Journal

The official publication of the Jacksonville Orthopaedic Institute Volume IV, Issue I

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www.JOIonline.net &/+0*-DA@ • Complete care from diagnostics through rehabilitation • This region’s largest orthopaedic group practice offering the expertise of 28 physicians (board-certified or eligible, many with sub-specialties) • The most advanced techniques • The latest proven technology • Individualized treatment plans • Most major insurances accepted

Official Sports Medicine Partner

Baptist South Beaches Orange Park Point Meadows Riverside San Marco University 880.1260 241.1204 276.5776 241.1204 388.1400 346.3465 739.3319 Greetings from the Journal President of JOI… Spring/Summer 2007 acksonville Orthopaedic Institute continues to grow to meet the needs of our patients in this region. We offer seven convenient JACKSONVILLE ORTHOPAEDIC INSTITUTE Joffice sites, six rehabilitation centers, and three MRI sites. Our &/ 1325 San Marco Boulevard, Suite 701 group practice has welcomed many new physicians in the past year – Jacksonville, FL 32207 +0* SAN MARCO (904) 858.7199 David A. Doward, MD Physical Medicine Rehabilitation, Interventional Spine -DA@ Patrick A. Hinton • Complete care from diagnostics through rehabilitation Executive Director Brandon J. Kambach, MD Spinal Disorders, General Orthopaedic Surgery • This region’s largest orthopaedic group practice

offering the expertise of 28 physicians (board-certified The mission of the Jacksonville Orthopaedic BAPTIST SOUTH AND SAN MARCO Gregory Solis, MD or eligible, many with sub-specialties) Institute (JOI) is to provide high quality orthopaedic health care for our patients Foot, Ankle, and Knee Surgery with musculoskeletal disorders. • The most advanced techniques UNIVERSITY • The latest proven technology Maxwell W. Steel III, MD General Orthopaedics, Foot & Ankle Surgery, Sports Medicine • Individualized treatment plans The “official sports medicine partner” RIVERSIDE of the Jacksonville Jaguars Stephen J. Augustine, DO • Most major insurances accepted Sports Medicine & Arthroscopy, Shoulder & Knee Reconstruction

In August we will add one more fine physician to our group complementing JOI provides our group practice. SAN MARCO expertise in: Jennifer L.M. Manuel, MD Hand & Microvascular Surgery; Shoulder, Elbow Arthroscopy/Arthroplasty • HAND As the largest orthopaedic group practices in in Northeast Florida, our Mission is to meet the orthopaedic needs of our patients through diagnosis, treatment and rehabilitation. Our • FOOT AND ANKLE team approach offers efficient and effective care focused on the positive outcome of each patient. As a patient-centered practice of the highest quality, we value each patient-physician • JOINT relationship and hope to go beyond traditional expectations by delivering personalized, high-quality medical care. • SPINE All of our physicians are board certified or board eligible, many in subspecialty areas. Many of our doctors are involved in national research protocols, and some participate in the • SPORT MEDICINE research and design of equipment to enhance quality of care delivered by all orthopaedists. & ARTHROSCOPY Outside of the walls of our practice, we are your neighbors and friends. We are on the high We are dedicated to fostering a school, college and university fields, as well as the NFL’s Jacksonville Jaguars. We were a personalized and compassionate founding member of the Jacksonville Sports Medicine Program which offers free sports level of medical care for our patients. physicals every year to high school athletes in order to diagnose issues before they cause danger to our young athletes. We are diverse and represent many cultures, and have been part of the business fabric of Jacksonville for more than 12 years with a combined experience of hundreds of years, and we are on the leading edge of our specialty. Our practice is pleased to The JOI Journal is designed & published be a part of Baptist Health, Memorial Medical Center, and St. Vincent’s HealthCare. Official Sports by Custom Publishing Design Group Medicine Partner www.mycompanymagazine.com Jacksonville Orthopaedic Institute will continue to serve the families of this region with a To advertise in an upcoming issue please sincere commitment to utilize the most advanced techniques and proven technologies. contact Rebecca Reed at 800.246.1637 Families of this region can depend on our expertise. Jacksonville Orthopaedic Institute – a Jacksonville tradition since 1994.

