Patients with High Body Mass Index (BMI) and in Need of Hip Replacement Also Benefit from New Less Invasive Surgery

Anterior Surgical Approach Beneficial in Patients Often Told They are Not Candidates for Hip Replacement Due to Obesity

Zawadsky Surgery (Washington, D.C.) Rita Holliday of Laurel, Maryland couldn’t wait for her hip replacement.

“I had shooting pain down my legs and charley horses in my legs each day,” said Rita.  “When I woke up in the morning the only way to get going was to take a warm bath and rub my legs. The pain was often disorienting.”

Rita’s doctors diagnosed her with degenerative osteoarthritis.  As the pain worsened, she was less able to move around. Regular exercise became excruciating. Her Body Mass Index (BMI) rose as she gained weight.  

“It was a vicious cycle. I used to power walk with my co-workers three miles at a time, but the pain meant I couldn’t move. In my younger days I was a cheerleader and enjoyed roller skating until the spring of 2013, the year the pain began to worsen.”

Rita’s BMI (Body Mass Index), an indication of obesity reached 40.  She was turned down for hip replacement surgery because of the known risk for complications in people with a BMI over 30.  In addition she struggled with high blood pressure, type-2 diabetes and an autoimmune disease that required taking prednisone since 2009.

The World Health Organization (WHO) defines obesity as a person with a BMI of 30 or over.  People with a BMI between 25 and 30 are considered to be pre-obese.  

But orthopaedic surgeon Mark Zawadsky, MD and colleagues at MedStar Georgetown University Hospital recently published data showing that patients with a high BMI can also benefit from a new frontal approach to hip replacement. “The anterior approach to hip replacement surgery is easier on patients because I don’t have to cut muscle to access the hip joint,” said Dr. Zawadsky.  

Dr. Zawadsky conducted earlier published studies which found that the anterior or frontal approach to hip replacement meant patients left the hospital sooner, experienced less pain and needed fewer narcotics than those whose incision was made the traditional way, in the back.  Patients who had the anterior approach to hip replacement were also more likely to be discharged to their home rather than a rehabilitation center and were far less likely to need a walker after surgery.

But still the question remained.  Could obese patients benefit from the same technique?

“Obese patients receiving hip replacement have a greater risk of wound complications, infections increased time in the operating room and a greater need for pain management after surgery,” said Dr. Zawadsky.  “They also are in greater need of assistive devices and stay in the hospital longer after surgery than those with a normal BMI.”

To answer the question about the anterior technique and individuals with a high BMI, Dr. Zawadsky and his team looked at 210 consecutive patients who received total hip arthroplasty through the direct anterior approach. Sixty-one patients had a normal BMI, 71 were pre-obese and 79 were obese as defined by the WHO.  

 “While the obese group clearly had more of the expected complications than the other two groups, this study showed that they also saw the same benefits the other groups did due to the anterior approach,” said Dr. Zawadsky.  “The anterior approach was no more risky for patients with a high BMI in comparison to the other surgical approaches. In fact the technique showed advantages.”

The study is published in the March 2015 Journal of Arthroplasty.

After being turned down for surgery by another orthopaedic surgeon, Rita sought a second opinion from Dr. Zawadsky. He operated on Rita in April of this year and used the anterior approach. “I feel infinitely better,” said Rita.  “My family says I look so much better, just the expression on my face and the way I’m able to move around again.  This procedure has changed the quality of my life for the better. It’s been unbelievable. Patients should understand that it takes hard work and you must stick to the prescribed physical therapy regimen to see continued success. I am incorporating daily exercise and a healthy diet to get the weight off that I need to.”

Dr. Zawadsky, who helped establish MedStar Georgetown’s Bloodless Medicine Program, also applies bloodless medicine protocols, so the anterior hip approach has reduced his blood transfusion rates for hip replacement to less than 1%.  “We pay attention to pre-operative anemia and treat it before surgery. We use anesthesia techniques and medication during surgery to lessen blood loss. When you combine these protocols with the anterior approach, we’re finding that all of our patients, including those with a high BMI are tolerating hip replacement much better than patients of just three to five years ago.”

 

 

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The Journal of Arthroplasty

Obese Paper

Back in The Saddle: Surgery Brings Immediate Relief to Back Pain

By Emily Turk

Standing still isn’t an option for Deborah Mills. If she isn’t riding her horse in the Virginia countryside, she’s playing a round of golf or skiing on the slopes of Idaho.

