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Aching pains? Broken bones? Nagging sports injury? These are the best orthopaedic medicine providers in the region. Each one has a unique story to tell about how they're moving the field forward.
Click the 'play' button on the slideshow top right or select from the list below.
On a cold Saturday morning, Dr. Jon Divine, medical director of University of Cincinnati Athletics, stood in a parking lot with the parents of an athlete to show them their son’s MRI. The parents were concerned about the health and recovery of their son, and so was Dr. Divine. When sports medicine professionals share the sense of urgency that athletes, parents and coaches have, a superb sports medicine program results.
“In sports medicine, everything needs to get done yesterday. From the athlete to the coaches to parents of the athletes,” says Dr. Divine.
“Our practice, whether it is here or in the office, is set up to deal with that. In other words, let’s say an athlete has been injured on the lacrosse field. We need to get an MRI to that athlete and the parents and coaches to show that she tore her ACL, so they can plan accordingly and can get the surgery done in a timely manner.”
Dr. Divine, who is trained in family medicine with a certification in sports medicine, understands that caring for athletes requires a high level of drive and commitment. “There are six of us that are on the medical staff for the athletic department. We take turns to cover each event.”
The medical staff has to be ready at all times to deal with an injured athlete. Dr. Divine’s role with the athletes is to deal with injuries or illnesses that happen to active people. This includes providing care for 550 to 600 intercollegiate athletes, as well as a large number of students who play intramural sports.
As the region’s only academic health care center, UC Health is uniquely positioned to provide state-of-the-art care to the university’s athletes. The combination of a world-class healthcare system and a Division I college athletic program drives physicians like Dr. Divine to go beyond basic care for athletes. With the support system of UC Health, Dr. Divine can invest in his athletes in extraordinary ways, which is appreciated by the parents and coaches of these athletes.
For example, Dr. Divine and the sports medicine staff are using specialized, optical technology to make scientific strides in the treatment of concussions. Optical Coherence Tomography (OCT) is an eye machine typically used in the clinical world to examine retinal damage and neuro-degenerative changes in the eyes. “We have picked it up thinking that maybe there is something to this with head injuries,” says Dr. Divine. “Anything we can do now to help us to diagnose and treat concussions is huge. We started using the OCT machine two years ago. We have a theory that a lot of concussion symptoms are visual based or linked between the eye, the retina and the optic nerve, all which affect the brain.
“Instead of looking at the eye from straight ahead, it actually turns it 90 degrees and we can look at an image of a layer of cells within the retina and pick out the damaged area that is there.”
Dr. Divine says he became frustrated with not being able to help athletes reduce recovery time from concussions by being proactive. The medical advice was to just rest and let nature take its course, but
“I wanted to research how we could help nature along a little bit while keeping safety at the forefront for athletes anxious to get back into the game. We have tried to really promote that with our rehab program, especially with concussions. This curiosity has motivated us to find safe alternative treatments we could include for our concussed athletes to get better quicker, usually involving lower (intensity) exercise with balance and strength training exercises.”
This research has led to higher standards within when dealing with concussions. “Five years ago, we adopted a policy on managing concussions similar to what professional leagues have,” Dr. Divine says. “The NFL, for example, has asked that an independent doctor, not the team doctor, evaluate men and women athletes suffering from concussion.”
In addition, internal studies are a large part of the medical staff’s research. Every year the football team, during its two-week training, become test subjects. “We take our show on the road and do most of our data collection for our research,” Dr. Divine says. “We do things like measuring reaction times with light stimuli and looking at the eye with the OCT machine. All things related to concussions. We are in our fourth year and the research is finally beginning to come to fruition, including some publications coming out that will validate our research.”
When Dr. Divine stands in a parking lot on a cold Saturday morning with the parents of an injured athlete, he’s not doing so out of obligation. His interest goes beyond mere duty; it’s motivated by a deep concern for his athletes and a determination to stretch the established lines of the sports medicine world.
Do you have a nagging tennis elbow? Just get it zapped with an ultrasound needle. Rotator cuff won’t heal? Perhaps try an injection of your own blood platelets or stem cells and get the tendon to regenerate.
Of course, it’s not that easy. Or is it? As often happens in modern medicine, what might sound like science fiction is here today. Seemingly miraculous regenerative procedures are now readily available in the orthopaedic world, a potential game changer for mending the ailments listed above and more.