Baptist South Beaches Orange Park Point Meadows Riverside San Marco University Michael S. Scharf, M.D., President 880.1260 241.1204 276.5776 241.1204 388.1400 346.3465 739.3319 www.JOIonline.net 3 Minimally Invasive Surgery

his is a term which is currently being not improve the rate or recovery other than that widely used by the medical profession due to pain from the skin incision. In other T and the lay press alike, and is the new words, it is the extent of the ‘invasion’ of the watchword with regard to joint replacement deep tissues that affects the rate of recovery to Philip R. Hardy, MD, JOI surgery. The concept of minimally invasive a greater degree than merely the length of the surgery, is not restricted to that specialty, incision. A specific example of this is that of however, but instead applied overall to the the ‘two incision’ approach that has been used concept of any surgery which involves less to perform total hip replacement surgery. surgical dissection, and therefore a faster and In this surgery, two small incisions, typically more complete recovery for the patient is to be 1-1/2 to 2 inches in length, are used to perform expected. As such, it was first widely in use in a total hip replacement operation instead of the the field of arthroscopic surgery, and is now more traditional single, longer incision. There being progressively incorporated into all types is, in fact, evidence which indicates that the of orthopaedic and other surgery, including trauma to the muscles about the hip is actually that of trauma surgery. more with this approach due to a significant amount of the surgery being done ‘blind’ and The term has often been used interchangeably there is no question that the complication rate with that of minimal incision surgery, is significantly higher due to the restricted however, these two concepts are by no means access in combination with the lack of the same. Performing the exact same amount visualization. Additionally, this particular type of dissection through a smaller incision will of approach cannot be converted to a standard

4 www.JOIonline.net JOI Journal “In this surgery, two small incisions, typically 1-1/2 to 2 inches in length, are used to perform a total hip replacement operation instead of the more traditional single, longer incision.”

approach in the event that complications occur, and therefore the lengths can be gradually reduced without compromising the potential advantages of this approach have to be ability of the surgeon to perform the surgery. In this way, the carefully weighed against the potential risks. These increased risks benefits of minimally invasive surgery can be achieved whilst and the most experienced surgeons trained in the techniques of avoiding the complications inherent in learning an entirely new minimally invasive surgery, and can lead to poorer outcomes. technique. Accordingly, whenever someone asks me how long Additionally, the lack of visualization can lead to less than ideal their incision will be for any particular surgery, my answer will positioning of the implants, and, as a result, the length of time the remain, “Just as long as it takes to get the operations done right.” replacement lasts may be reduced as well, compared to traditional techniques. This difficulty of visuali- zation is, however, being addressed by incorporating computer navigation during minimally invasive surgery.

In this type of surgery, computer navigation is utilized to assist in the correct placement of the implants even though direct visualization of the surgical site may be restricted. Reference markers are employed during the surgery which are attached to the boney skeleton and by using three dimension- al spatial analysis, the computer is able to assist the surgeon in knowing how and where the implants are placed compared to known ideal placements. This type of computer assisted navigation has indeed been shown to decrease the variability in implant placement compared to that achieved by the use of traditional instruments alone. Unfortunately, this dependence upon the computer rather than upon direct visualization of the surgical site produces yet another source of error, and requires another learn- ing curve on the part of the surgeon. This is an area in which experimentation is ongoing, and in which, realizing the frequency with which computer malfunctions occur, multiple fail safe mechanisms will need to be in place before this type of surgery will become widely accepted.

As has been the case with arthroscopic surgery, procedures are now being performed commonly, whereas 20 years ago they were inconceivable, and it is my expectation that such will occur in the field of minimally invasive surgery of all types. The change from traditional approaches to those used in mini- mally invasive surgery can be approached safely, however, and this is best achieved by a gradual transition from one to the other, such that a traditional approach can be resorted to, in the event that unforeseen circumstances arise, and incision

Jacksonville Orthopaedic Institute www.JOIonline.net 5 I thought I needed Jerry, age 58. Hikes 5 miles every week. a total knee replacement. Refuses to grow old.