But years of persistent and progressive pain from a degenerative disc threatened to diminish her active life. And that was an outcome Deborah simply wouldn’t accept.

“I did my research and saw more than half a dozen doctors,” Deborah says. “All of them told me that open surgery to fuse my spine was my only recourse. But that would mean months of painful recovery—and I was very afraid of that.”

Early last year, pressure on Deborah’s spinal nerves was causing debilitating pain in Deborah’s back and down her leg. Standing was becoming difficult. She was at her wits’ end when she was referred to MedStar Georgetown University Hospital orthopaedic surgeon Bobby Kalantar, MD. “He was a breath of fresh air,” Deborah says.

“I wasn’t feeling hopeful when I asked him if there was anything he could do for me. But he said ‘Yes, there is.’”

Additional tests revealed that Deborah was a perfect candidate for a minimally invasive spinal fusion—a procedure Dr. Kalantar has perfected. As chief of spinal surgery and co-director of the new, first-of-its-kind MedStar Spine Center at Chevy Chase, Dr. Kalantar focuses on personalized care—and seeks the least invasive treatment option for his patients.

DeborahMills_Horse_9696Final

Deborah’s quick recovery following a minimally invasive spinal fusion at the MedStar Spine Center at Chevy Chase has her back in the saddle and pain-free.

Patient-Centered, Collaborative Care

The center, which opened in August, offers patients like Deborah a multidisciplinary approach to evaluation and treatment of back and neck pain. The team of physical medicine and rehabilitation physicians and physical therapists from MedStar National Rehabilitation Network, and the neurosurgeons and orthopaedic spine surgeons from MedStar Georgetown, work collaboratively to treat simple and complex spinal problems—from common back pain to congenital disorders.

“We work in partnership to promote the best outcomes,” says Dr. Kalantar. “Our job is to work with the patient to find the treatment option that is right for them.”

“We have a central scheduling number and trained individuals who respond to phone inquiries to ensure a patient’s first visit is with the most appropriate physician. Our offices are next to one another, so a consult can mean a simple walk down the hall,” he adds.

In addition to providing easy access to a variety of medical and surgical specialists, the center provides imaging services and state-of-the-art interventional spine injections, all in the same location. “We’re giving patients what they need most, when they need it,” Dr. Kalantar says.

Less is More

For patients like Deborah, the Spine Center can eliminate the time—and personal cost—of shuffling from one office to another looking for answers.

The answer for Deborah was XLIF surgery—lateral lumbar interbody fusion. “The procedure is far less invasive, performed in half the time, and results in a faster recovery,”

Dr. Kalantar explains. “Instead of cutting through the major muscles in the back, I make several small incisions on the patient’s side. I use a surgical microscope to navigate to the area, insert instruments to remove the disc material, correct the alignment and fuse the vertebrae together. It’s often an outpatient procedure.”

Relief was immediate for Deborah. “In recovery, when I first stood up, I realized the pain in my leg was gone!” she says. “After some physical therapy, I was my old self—playing nine holes of golf and jumping fences on my horse.”

“Dr. Kalantar is the whole package,” a very grateful Deborah says. “He told me I wasn’t alone in this. He said we were partners, and we would work it out together. And we did.”

 

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MedStar Health at Chevy Chase

MedStar Health at Chevy Chase brings experts from MedStar Georgetown University Hospital, MedStar Washington Hospital Center and MedStar National Rehabilitation Network to the Chevy Chase community, making it convenient for you to get the care you need close to where you live and work.

Services Offered at MedStar Health at Chevy Chase:
MedStar Spine Center at Chevy Chase
• Primary and Preventive Care
• MedStar PromptCare Urgent Care
• Neurology
• Women’s Health
• Endocrinology
• Thyroid Surgery
• Vascular Testing
• Imaging Services
• Rehabilitation
• State-of-the-Art Medical Technology

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Spine Brochure

Two-Decade-Old Broken Bone Healed

Orthopaedic Patient Story
With her broken tibia finally healed, Anne can now enjoy daily walks with her beloved Lab, The Colonel.

Twenty years ago, a 20-something Anne Pfrimmer took to the road for her very first grown-up vacation.

But on a highway in South Carolina, her fun trip took a dangerous turn when she was hit head-on by another car that had crossed the median.

Anne was rushed to a local hospital with an open fracture of her tibia. To stabilize the bone and repair the break, surgeons inserted a titanium rod the length of her lower leg.