Orthopaedic doctors caution these techniques are still being refined as to exactly what works and on what type of damaged tissue, but they report many success stories. Some experts say the future is now when it comes to these procedures.
“People don’t want pills, they want cures. They don’t want a damaged tendon or ligament just covered up with steroids or cortisone,” says John Bartsch, MD, a certified specialist in physical medicine and rehabilitation at Beacon Orthopaedics. “These types of (regenerative) procedures offer hope in that direction.”
Bartsch is part of a new and evolving sub-specialty known as interventional orthopaedics. It focuses on non-operative, minimally invasive management of chronic issues. It is growing field, thanks to new technologies in diagnostics and imaging, along with breakthroughs in platelet and stem cell research.
Traditionally the orthopaedic specialist treats a patient with ligament and tendon damage on a conservative continuum of care that progresses from such techniques as diet, ice, ibuprofen and physical therapy to anti-inflammatory drugs and steroids, with surgery as the last resort. Bartsch says many patients are stuck in a “no man’s land” where treatments aren’t working and surgery seems too extreme. That’s where interventional orthopaedics can be of service, offering various regenerative technologies that might be effective.
“These are the people I talk to about interventional options,” Bartsch says. “We’d love to get away from cortisone and steroids, because we are finding more and more problems with that treatment.”
Bartsch says breakthroughs in imaging have made it possible to explore these options. “We can now see exactly where tendons and ligaments are broken down. Advanced imaging has already helped guide the surgeon; now it is getting so good we can see a diseased area without opening the skin. New devices allow us to target injections into the diseased part of a tendon and avoid injecting something into the healthy part.
Several injection treatments are available. First, ultrasound waves can be used.
Although “zap” is not a technical word doctors like to use, Bartsch says, in a sense that’s what happens in a procedure where a needle directs an ultrasound wave at damaged tissue. “The energy from the ultrasound is able to break down the diseased part of the tendon, leave the healthy part, and sort of washes that area as it is doing it.”
He compares it to a sonic toothbrush breaking down plaque around gums, or, for that matter, the opera singer breaking the glass. Even more exciting is the use of platelet-rich plasma (PRP). A
PRP solution is prepared by drawing a small amount of the patient’s blood and putting it in a centrifuge to separate platelets from the other blood cells. Platelets are known for their growth proteins that are important in the body’s healing process. The PRP is then injected into the damaged area with imaging directing it to the tendons that need to be repaired.
A similar procedure is used with a person’s own stem cells, although the extraction process can be more complicated.
In each case, the patient’s body is used to heal tissue. “PRP acts as a signaling component injected into worn down tendons and tells a healing process to begin, almost a rebooting of the system,” Bartsch says. “In our bodies, platelet cells are the first to arrive at an injury, such as when you get a cut. They send signals to cells all over the area to start a cascade of healing.
“PRP has been changing everything in the way we look at nonoperative treatment.”
Physicians have reported the best results with PRP in patients suffering from chronic tendon and ligament injuries such as tennis elbow, runners knee and plantar fasciitis.
Bartsch acknowledges the jury is still out on how effective the procedure can be. Technically, the treatment is regarded as experimental, but it is extremely safe since patients are using their own blood-based fluids. There are no foreign drugs introduced.
The profession is still learning when it comes to getting the PRP recipe just right, Bartsch says. “We are fine tuning the amount of platelet concentration, and how many white versus red blood cells to put in the mix, and learning what type of injection works in tendons.
Yes, there have been mixed reviews, but we are honing this, and clarifying and we are getting better. We are getting it nailed down.”
Doctors and patients around the country have reported spectacular results from such injections. For example, Bartsch says he recently treated a woman with bursitis in her hip who was not getting better
after multiple cortisone shots. “I gave her one PRP and she got 90 percent better in three weeks. So absolutely we are seeing benefits.” Bartsch says it is an especially viable option for a younger person
who has a tendon or joint injury but doesn’t want to commit to replacement surgery at a young age.
No major study has been done to confirm the body of positive anecdotal evidence. That’s one reason such techniques remain experimental and many insurance companies do not cover the cost of such procedures. But Bartsch believes it is only matter of time before that begins to change as PRP and similar procedures become more commonplace.
“It’s very safe and a game changer, because who knows if we can ever mimic in the lab what the body’s own cells can do,” he says. “Cardiologists are doing amazing things with healing scarred heart tissue in heart attack patients by injecting new cells. We can do a similar thing. This is the direction of orthopaedics and general medicine for at least the next 15 years.”