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Individual results may vary. There are potential risks to knee replacement surgery. Visit www.biomet.com and Individual results may vary. There are potential risks to hip replacement surgery. Visit www.biomet.com and read read “Risk Information.” The life of any joint replacement will depend on your physical condition, activity “Risk Information.” The life of any joint replacement will depend on your physical condition, activity levels, levels, willingness to follow surgeon’s instructions, and other factors. Only an orthopedic surgeon can determine willingness to follow surgeon’s instructions, and other factors. Only an orthopedic surgeon can determine whether whether you are a candidate for knee replacement surgery. you are a candidate for hip replacement surgery. M2a-Magnum™ is a trademark of Biomet Manufacturing Corp. © 2006 Biomet Orthopedics, Inc. © 2006 Biomet Orthopedics, Inc. Buying,building,orrefinancingahome? Wecanputtogethertherightmortgageforyou.

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6 www.JOIonline.net JOI Journal Your Shock Absorbers Treating the Knees with Respect

othing smoothes a walk through life like a good pair of knees. N Those knobby shock absorbers do yeoman’s work, making it possible for you to get around however you like.

That is, unless they break down.

As we get older, the knees seem almost inevitably to wear out. It makes for quite p u o a bumpy ride. But the truth of the matter r G is that the knees take a lot of unnecessary n g i s strain simply because people don’t know e D

how best to care for them. g n i h s i l b u P

Giving your knees a little respect does a m o t lot for your long-term freedom. A little s u

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5

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2 By Louis Bradford © Jacksonville Orthopaedic Institute www.JOIonline.net 7 What Can Happen? Another injury borne from overuse The meniscus, the cartilage disk is tendonitis. Athletes participating that cushions the ends of the large First, the bad news. Here are a few in dancing, cycling and running can leg bones, can be damaged when one of the more common knee injuries stretch their tendons out, breaking quickly twists the upper leg while that people experience, according to down their elasticity and causing the foot remains planted. It’s a com- the National Institute of Arthritis and inflammation. It can cause pain mon problem in sports such as bas- Musculoskeletal and Skin Diseases around the kneecap during any kind ketball and tennis, causing some (NIAMS) of the National Institutes of strenuous leg exertion. pain and swelling that can become of Health (NIH). severe if the meniscus breaks apart.

Young adults can contract chondro- Arthritis breaks down the knee’s malacia, which refers to the soften- Sprains occur when the cruciate cartilage, which otherwise keeps the ing of the articular cartilage in the ligaments (anterior and posterior) are bones, muscles, tendons and liga- kneecap. The disorder can be stretched or torn. Such an injury can ments around the knee in order. The caused by injury, overuse, misalign- occur from violent impact, such as in problem is caused by joint stress, ment or muscle weakness, causing a football or in a traffic accident. It repeat injury or excess weight. dull pain most evident when walking may not cause pain, but the recipient Symptoms include pain, swelling stairs or hills. It’s common among may hear a pop, and the leg won’t be and a decrease in knee motion. runners, skiers and cyclists. capable of bearing weight. 8 www.JOIonline.net JOI Journal What To Do!

erly stretching your quadriceps (in There is hope. Treating your knees the front of your thigh) and ham- Cross Train – Engage in a variety of with a little care can help you prevent strings (in the back) you’ll reduce exercises, including activities like potential problems. pressure on your tendons. This will ball sports, hiking and yoga. The lead you into a healthy… variety gives you the most complete balance of motion to exercise your Watch Your Weight – If you’re over- legs. Of course, no matter what kind weight, when you walk around you’re Work Out – Specific exercises that of workout you prefer, you’ll do your wearing out your knees. Balancing build your leg muscles help reduce knees no favors unless you… your diet will help out with those wear and tear on your knees. joints as well as other health issues. Walking up stairs or hills, swimming, It’s easier to stay in shape if you stay riding a bicycle or engaging in a Wear Proper Footwear – Appropriate active. But first… supervised workout with weights shoes help you maintain your balance pays off in leg support. Evenly and leg alignment when walking, run- building your ankles, glutes, hammies ning or biking. If you’ve got flat feet Warm Up – Before exercising take a and quads will help ease shocks and or feet that roll inward (overpronate), short walk or ride a stationary bike. take some of the strain off your you may need orthotic shoe inserts to Then stretch out your legs. By prop- knees. Blend it all together in a… stay healthy. Jacksonville Orthopaedic Institute www.JOIonline.net 9 For More Information

National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse (877) 226-4267 www.niams.nih.gov/

The clearinghouse provides information about various forms of arthritis and rheu- matic disease and bone, muscle, and skin diseases.