But the break wasn’t healing properly and examination by a local orthopaedic surgeon revealed an infection. Many additional procedures followed over several years—and Anne tried hard to return to her active life despite constant discomfort. But she now knows, “I walked around for 19 years on a broken leg and had accepted that it was as good as it would ever get.”

A Snowy Fall Becomes a Good Break

Fast forward to a snowy day in February 2014. Forty-three-year-old Anne, now a Washington, D.C., resident, took her beloved Labrador retriever, The Colonel, for a walk. She fell and knew instantly that the bone was severely reinjured. Luckily for Anne, a neighbor heard her cries for help. An ambulance took her straight to MedStar Georgetown University Hospital.

In the hospital’s Emergency Department, physicians found the impact of the fall had bent the metal rod to a 30-degree angle. The tibia had never healed. Anne would need surgery. “That’s when they called in the big guns,” says Anne.

She was sent home with an appointment to see MedStar Georgetown orthopaedist Francis X. McGuigan, MD.

“I was terrified I might lose my leg,” says Anne. “But Dr. McGuigan was so impressive. He explained every option. He had a plan for every possibility.”

Hope Comes in a Metal Frame

For Anne’s type of injury, Dr. McGuigan used a procedure that combines an advanced external fixation device, called the Taylor Spatial Frame, and computer-assisted surgery (Spatial CAD). “He was so confident this would work that I believed it, too,” Anne says.

Dr. McGuigan developed experience using the device and its computer applications while serving as a surgeon at the National Naval Hospital in Bethesda. He was one of only a handful of orthopaedic surgeons who used the procedure extensively to treat Marines who suffered severe lower-leg blast injuries in Iraq and Afghanistan. Now he is adapting it for patients with a number of complex orthopaedic problems.

“I thought Anne would be a good candidate for this surgery,” says Dr. McGuigan. “She had a chronic non-union—a compound break. Normally, the metal rod that was used in her leg would have compressed the bone, allowing it to heal. But Anne’s tibia never healed,” he explains.

During the procedure, Dr. McGuigan removed the bent metal rod from Anne’s leg, closed the incision and then affixed the frame to the outside of her leg.

The device is composed of two rings of metal with struts that join the rings. The computer calculates the precise length for the struts that will align the bone and encourage the body’s natural ability to grow healthy new bone tissue.

“After surgery, I wore shorts for nine months,” laughs Anne. “But I didn’t care. When the frame was removed in December, I was on my way to being free of pain for the first time in 20 years!”

Anne, who is back to work and walking The Colonel, knows that, if she had not been at MedStar Georgetown, the outcome could have been very different. “I got the expert. After the short surgery to remove the frame, I saw the grin on Dr. McGuigan’s face and knew the last months had been worth it. I’ll be forever grateful for the care I received,” she says.

 

To contact the MedStar Georgetown Foot and Ankle Center, call 855-546-0605 or visit MedStarGeorgetown.org/Ortho for more information.

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Marianne Worley
[email protected]
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Ankle Do Overs, Do Rights

Francis X. McGuigan, MD, and his colleague Paul Cooper, MD, are often called the “fixers.” They are the orthopaedic team of the MedStar Georgetown University Hospital Foot and Ankle Center, with special fellowship training in the repair of ankles—one of the most complex joints in the human body.

“Not every case we treat is complex. Often the injuries are more subtle, like an ankle fracture,” explains Dr. McGuigan. “In some cases, the fracture may have been repaired, yet the original procedure didn’t address damage to the articular cartilage, the super smooth joint surface that allows the ankle to move easily and painlessly.”

Dr. McGuigan often performs arthroscopic “revision surgery”— a minimally invasive procedure that results in less bleeding and a faster recovery. Using an arthroscope— a thin, flexible tube with a small camera—real-time images are captured on a video screen. He removes scar tissue and repairs the damage, which is often a joint surface that has been left rough following the first surgery.

“Right now, ankle arthroscopy is only done by a few surgeons, but in the future it will be the gold standard,” Dr. McGuigan adds. “We should do everything possible to get it right the first time to avoid unnecessary pain, a second surgery and possibly permanent limitations.”

Anterior Hip Replacement Surgery Questions Answered

Dr. Zawadsky

Mark Zawadsky, MD, Studied Standard Approach versus Anterior Total Hip Replacement for Patient Benefit and Cost  

(Washington, D.C.) Patients who need a hip replacement are benefitting from research conducted at MedStar Georgetown University Hospital that sought to answer a question no center had studied before: which works better, the standard minimally invasive hip replacement with the surgical approach from the back, or anterior hip replacement where the surgeon operates through the front of the patient?