Orthopaedics differs from many of the other branches of medicine in two important and interrelated respects. First, because the specialty is primarily concerned with bones, ligaments, tendons and joints, it focuses more on the mechanics of body movement. Second, after having repaired a bone, ligament, tendon or joint, orthopedic surgeons can immediately see the effects of their work so there is immediate satisfaction that does not necessarily prevail in other specialties.
“A lot of times we can see the impact directly, especially if the treatment is surgical,” says Joseph Thomas, MD, an orthopedic surgeon at TriHealth Orthopedic and Spine Institute. “Obviously you have the before and the after apparent on an x-ray, and so you can clearly tell that you have done the best you can to improve someone’s life.”
Thomas graduated from the University of Cincinnati College of Medicine. Afterward, he did his orthopedic residency in Columbus at Mount Carmel Medical Center. Three years of active duty in the United States Air Force later, he returned to Cincinnati and has been here ever since.
Most med students learn about Orthopaedics in school. They gain experience in their courses and then decide through long deliberation that Orthopaedics is the specialty for them. Not Thomas. He was familiar with the role of an orthopedic surgeon by the time he started ninth grade.
“My experience with orthopedic surgery started very young,” he says. “I probably spent more time in my orthopedic surgeon’s office as a child than I did with my pediatrician.”
But Thomas has a rich affinity for Orthopaedics, one that may have started on the playground, but has since developed into a serious and successful career.
“The most rewarding thing about Orthopaedics is that when a patient comes to you and they are suffering from an injury or arthritis or a nonfunctional extremity, you get to play that role of making them better, whether that’s operatively or non-operatively to improve their extremity so that it’s functional. It really does improve that person’s life, and that makes this a very rewarding profession,” says Thomas.
Thomas joined Ohio Valley Orthopaedics in 2000. In 2007, the practice had built a new facility in Kenwood to “improve patient care and patient flow,” he says. In 2012, consolidation within the healthcare industry led Ohio Valley Orthopaedics to join TriHealth.
“We are lucky to be part of the TriHealth Orthopedic and Spine Institute,” says Thomas. “We are fortunate to have representation subspecialty-wise in multiple areas, which includes sports medicine, joint replacement, oncology, hand, spine, foot and ankle.”
TriHealth, says Thomas, has worked diligently to develop a culture of collaboration between physicians and administration, and physicians have been encouraged to take leadership roles. “I believe that this will be a stepping stone to improving patient care and improving the quality of our orthopedic service line.”
He also notes that TriHealth has been working hard to bring its specialty and subspecialty institutes together with primary care physicians to be able to make a “seamless, integrated healthcare delivery system for the purpose of improving patient outcomes, access to care and providing a way to measure it.”
Still, through all these changes, Thomas hasn’t forgotten the most enjoyable part of his job: patient care.
“That is what really draws physicians to be physicians,” he says. “It is one part that I find to be the most satisfying part of my job. Obviously there is the surgical side, which we train very hard to gain expertise in.
“But ultimately the real reward comes when you’re interacting with your patient and you know that the things you have done have improved their lives. I think that relationship between physicians and patients is special, and I hope it always remains that way."
An independent physician group with five locations around the Greater Cincinnati/ Northern Kentucky region, Commonwealth Orthopaedic Centers has resisted a trend within the healthcare industry towards consolidated employment models.
“There are some employment models out there where the orthopedic surgeons are employed by hospital systems, but we are not in that situation,” says Nick Gates, MD, orthopaedic foot and ankle surgeon at Commonwealth Orthopaedic. Gates laughs when he thinks about the term “independent physician group” because when he started practicing medicine, “that name didn’t exist. Every group was an independent group.”
Times have changed. The recent policy emphases on patient wellness, measurable results and information technology have caused a slew of acquisitions and mergers. Yet Commonwealth Orthopaedic Centers has adopted a different approach by collaborating with its long-time partners, St. Elizabeth Healthcare and the St. Elizabeth Physicians Group, to create a new Orthopaedic Institute.
“Our relationship with St. Elizabeth has evolved into an organized operation for the delivery of orthopaedic care,” says Gates. “The Orthopaedic Institute is a way of managing orthopaedic service lines across the board, be it foot and ankle, spine or total joint replacement. It allows the hospital and the orthopaedic surgeons to sit down and figure out the best way to deliver care, geared toward quality of care and improving the patient experience. Healthcare has changed a lot in my 18 years of practice, and by working with St. Elizabeth rather than separately, we’ve been able to deal with those changes in a way that benefits the patients most.”
