience."

Needing A Shoulder to Rely Upon

Unlike Moore, who didn't have to look for a trauma surgeon, finding the right doctor was important for Flagstaff resident Daniel Smith, who came to John C. Lincoln Deer Valley Hospital for innovative shoulder surgery.

And his shoulders needed serious help. Working on the railroad will take its toll, even on the toughest men. During his 30 years with the Santa Fe and later the B&N Santa Fe Railroad, Smith had five surgeries to repair damage to his right shoulder — and four on his left.

"It was putting the trains together, putting on the cars," he said. "I worked in the rail yard for over 17 years and that's a lot of wear and tear."

Smith's most recent surgical solution — something radically different — started a year ago when surgeons at Flagstaff Medical Center repaired a torn chest muscle. But a few months ago, it was clear that the repair hadn't solved the problem.

"They told me I needed a 'reverse' shoulder repair, but they were hesitant to do it because they didn't have the experience. So they referred me to Dr. Wall at Deer Valley Hospital," Smith said.

The Specialized Answer: Reverse Shoulder Arthroplasty

According to Brian Wall, MD, who is part of the CORE Institute and operates on patients at Deer Valley, reverse shoulder arthroplasty — one of his specialties — has only been available in this country for a half-dozen years and not many surgeons are doing it.

In traditional shoulder surgery, the ball at the top of the arm bone is replaced with a metal ball and the shoulder blade socket is replaced with a plastic socket. The reverse repair also uses a ball-and-socket joint, but the ball is attached to the shoulder blade, and the socket is grafted to the top of the arm bone, reversing and reconstructing normal anatomy.

The reverse procedure was specifically designed for patients such as Smith who have had traditional shoulder surgery complicated by shoulder arthritis and a torn rotator cuff. The rotator cuff is a group of four tendons and muscles that surround the shoulder joint. In these patients, the traditional artificial shoulder socket may loosen, causing excruciating pain.

Smith came to Deer Valley on March 18 where Dr. Wall had to break the artificial ball from the top of his arm to rebuild his joint.

"This is the first broken bone I've had in my whole life," Smith said, "and after two months, it's still a bit sore. But it's nothing compared to the pain I had been living with, and the difference is that I know this pain is going away. I really thank Dr. Wall for his work."

Healing is extra important now, because Smith's wife and daughter are nurses at Flagstaff Medical Center, which means his job is at home caring for his grandchildren, 4-year-old Jaylee Rose and baby Zach. "I've always been good with kids, cousins, nephews or others," he said, "so this is good. But I have to heal. Babies get heavy!"

The "Carpenters of Medicine"

Being able to solve Smith's problem is the kind of thing that initially appealed to Dr. Wall during his medical training. "I was attracted to orthopedics and specifically to shoulder work during my residency because it is so concrete, something that can be fixed. I like a problem I can solve," Dr. Wall observed.

Dr. Wall worked his way through college as a carpenter. "There are a lot of similarities to what I do now," he mused. "You could say that orthopedic surgeons are the carpenters of medicine."

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