It might seem like a minor variation, but for patients, one approach versus the other can make a big difference in recovery and cost.

Mark Zawadsky, MD, orthopaedic surgeon with the MedStar Georgetown Orthopaedic Institute found that the anterior hip procedure, also called anterior total hip or direct anterior hip replacement, is easier on the patient in several ways.

Dr. Zawadsky studied 150 of his consecutive patients using both a minimally invasive approach from the back (posterior) and the direct approach from the front (anterior) to access and replace the bad hip.  What he found is that patients who had the newer, frontal approach left the hospital sooner, experienced less pain and needed fewer narcotics after surgery than those whose incision was made in the back. Patients who had the anterior hip replacement were also more likely to be discharged to their home, rather than to a rehabilitation center and were far less likely to need a walker, after surgery.

Justin Kenney, 52, of Maryland is one such patient.

“I have two children, age five and seven and I noticed it was getting more painful trying to keep up with them,” said Justin who had his hip replaced at MedStar Georgetown University Hospital in April 2013. “I liked the idea that because he accessed my hip from the front, Dr. Zawadsky didn’t need to cut through my muscle to get to my bad hip and put in a new hip. I left the hospital the next evening able to walk with the use of a cane and manage my pain.  There is no question that my hip feels better now than it did before the surgery.”

For a direct anterior hip replacement the surgeon makes a three to four inch incision at the front of the upper thigh and unlike the posterior approach, does not need to detach the muscle from the bone.  “This means that I don’t have to repair muscles and the patient doesn’t have to wait for a repair to heal,” said Dr. Zawadsky. “There are no ‘hip precautions,’ like restricting movement that patients usually have to follow after hip surgery. And there isn’t the pain associated with cutting through muscle. The posterior procedure goes through the gluteal muscles and that usually means a pretty painful recovery.”

Dr. Zawadsky, medical director of MedStar Georgetown’s Bloodless Medicine Program, also applied bloodless medicine protocols, so the anterior hip approach reduced his blood transfusion rates for hip replacement from 30% to less than 1%.  “We pay attention to pre-operative anemia and treat it before surgery. We use anesthesia techniques and medication during surgery to lessen blood loss.”

The Centers for Disease Control and Prevention (CDC) reports that one in four people will develop hip arthritis, also called hip osteoarthritis, sometime in their lifetime. The symptoms include pain, aching or stiffness in the thigh, buttocks or groin and the incidence is the same in men and women, blacks and whites, across education levels and regardless of body mass weight.

The CDC also reports that hip replacement surgeries in nonfederal community hospitals rose from 304,700 in 2000 to more than 453,600 in 2010. In national costs, that translates to a growth in healthcare dollars spent from $4.5 billion in 2000 to $7.9 billion in 2010.

“In addition to a more rapid recovery for patients this anterior or frontal approach means a cost savings for the health care system overall, “said Dr. Zawadsky. “Patients need fewer hours of physical therapy and are back to walking with no aid or just a cane much more quickly, functioning in society earlier and not out of work for as long.  They can drive and be independent much sooner.”

 “I followed ‘doctor’s orders’ to rest and took it easy for about four weeks after my surgery,” said Justin. “I did in-home physical therapy and slowly increased my walking from the end of the driveway to around the block.  Six weeks later I was back in the pool, riding my bike and driving my car.”

 “Performing an anterior hip replacement or anterior total hip is a technique that requires a steep learning curve for the surgeon,” said Dr. Zawadsky. “It’s a difficult procedure to perform and it takes extensive training.  I attended courses, had video training and observed experienced surgeons conduct this approach.  This is a procedure where experience matters. The more you do, the more routine it becomes and outcomes improve. It’s a win-win situation.”

Dr. Zawadsky’s study was published by the Journal of Arthroplasty in 2014 and was presented at the October 2013 meeting of the International Society for Technology in Arthroplasty Annual Congress.