American Physical Therapy Association (800) 999-2782 www.apta.org

The association publishes a free brochure titled "Taking Care of the Knees."

Arthritis Foundation The key to enjoying a lifetime of healthy movement is (800) 283-7800 or call your local chapter awareness. If you’re experiencing any unusual twinges or (listed in the local telephone directory) soreness, back off your usual routine. If problems persist, see a doctor. www.arthritis.org

By paying attention and taking some preventive meas- A free brochure on protecting your joints ures, your knees can stay strong. Stay active and alert is titled "Using Your Joints Wisely." The and you’ll see. They’re built to last. foundation also can provide addresses and phone numbers for local chapters and physician and clinic referrals. NOTE – The information included in this article serves as a rough guide to preventive practices for good health. Do not engage in any challenging activities without first consulting a qualified physician.

10 www.JOIonline.net JOI Journal The Doctors and Staff

of Jacksonville Orthopaedic JOI was a proud sponsor of the 30th Annual GATE River Run – Institute wish to thank the enJOI these Running Tips! River Run Tip #1: following businesses Do You Need Orthotics? FOOTWEAR: Make sure you are wearing prop- for their support Orthotics are custom-made biomechanical er shoes for your foot type. If you have high inserts that are placed in a shoe to either support arches, you will need a cushioned shoe. If you in JOI Journal. or cushion the arch to decrease forces up the have flat feet, you need a motion control shoe. lower extremity. There are several types that are Those in- between will do fine in a stability shoe. appropriate for different types of feet and PAIN: Listen to your body! Expect some sore- people. ness in the first few weeks of training; sharp pains Foot Type I: Requires a Shock-Absorbing should be addressed by a professional. Orthotic; Pes Cavus (High Arch) – Rigid Foot CROSS TRAIN: Mix in a different kind of work- Foot Type II: Requires a Rigid/Supportive out to your training program on off days. Ride a Orthotic; Pes Planus (Flat Foot and most com- bike, swim, play basketball or another physical mon) – Flexible foot activity. This will build complementary muscle • Akerman Senterfitt ...... page 11 groups and give your running muscles a break. What Shoe Will Work Best for You? • BioMet ...... page 6 Advances in shoe technologies have enabled REST: You need one to two days off per week to give your body time to recover. • Beaches Open MRI...... back cover runners to select shoes that accommodate partic- ular foot types and demands. For example, peo- FORM: Your upper body should be as relaxed as • Bennett’s Business Systems . . . . . page 23 ple with high arches need cushioning support, but possible with a feeling of being pulled along by a different size frames of people warrant different • Boger’s Shoes, Inc...... page 26 string attached to bellybutton. Your feet should hit levels of shock absorption. A flat foot requires without crossing over the midline of your body. • Brooks Rehabilitation Hospital . . page 31 stability support; but if the person is heavy, he or she will need some cushioning, also. River Run Tip #3: • Converged Communications. . . . page 31 The website www.roadrunnersports.com Stretching and Hydration PEARLS! offers a great chart that breaks down shoes into For every pound of weight lost during exer- • DJ Ortho (DonJoy Defiance)...... page 14 different categories for different foot types and cise, a 20-ounce electrolyte “sports” drink should • DJ Ortho (Bone Growth Simulator) . . page 14 size frames. This will enable a person to look at be consumed. the chart and buy a shoe that will help with their Eating should be modified to fit exercise goals • Durden Surgical ...... page 14 unique biomechanical needs instead of buying a leading up to a race. shoe based just on the look. Runners should perform a full body stretch • Joint Venture (DePuy) ...... page 26 routine that hits all lower and upper body muscles • Jaguar Computers...... page 26 River Run Tip #2: utilized during running. Tips for Injury Prevention Lower body stretches should include (mini- • Misys Health Systems ...... page 31 mum): quadriceps, hamstrings, IT Band, and calf VOLUME: Give yourself time! Running volume (gastrocnemius and soleus). • Pavilion Pharmacy ...... page 23 should increase at a slow pace over the course of Stretching should be performed pre- and 10-15 weeks to prepare your body for running post-workout to ensure maximum flexibility and • PSS Physician Sales & Service . . page 23 15K. prevention of injuries. • Suntrust Mortgage ...... page 6 STRETCHING: Maintaining good lower body A short warm-up should be completed prior to pre-workout stretching. • Surgical Concepts, Inc...... page 11 flexibility is essential to injury prevention. Stretch following your training runs when your Your routine should include stationary “static” muscles are warmed up. stretches as well as active “dynamic” exercises.

