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Polishing the Practice

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LEXINGTON An orthopedic practice that performs over 1200 knee and hip replacements a year yet seeks to exhaust all non-surgical options first, must have vision, discipline, and deep commitment to patient care. Lexington Clinic’s orthopedic unit, anchored by 10-year veteran Christian P. Christensen, MD, and including newcomer Tharun Karthikeyan, MD, has these in abundance. Both physicians are energized by the prospects of their collaboration and Lexington Clinic’s professionally supportive atmosphere. “A shared vision for excellent care for the community, tackling of complex cases, commitment to research, and tracking outcomes brought me Lexington Clinic to work with Dr. Christensen,” says Karthikeyan. Christensen adds, “The camaraderie of the physicians at Lexington Clinic is really impressive; we all hold each other to high standard.”

Across the country, orthopedic surgery is a boom industry. There are three basic factors for this: the number of people experiencing load-bearing joint arthritis increases with the obesity epidemic; advancements in replacement materials and rehabilitation rates eases surgery issues; and the dramatic degree of pain relief associated with joint replacement makes it appealing. As a result, Karthikeyan says osteoarthritis sufferers are more likely than ever to seek what they call “an arthritis surgeon.” Most patients in the Lexington Clinic practice are 40–80 years old, present with pain (often at night), noticeable stiffness or deformity (bowleggedness, for example), or are returning for a revision of a previously replaced joint. Christensen agrees with Karthikeyan, who says that, despite many patients’ preference, “Surgery is an option at the end of the line, not the beginning. In my practice, surgery is the last resort.” Clarity about real long-term solutions motivates this conservative approach for Christensen. “There are a lot of non-surgical alternatives for pain relief. I see a lot of patients who want to jump into surgery not having tried the alternatives available, so we have the conversation that surgery is not the right magic bullet.” He is frank with his patients, saying, “Let’s try rehabilitation. I know it’s going to be slower and the pain relief is going to be less complete, but it’s important for you because there is a greater risk of proceeding with more aggressive surgery.’”

Surgeries that Do Less Harm

Despite this approach, Christensen performed over 800 replacement surgeries in 2012 and has a waiting list of three months for his surgical services. Karthikeyan expects to work up to this pace over the next five years. Both utilize direct anterior approaches for some 80% of their first time hip replacements. This method has come into favor because “it is muscle sparing; you go between the muscles, which allows patients to get better faster,” Christensen explains. “Revision, however, is harder this way. With the traditional approach, you get better exposure when you extend your incision.”

Another orthopedic advancement they are working with is unicompartmental knee replacement. Some knee pathologies are limited in scope, allowing the surgeon to remove only part of the joint. While only about one in 10 cases of debilitating knee osteoarthritis allow this, Christensen says, “It offers the patient the opportunity to have an operation which can provide great pain relief and faster recovery, and it preserves more ligaments and bone.”

Both doctors are pleased with the decrease in rehabilitation time for these major surgeries. In 1986, a first time hip replacement patient could expect to spend six weeks on his back following surgery. Today, that same patient would be out of the hospital in one or two days and rehabbing at home. Less invasive surgeries and proactive pain control, prior to and during surgery, is the key to this. Both doctors agree that the aggressive pain control allows patients to do more soon after surgery. “They need aggressive pain control to try to gird themselves for the arduous rehabilitation they face,” says Christensen.

Challenges and Opportunities

There are both real and perceived challenges for orthopedic surgeons like Christensen and Karthikeyan. Christensen explains that, “The obesity epidemic is resulting in premature onset of load-bearing joint pain. Many of these additional surgeries also have suboptimal outcomes because of obesity related complications.” In addition, revision rates increase as the average age of first time surgeries lowers. Both doctors also see patients who assume that their non-arthritic, undetermined knee pain will be relieved if the whole joint gets replaced. Christensen says, “Knee replacement is not an operation that we do for pain that we do not understand. Arthritis is an obvious indicator for surgery.” He continues, “Someone who weighs too much, has a low pain tolerance, and no arthritis” should not be a candidate. He occasionally has to explain to a patient that weight or lifestyle could be causing the issue. “Not everything needs to be managed with surgery,” Karthikeyan concludes. “We are not dealing with a life-threatening condition here.”

It’s an exciting time to be in orthopedic surgery, especially at Lexington Clinic. With advancements in surgical methods and replacement materials always coming, an attitude of committed, thoughtful progress pervades this practice. For Karthikeyan, innovation is a responsibility: “We get better at what we do by trying new technologies; we should not be too cautious to try something new, because that will keep us from getting answers.” For Christensen, refinement of surgeries is the medical practitioner’s calling: “That’s why we call it a practice of medicine, because every day you are learning, every day you are refining. We want to be great at what we are doing.” The next step for this practice is to increase sub-specialization – “It is the key to our growth,” Christensen says. Adding a foot and ankle specialist this fall and a shoulder replacement specialist in 2015 are the current plans.