Anterior Hip Replacement video

MedStar Georgetown Launches Project to Improve Bone Health and Prevent Fractures in High Risk Patients

Bone Health Collaborative Looks to Close a National Gap in Care

(Washington, D.C. June 26, 2014) MedStar Georgetown University Hospital has launched a pilot project to coordinate care for people at risk for debilitating and potentially deadly bone fractures. In collaboration with groups that work to promote bone health, clinicians at MedStar Georgetown are seeing patients through a new Fracture Liaison Service (FLS) that evaluates people who have had a fracture for osteoporosis, and offers them treatment.

Osteoporosis is a skeletal disorder that causes bones to thin and weaken, making them more likely to break.

Gloria Trumpower receives bone density scan to test for osteoporosis.

“People with osteoporosis are at higher risk for suffering bone fractures,” said Andrea Singer, M.D., an internist and director of Bone Densitometry at MedStar Georgetown and medical director for the new FLS program. “Statistics show that only half of people over 50 who suffer a hip fracture ever return to their previous level of functioning and 25 percent of patients who break their hip die within the first year. So, this is an important disease to find and treat early.”

66-year-old Gloria Trumpower of Virginia is an active boater and ball room dancer. When she tripped and fell over her kayak and broke her arm recently she was invited to enroll in the FLS program at MedStar Georgetown. That’s where she learned from Dr. Singer that her fracture places her at higher risk for a potentially life-threatening second fracture. A bone density scan as part of the FLS program confirmed a diagnosis of osteoporosis. Gloria is now considering medication to treat the condition.

“The accident made me feel so vulnerable. I still can’t do normal things with my arm like zip a zipper or brush my teeth,” Gloria said. “I really hope to get back to my kayaking and ballroom dancing which I was doing three to five times a week until now. I also want to avoid a second fall at all costs.”

Here’s how the FLS works. Patients over the age of 50 who suffer a fracture after a low trauma incident will be identified through the inpatient service, emergency room, interventional radiology, orthopaedics, and other outpatient practices. They will next be invited to meet with a member of the FLS team to discuss their risk for osteoporosis and to undergo a painless bone density scan.

“If the scan or clinical situation is consistent with osteoporosis or a high risk for future fracture, I will offer the patient strategies to improve their bone health including nutrition, exercise and medication,” said Dr. Singer.

Andrea Singer, M.D. discusses test results and treatment options with Gloria Trumpower.

“To me osteoporosis has been a silent disease,” said Gloria. "I didn’t feel bad and couldn’t see my bones on a daily basis so I guess I took my bone health for granted.”

“One of the biggest obstacles in identifying and treating people with osteoporosis is our sometimes fragmented healthcare system,” said Dr. Singer. “We hope a Fracture Liaison Service will demonstrate a model of improved care that many hospitals in the U.S. can adopt.”

The Centers for Disease Control and Prevention reports that 10 percent of women and two percent of men over age 50 have osteoporosis.

“The numbers are devastating,” said Dr. Singer. “Of the 99 million Americans over age 50, half have osteoporosis or low bone mass, putting them at increased risk for fracture. And that number will continue to grow.“

The National Osteoporosis Foundation reports that half of women over 50 and about a quarter or men over 50 will break a bone in their lifetime due to osteoporosis. That works out to two million fractures each year due to osteoporosis.

The National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) reports that only 23 percent of women over age 67 who suffer a hip or other fracture are ever tested or treated for osteoporosis. Medicare spends more than $5 billion each year to treat bone fractures in seniors, yet most of the patients are not being evaluated for osteoporosis.

Dr. Singer recommends people ensure they’re getting enough calcium and vitamin D in their diets and supplementing with vitamins if necessary. Weight bearing and muscle strengthening exercises also help to strengthen bones. “And if you’re over 50 and have a low-trauma fracture seek an evaluation for osteoporosis that includes an easy 15-minute bone density scan.”

Bone density images can be compared with previous scans.

Those at highest risk for osteoporosis are Caucasian women with a small build. There are many other risk factors for osteoporosis and fracture including increasing age, a family history of broken bones and osteoporosis, current smoking, alcohol intake (3 or more units per day), poor calcium intake, low vitamin D, and inactivity to name a few. Certain medical conditions and medications can also cause bone loss.

Calcium rich foods include dairy products, fortified juices, cereals and other foods and some vegetables like leafy greens.

Dr. Singer says daily calcium requirements differ based on age and gender but generally the following is recommended from diet and supplements combined:

  • Women age 50 and younger 1000 mg calcium
  • Women age 51 and over 1200 mg calcium
  • Men age 70 and younger 1000 mg calcium
  • Men age 71 and over 1200 mg calcium

Women and men age 50 and older should get 800-1000 International Units of vitamin D each day, although some people need more.