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Jacksonville Orthopaedic Institute www.JOIonline.net 11 Not All Bunions Are

Created Equal he painful bunion is a common condition that may restrict activities Tof daily living as well as recreational activities. In addition, it makes it difficult to wear fashionable shoes as well as Hiram A. Carrasquillo, MD, JOI decreasing the quality of life in general. A bunion condition can occur in adults as well as in the early adolescent population.

Numerous factors have been proposed as contributors to the development of bunion deformity. Among them are inappropriate shoe wear, particularly in women’s shoe fashion, preexistent congenital deformities, such as metatarsus adductus or pigeon toes, and even a flexible flat foot deformity. Also, conditions that affect joints, such as rheumatoid arthritis and other types of arthritic processes, may contribute to the development of the deformity. Finally, traumatic injury to the greater toe may cause, in rare cases, the deformity.

Several factors should be taken into account whenever a painful bunion is being treated, with treatment options that are geared to match the patient’s symptoms and expectations. Treatment alternatives include shoe modifications to match the Mild bunion before Mild bunion after shape of the foot with the shoe, and surgical alternatives where the shape of the foot is altered. All patients with painful bunions should attempt non-surgical routes prior to considering surgical alternatives. Fortunately, nowadays the shoe industry has become more conscientious to the demands of the population in creating a shoe that is comfortable as well as socially acceptable. Multiple brands are coming out with shoes that were created while having considera- tion for conditions such as bunions. Factors such as increasing the width of the toe box and avoiding seams over the prominent bony areas play major factors in providing comfort to the patient with a bunion deformity. Only those patients who fail to match their symptoms and expectations with shoes should consider the surgery.

Surgical alternatives for bunion correction should be customized to the origins of the deformity. There is no one single procedure Severe bunion before Severe bunion after that will correct all types of bunions.

12 www.JOIonline.net JOI Journal “All patients with painful bunions should attempt non-surgical routes prior to considering surgical alternatives.” Moderate bunion before

Not All Bunions Are Created Equal actors such as the degree of arthritis of the affected joint, the severity of the angle of the bunion deformity, Fseverity of the deformity of the bones surrounding the bunion deformity, whether or not there is abnormal motion on the joints next to the bunion, and the alignment of the toes next to the bunion deformity should be taken into consideration whenever a procedure is being chosen. Every surgical intervention should be well planned taking all these factors into consideration to obtain a successful outcome. More often than Moderate bunion after not, several procedures need to be performed in order to correct a bunion.

Most of the surgical interventions for the correction of bunions take place as an outpatient procedure. Recovery and the return to normal activity depend on the severity of the bunion, the number of procedures that are used, and whether or not weight bearing, swelling and pain can be controlled. Factors such as doing surgery on the right foot may involve limitations or restrictions of driving as part of the recuperation period. The possibility of being able to wear regular shoes varies from one patient to the other along with the duration of swelling. Additionally, early return to activities should be avoided as this may cause loss of correction or other associat- ed problems such as stress fractures. The cosmetic and functional satisfaction after surgery outweighs the common side effects of some loss of flexibility of the joint.