“The institute allows for the coordination of care that provides for the delivery of high quality and consistent care across St. Elizabeth’s six surgery sites,” says Garren Colvin, St. Elizabeth interim CEO. “This conduit for quality is not dependent upon a physician’s desire to be independent.”
Part of that high-quality care includes new technology, including a new internal brace, developed by Gates in collaboration with other orthopaedic surgeons around the nation. The new brace is ideal for patients with chronic ankle sprains. “Once you sprain your ankle ligaments, they heal looser, and that tends to lead to more ankle sprains,” explains Gates.
“The internal brace implant is far more reliable and allows us to advance the rehabilitation and recovery for those patients, not only in the short term but also in the long term.”
Other medical advances available at Commonwealth Orthopaedic Centers include specific implants for joint replacements, anterior hip replacement and robotic-assisted surgery.
Commonwealth Orthopaedic Centers remains an independent physician group, but its unique partnership with St. Elizabeth allows it to excel in just the right places, says Gates. “We have done a great job of combining our goal of having the newest medical technology with our goal of taking care of the community.”
In the 25 years since Michelle Andrews, MD, orthopaedic surgeon at Mercy Health – Cincinnati SportsMedicine and Orthopaedic Center (CSMOC), started practicing medicine, many things have changed.
“I am astounded at how well we now control pain,” she says. Anesthesia with the use of nerve “blocks” and local tissue injections plus decreasing surgical time and blood loss have had a positive impact in reducing patients’ post operative pain.
Medicine is rapidly changing and orthopaedic surgery is no exception. Technology is driving new techniques. But of course technology also raises costs. “As physicians, we need to be mindful of costs and make sure there is added value for our patients and that their ultimate outcome is improved. How do we maintain our technology improvements and continue to push forward when our healthcare budgets shrink? It is a bit of a puzzle, but not impossible. The solution takes creativity and commitment.”
As for the industry of healthcare, Dr. Andrews notes there have been plenty of changes there as well, especially in the last five years. Healthcare providers are leveraging information technology to benefit their patients. Electronic medical records (EMR) allow doctors to record information about a patient so that the information is available to other members of the patient’s healthcare team. This ability to share information improves patient care and decreases costs by decreasing redundancy of diagnostic tests. Andrews is a huge fan of EMR.
As with all professionals, excellence can only be achieved with a personal commitment. “I personally have put in thousands of hours learning EMR in an in-depth way to allow me to document vital patient information efficiently and allow me to move smoothly through the clinic and OR. I actively embrace the new technology. I appreciate the fact that I can use dictation software to get information into the medical record efficiently.” says Andrews, who is a self-proclaimed computer nerd and whose dream after retiring from medicine is to become an Apple Genius.
But implementing the use of electronic medical record software and hardware is an enormous up-front investment that small medical practices find difficult to afford. Thus, many healthcare providers have begun to consolidate into larger healthcare networks that are in a better position to bear these costs and manage the scale of these services.
For example, The Jewish Hospital, where Andrews has practiced since 2005, was acquired by Mercy Health in 2010. CSMOC, Andrews’ own practice, was acquired by Mercy Health in January 2014. A large part of the reason why Andrews and her fellow orthopods at CSMOC chose to become part of Mercy Health was Epic, a leading electronic medical record system. The Epic software makes it possible for instant access to patient information. This seamless access in turn improves patient care by improving documentation and access to test results and communication and data exchange between doctors, patients and insurance companies.
The use of technology in healthcare and the consolidation of healthcare providers is, Andrews notes, part of a larger industry trend to become more patient focused. “I love this because I’ve always been a patient-focused doctor,” says Andrews. Mercy Health and Andrews have mutually embraced patient-centered care. An example given by Dr. Andrews is the newly nationally recognized The Jewish Hospital – Mercy Health Total Joint Replacement Center of Excellence, “which not only has earned the distinction of superlative health care for our Total Knee and Total Hip Replacement patients but it also recognizes the measures of our success in patient outcome.
“It’s not just about the number of procedures done at our hospital, it’s about doing them right and measuring and documenting our patients’ success,” Andrews continues. “As an example, we can show that our length of stay is better, our complication rates are less and patient satisfaction scores are high. We have data driven quality measures that show our successes and provide learning opportunities for improvement in an objective manner. We can learn from each other as data is exchanged through clinical measures and joint registries. A rising tide lifts all boats.”