The Bone Health Collaborative coordinating the FLS project is made up of the National Bone Health Alliance, the National Osteoporosis Foundation, and technology partner CECity which is providing its cloud-based MedConcert platform and an FLS application that includes a patient registry and care coordination application. The Johns Hopkins Armstrong Institute will analyze the collected data from MedStar Georgetown as well as the two other clinical centers, Alegent Creighton Health in Omaha, Nebraska and University of Pittsburgh.

Merck is providing funding to CECity for the pilot program.

Media Contact

Marianne Worley
703-558-1287
[email protected]

Patient Contact: 202-342-2400

MedStar Georgetown First in Washington, D.C. to Perform Two Level Artificial Disc Replacement in the Cervical Spine

New “Mobi-C” Device is Alternative to Spinal Fusion; Easier on Patients

Washington, D.C. – February 27, 2014MedStar Georgetown University Hospital became the first center in Washington, D.C. today to perform a two level artificial disc replacement in a patient’s neck. The hour and a half operation was performed on a 44 year-old Fairfax woman who has suffered with numbness in her arms and severe daily headaches after a car accident in 2007 caused herniated discs in her cervical spine.

Two Level Artificial Disc Replacement in the Cervical SpineThe woman received an implantable device called the Mobi-C© artificial cervical disc, FDA approved as an alternative to spinal fusion. The purpose of the Mobi-C is to restore disc height and natural segmental motion in the neck.

“This is a new technology that will clearly change the way we do cervical spine surgery in the future,” said Faheem Sandhu, MD, director of Spine Surgery and a neurosurgeon at MedStar Georgetown specially trained in minimally invasive spine surgery.

“This patient wanted to avoid fusion at all costs. She’s a young mother with an active life and wanted an end to her daily pain while preserving as much of her normal neck motion as possible.”

“To perform this operation I make a two centimeter incision in the front of the neck and remove the herniated discs,” said Dr. Sandhu. “Then, instead of implanting a bone graft, screws and plate to fuse the bones together, I implant the Mobi-C. This allows me to replace two disc levels at once without a fusion. What it gives the patient is more fluidity of movement in the neck, less post-operative pain and a quicker return to normal activities.”

“Mobi-C” DeviceDr. Sandhu says that studies show the Mobi-C also helps prevent future surgeries in fusion patients due to the additional stress fusion causes to adjacent discs above and below the fusion site.

“The patients also recover faster because they don’t have to wait for the bone to fuse to the graft. They wake up and can move their neck right away. I usually restrict their activity somewhat for about two months, but after that they can go back to their normal activities, including sports and workouts.“

Dr. Sandhu says the Mobi-C is not for everyone. It’s not recommended in patients with more than two levels of disease or who have bone spurs or a curved spine. Patients over the age of 55 should also be very carefully evaluated for the Mobi-C according to Dr. Sandhu because the spine changes significantly in older people.

Each Mobi-C device comes in three pieces made of cobalt chromium and titanium with a plastic core made to rotate and mimic natural motion of the cervical spine. Mobi-C is the first and only cervical disc approved for use at two contiguous levels of the spine.

Patients can go home the day after surgery and are encouraged to move their neck normally.

“I’ve been encouraged that my experience with Mobi-C has paralleled the literature that reports patients have more immediate pain relief than those who have fusion,” said Dr. Sandhu. “They do well and are very satisfied with their choice.”

Media Contact

Marianne Worley
703-558-1287
[email protected]

Patient Contact: 202-342-2400

Bloodless Medicine and Surgery Program at Georgetown University Hospital First in the Washington, D.C. Area

Procedures Performed to Honor Religious Beliefs Can Benefit All Patients

(Washington, D.C.) When Linda Lee, 57, of Washington, DC needed to have a non-cancerous tumor removed from her stomach in May of 2011 she was relieved to know that her surgery could be successfully performed in a way that respected her religious belief in not receiving a blood transfusion.

“As a Jehovah’s Witness I was not going to go against my belief not to receive blood. But I also understood that abdominal surgery very often requires a blood transfusion. After talking with my doctor at Georgetown and the staff of the bloodless medicine program, I felt confident about having the surgery I needed, without the blood transfusion I didn’t want,” said Linda Lee.