In this day and age, a high success rate makes the surgical correction of bunions a rather common procedure. However, the training and experience of the surgeon to put together treatment alternatives and offer the best option for each individual is still very important. At the Jacksonville Orthopaedic Institute, fellowship trained foot and ankle sur- geons provide you with the knowledge and experience required to maximize the success and treatment of your painful bunions. Complex bunion before and after

Jacksonville Orthopaedic Institute www.JOIonline.net 13 CMF_JOI magazine Ad.pdf 4/10/07 12:37:01 PM

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14 www.JOIonline.net JOI Journal

We Treat You Like A Pro!

acksonville Orthopaedic Institute (JOI) is a diverse We have six convenient Rehabilitation Centers to orthopaedic practice that focuses on the comprehensive accommodate a patient’s busy schedule: South (corner of Jcare of orthopaedic problems and musculoskeletal St. Augustine Road and Philips Highway), Beaches disease. Their practice includes general orthopaedics; the (adjacent to the office), Point Meadows (as above), management and treatment of occupational injuries; Riverside/ Westside (on Roosevelt Boulevard by San Juan), arthroscopic surgery; arthritis and bursitis; sports medicine; San Marco (as above), and University (adjacent to the hand, elbow and shoulder surgery; foot and ankle surgery; office); and three MRI Centers: Beaches (adjacent to the knee surgery; spine surgery; and joint replacement surgery. office), Riverside/Westside (at the Rehabilitation), and San Our mission is to provide a high quality, comprehensive Marco (adjacent to the office). We are a regional leader in service for individuals of all ages in order to promote and rehabilitation. restore health and fitness to the highest level of function. Patient care is coordinated so that all aspects of are smooth- JOI participates in more than 140 health plans, including ly integrated and streamlined, from initial diagnosis through Aetna, Blue Cross Blue Shield of Florida, CIGNA, completion of treatment and rehabilitation. Medicare, Prudential, United, and workers’ compensation. We make every effort to work with our referring Primary We have seven convenient office locations serving Care physicians to serve the needs of each patient and to Northeast Florida: Baptist South (at Baptist Medical Center satisfy the requirements of a patient’s managed care plan. – South on Old St. Augustine Road), Beaches (Jacksonville Beach), Orange Park (just past the corner of Kingsley Patients are our priority. We are dedicated to providing Avenue and Blanding Boulevard), Point Meadows (just off high quality, timely and appropriate medical care. If you 9A then Gate Parkway), Riverside (dePaul Building at have any questions about our physicians, facilities or treat- St. Vincent’s), San Marco (corner of San Marco Boulevard ment options, please call us or go to www.JOIonline.net. and Nira Street) and University (just down from Memorial Health). 1 BAPTIST SOUTH 4 POINT MEADOWS 14546 St. Augustine Rd., Ste 107 7740 Point Meadows Drive Suite 7 Jacksonville, FL 32258 Jacksonville, FL 32256 904.880.1260 904.241.1204

John M. von Thron, MD Richard R. Grimsley, MD General Orthopaedic General Orthopaedics, Joint Replacement

Brandon J. Kambach, MD Steven J. Lancaster, MD Spinal Disorders, General Orthopaedics General Orthopaedic Surgery Dale A. Whitaker, MD General Orthopaedics Stanton L. Longenecker, MD General Orthopaedics, Sports Medicine, Total Joint Replacement Dale A. Whitaker, MD Richard A. Picerno II, MD General Orthopaedics General Orthopaedic Surgery, Arthroscopic & Adult Reconstructive Surgery Edward D. Young, MD General Orthopaedics

3 ORANGE PARK H. Lynn Norman, MD General Orthopaedics, 454 Blanding Boulevard Total Joint Replacement, Orange Park, FL 32073 Edward D. Young, MD Surgery of the Knee & Shoulder 904.276.5776 General Orthopaedics 6 5 SAN MARCO Robert G. Savarese, DO RIVERSIDE 1325 San Marco Boulevard Physical Medicine Rehabilitation, 1801 Barrs Street, Suite 300 Suite 200 Non-Surgical Spine Rehabilitation Jacksonville, FL 32204 Jacksonville, FL 32207 904.388.1400 904.346.3465

