Blog 3

Blog 3: 12/17/08

I'm continuing my rotation with Dr. D--- this week. Today, I was in the O.R. watching mainly knee replacements. However, I also saw an amazing hip revision! I said this in my last post and I'll say it again, Dr. D--- is an amazing joint-replacement surgeon, in which people from all parts of California come to see. His skills and knowledge in hip and knee replacements in unparalleled, he knows all the intricacies of the procedure on a level most orthopedic surgeons cannot.

As I watch more knee replacements, I'm beginning learn the sequence of steps in the surgery. I've watched maybe five knee replacements so far, and it's pretty cool when you start understanding each step as it's going on. Dr. D--- first enters the knee through small incision and removes parts of the lateral meniscus, which is fibrocartilage that provides cushioning between the left part of the femur and tibia. He then attaches a cutting block to the femur by drilling screws into the bone. After the cutting block is attached, he shapes the distal end of the femur by sawing through the grooves of the cutting block. He then drills a large holes on the left and ride side of the distal femur end to accommodate the femoral implant. The proximal end of the tibia is also cut through the usage of a cutting block, however the cutting block is held to the bone with a large apparatus attached externally to the leg. Once he shapes the tibia with the saw, he makes a hole through the tibial medulla, which accommodates the tibial implant. He then fills the attachment holes in both the femur and tibia with cement, and attaches the implants (The femoral implant was attached way before the tibial implant). A plastic spacer fits on top of the tibial implant to serve as a bearing between the femoral and tibial components. It's a pretty simple concept, and it works flawlessly. At the very end of the surgery the back side of the patella (shaved down in the beginning), has a flag plug inserted. The whole process takes 45 minutes.

K--, Dr. D---'s main PA made a joke that I've watched so many I might as well be a resident. Although, it was a joke, I took it as a compliment. I know, I'm a dork!

Later in the day, I was able to see a hip revision. The particular case I saw was a tough one. The patient had a previous hip replacement from another doctor, but unfortunately the implant twisted and sunk further into his femur. The reason for sinkage may have been because of a fracture that occurred around the femoral component. His previous doctor neglected to really look into it, and gave him crutches. Because the problem was improperly addressed, the fracture healed around the sunken implant, which caused the patient more problems (pain etc.) Dr. D--- had to remove the femoral implant and replace it with one of a larger gauge, so that the new component doesn't sink as well. The surgery was extremely complicated. There were a lot of problems trying to remove the old implant because it was deeply seated and infused with ingrowths of bone. Also, the surgical tool used to remove the implant wasn't working properly and it jammed, so Dr. D--- had to use another tool. The implant came out with the application of a LOT of force (reverse hammering). Unfortunately, when it came off, it did so with a huge chunk of the proximal femur. The sheer force of the removal had caused the patient's old femoral fracture site to re-fracture. Fortunately, it wouldn't cause any problems because the implant didn't need to rely on the fractured portion of bone for it's function. Therefore, there was no need for a bone graft or fixation of the fracture. Because of the unforeseen factors and some technical difficulties, the surgery was an amazing learning experience. I was able to watch Dr. D--- use his vast knowledge in orthopedics to solve problems. He was able to use different tools in new ways because of the technical difficulties that occurred with the normal tools. He's brilliant, and I was EXTREMELY fortunate to a person of his calibre problem solve through the situation. He was able to use bone physiology and fracture pathology to deduce the insignificance of the fracture in relation to hip function; most orthopedic surgeons would have put in a bone graft and tried to treat the fracture further. I would attribute his reasoning skills and vast knowledge to his training at UCSF and other prestigious institutions. I believe his training separates him from all the other orthopedic surgeons who practice in the area.

In one of the knee operations, Dr. D--- had addressed something that had been in my mind for a long time. I always wondered if he got bored or disillusioned by doing one type of procedure all the time. Nothing really changes in his practice, everything is predictable. He told me to look at it in another way. To become the best at anything, you have to do that one thing over and over again. Doing too many different things, leaves you only mediocre at all of them. I assume that once you become amazing at one thing, it may be boring initially; but as it becomes second nature, you're able to really appreciate your own skills. It's a really interesting way to think. He told me that it's the same way in sports. It takes practice in your particular sport to be the best, even though practice may be hard, boring, and repetitive; eventually you become good like Kobe Bryant. I'm going to take his advice and focus my efforts in something I'm passionate about. Neuro-oncology or Spinal & Brain Trauma seem to be just that; I might even have to specialize within those two topics. Specializing and sub-specializing are the way to go! I learned a lot today, and I hope Dr. D--- teaches me more about what he's learned though his journey in medicine.