Ms. Lee’s physician was GI surgeon and Georgetown University Hospital’s vice president of Medical Affairs Stephen Evans, MD. Dr. Evans says that many patients request bloodless procedures. “This reflects a shift in medicine today. We are more sharply focused on reducing blood loss and eliminating the need for blood transfusions across the board. It’s simply good medicine since it addresses the concerns about blood borne diseases as well,” Dr. Evans said.

Mark Zawadsky, MD, an orthopaedic surgeon is medical director of the Bloodless Medicine and Surgery Program at Georgetown University Hospital, the first center in the Washington, DC area to have a comprehensive bloodless program. Orthopaedic surgeries also often require blood transfusions. “We have established a bloodless program here at Georgetown primarily after having discussions with the Jehovah’s Witness community. They have a large population here in DC and have often had trouble obtaining medical services because of their religious belief in refusing blood transfusions. The purpose of our program is to reduce or eliminate the routine use of transfusion in surgical procedures. The result really benefits all of our patients, regardless of their religious convictions. Over the past 15 years studies have shown that some of the different benchmarks we’ve been using for giving a blood transfusion were too high. We now have compelling evidence that it is safe to allow the patient to recover at a lower blood level. They tend to have fewer complications and there is a medical benefit to not transfusing patients as liberally as we had in the past. “

How is bloodless medicine practiced? Dr. Zawadsky says there are three primary approaches: before, during and after surgery. “Before surgery we can give medications like iron supplements or EPO protein to boost the blood’s hemoglobin level. That helps if the patient is anemic. During surgery we are as precise as we can be with surgical technique to limit blood loss; we keep the patient warm with warming blankets which keeps blood loss down. There are anesthesia techniques to lower the blood pressure so patients bleed less. There is also a machine called Cell Saver that we use during surgery which collects the blood lost, suctions it into a canister, washes and filters it and then returns it directly into the patient as a product that is about 60-percent pure red blood cells. After surgery we can use medications to raise blood levels and we avoid taking multiple blood draws for blood tests. It’s really a focus on how much blood the patient is losing with the goal of reducing or avoiding the use of blood transfusions,” Dr. Zawadsky said.

Ms. Lee had a procedure called isovolemic hemodilution to minimize the loss of red blood cells during surgery. Hemodilution is performed by removing anywhere from one half to two liters of the patient’s blood while they’re asleep before surgery begins. That amount of blood is then replaced with a fluid like saline to maintain the blood volume during surgery so if there is bleeding, there is less loss of red blood cells. Afterwards, the blood removed before the surgery is then put back into the patient, a process that then boosts the patient’s red cell count.

Ms. Lee is now back enjoying her regular life. “I am once again able to take care of my mother, visit friends and enjoy my work with the deaf community in my church.”

Dr. Zawadsky performed a total knee replacement on Theresa Mack, 58, of District Heights, Maryland. Ms. Mack is a Jehovah’s Witness and also wanted surgery without a blood transfusion. “I was in so much pain with my knee before this surgery. Dr. Zawadsky was very cognizant of my religious beliefs; he was great. He did everything I had asked regarding taking in blood. I am so glad I was able to have this done in a way that honored my religious beliefs. I couldn’t have done it otherwise.”

“Ms Mack received medication to treat her anemia before surgery, we used some surgical techniques to help clotting in the wound during surgery and slow down blood loss after surgery, and we limited the number of times we had to draw her blood for testing after surgery. She did very well.”

The Bloodless Medicine and Surgery program is open to anyone who wishes to avoid a blood transfusion. In June of 2011 Milca Francisco Ford of Silver Spring, Maryland went through the bloodless medicine program for her mastectomy at Georgetown. “The program is wonderful. I had so many friends and co-workers who were making me feel ridiculous for not wanting to agree to a blood transfusion. It was nice to have people who understood how I felt and were willing to work with me. They explained everything to me and evaluated me. For me, I just didn’t feel comfortable having a blood transfusion.”

“The blood supply is safer than it’s ever been,” said Dr. Zawadsky. “But there are still risks of disease transmission; the risks are small, but not zero. That’s why we see this as good medicine. Studies have shown a benefit when there is a priority on reducing blood transfusions and all patients can benefit from that.”

“This really is about treating the whole patient—physically and spiritually,” Dr. Evans added. “And while there is a large group of people in the area who request blood conservation methods for religious reasons, no one wants to have a blood transfusion. We know that blood conserving techniques help shorten hospital stays, reduce the risk of contamination and decrease the cost of care. They are a win, win for everyone.”

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