Stephen J. Augustine, DO Sports Medicine & Arthroscopy, Shoulder & Knee Reconstruction

Gregory Solis, MD Foot, Ankle & Knee Surgery Stephen J. Augustine, DO Hiram A. Carrasquillo, MD Sports Medicine & Arthroscopy, Foot & Ankle Surgery, Shoulder & Knee Reconstruction General Orthopaedic Surgery

Richard R. Grimsley, MD General Orthopaedics, Joint Replacement Bruce Steinberg, MD Hand & Microvascular Surgery, Shoulder, Elbow Arthroscopy/ William N. Campbell, MD Steven M. Crenshaw, MD Arthroplasty General Orthopaedics General Orthopaedics, Sports Medicine 2 BEACHES 410 Jacksonville Drive Jacksonville Beach, FL 32250 Patrick M.J. Hutton, MD 904.241.1204 General Orthopaedics, Sports Medicine Arthroscopic Surgery Sunday U. Ero, MD David A. Doward, MD General Orthopaedics, Physical Medicine & Rehabilitation, Orthopaedic Traumatology, Interventional Spine & Spine & Scoliosis Surgery Sports Medicine

Steven J. Lancaster, MD General Orthopaedics

CONTINUED 7 UNIVERSITY 5737 Barnhill Drive Suite 102 Jacksonville, FL 32207 904.739.3319 SAN MARCO continued R. Stephen Lucie, MD Michael S. Scharf, MD Sports Medicine, Adult Spine Surgery, Joint Replacement Surgery Hip Reconstruction

Robert J. Kleinhans, MD Philip R. Hardy, MD Hand Surgery & Arthroscopic & General Orthopaedics Joint Replacement Surgery

Richard A. Picerno II, MD Gregory Solis, MD General Orthopaedic Surgery, Foot, Ankle & Knee Surgery Arthroscopic & Adult Reconstructive Surgery

Brandon J. Kambach, MD Maxwell W. Steel, III, MD Spinal Disorders, General Orthopaedics, General Orthopaedic Surgery Foot & Ankle Surgery, Bruce Steinberg, MD Sports Medicine Hand & Microvascular Surgery, William G. Pujadas, MD Shoulder, Elbow Arthroscopy/ General Orthopaedics & Arthroplasty Sports Medicine, Total Joint Surgery Gregory C. Keller, MD Adult and Adolescent Spinal Surgery, General Orthopaedic Surgery

Carlos Tandron, MD Sports Medicine & Joint Replacement Robert G. Savarese, DO Surgery, Knee & Shoulder Physical Medicine Rehabilitation, Arthroscopic Surgery Non-Surgical Spine Rehabilitation

Garry S. Kitay, MD Hand & Microvascular Surgery, Upper Extremity Reconstruction JOI REHABILITATION SERVICES BEACHES Aquatic Therapy – Biomechanical Analysis 436 Jacksonville Dr. – 904.247.3324 (Jacksonville Beach) Custom Splinting – Hand Therapy – Occupational Therapy POINT MEADOWS Post-Operative Therapy – Pre-Operative Programs Physical Therapy – Spine & Back Education Programs 7740 Point Meadows Dr., Suite 1 & 2 – 904.564.9594 (9A at Gate Parkway) Sports Injury Rehabilitation – Throwing Programs RIVERSIDE/WESTSIDE Work Injury Rehabilitation 4239 Roosevelt Blvd., Suite 600 – 904.389.8570 (by Roosevelt Mall) SAN MARCO PROFESSIONAL STAFF 1325 San Marco Blvd., Suite 102 – 858.7045 Athletic Trainers Certified (LAT) SOUTH Certified Hand Therapists (CHT) 14546 Old St. Augustine Road, Suite 107 – 904.880.1260 Certified Strength and Conditioning Specialists (Durbin Crossing at Phillips Hwy. and St. Augustine Rd) Occupational Therapists (OT) Physical Therapists (PT) …and more! UNIVERSITY 5737 Barnhill Drive, Suite 102 – 904.858.6426 (Next door to the University office)

We are dedicated to providing you state-of-the-art rehabilitation The Official Sports Medicine designed to meet your specific needs. With an expert staff committed Partner of the Jacksonville Jaguars to providing individual attention, we offer comprehensive and conven- ient locations. You couldn’t be in better hands than those at JOI! Choose JOI, the region’s leader in effective, healthy rehabilitation. 0XVFOH 0DGQHVV E\*(25*(-26(3+

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22 www.JOIonline.net JOI Journal Jacksonville Orthopaedic Institute www.JOIonline.net 23 creating prototypes and introducing consumer mod- els in rapid succession. The Revolution Thinking Green The difficulties encountered have included appear- ance, size, and most importantly, cost. But HEV The hydrogen fuel cell represents one dynamic break- By Donald Davis manufacturers have taken their cues from one Henry Ford, recognizing that cost-savings come through through in automotive technology. But a company in the the process of mass marketing. small town of Basalt, Colorado has incorporated the cell into a car that is different and new in virtually every way. And, as a result of high quality products at lower prices, consumers buy more and more. The design group? Hypercar. The design? Fittingly enough, it’s called the Revolution. The three keys are fulfilled. Lessons Learned | Of course, it’s a significant Company spokesman Michael Brylawski says, “If you bonus for any entrepreneur when the developed want to achieve results, then you must use a completely product significantly improves the world, as is the new methodology.” case with the HEV car. That moral advantage even Hypercar has. gains an economic aspect when governments, such as that of the United States, gets behind a product The hydrogen fuel cell is just one new component – one line, helping to incite the consumer culture. that offers more than 90 miles to the average gallon. As of 2002, manufactured passenger cars must Another feature of the Revolution is how the car is driv- meet a mandated requirement of 27.5 miles-per-gal- en. No steering wheel greets the driver. Instead, what lon. Light trucks, mini-vans and sport utility vehi- amount to joysticks positioned on either side of the body cles must average 20.7 miles-per-gallon. Legislators control the car’s direction and braking. That helps regularly argue for highly heightened standards, improve the safety of the vehicle, for the steering wheel even suggesting an 80 miles-per-gallon minimum itself is the most common cause of injury in accidents. Selling Ideas to the American Public within the next two decades. The body of the car itself is made of an advanced com- What these requirements mean for major manufac- posite – a polymer matrix with carbon fiber reinforce- turers is simply a change in focus to meet the stan- The Development of Eco-Friendly Cars ments. This extremely lightweight material replaces the dards. But it also opens the door to the next wave of entrepreneurs, who can follow the formula and steel traditionally used in a car’s body. Even though the t’s tough to sell a revolutionary techniques, the motor in motorcars combustion engines became very vehicle weighs less than one ton, it is still safe for passen- idea to a public accustomed to was powered by gas. His revolu- popular, only to be phased out by trends in public consciousness to reach business success. gers in crashes up to 35 miles-per-hour – 5 miles-per-hour Ithe status quo. As an entrepre- tionary ideas spawned an entire Ford’s work. better than the U.S. safety requirement. neur, you’ve got to have a few century of industry and transporta- Now, however, thanks to the In the automotive industry, hybrids are only one tion. things going for you: aforementioned environmental con- example. Vehicles can also be powered by hydrogen “Licensing the whole car would be the Holy Grail of our fuel cells, which create electricity by combining You must have a compelling rea- Speed on up ahead to the latter cerns plus great attention to the efforts,” says Brylawski from his office in the mountains gaseous hydrogen extracted from fuel with oxygen son to make something new. half of the century. Sure, people dwindling supply of oil and its near Aspen. “But it’s not necessarily feasible at this could use the car to get around accompanying global politics, car taken from the air. In fact, in early 2002 the federal point.” Your product must strike the pub- where they wanted, when they owners are again turning their government pushed for increased research into this lic fancy. Because of the company’s limited resources, instead of wanted, faster than ever before. But attention to alternative fuel vehi- concept with a program called Freedom CAR p (Cooperative Auto Research). Companies such as trying to sell the Revolution, Hypercar presents its com- u The product must be good enough sprawling cities, super-highways cles. o r Hypercar, Inc. are using that technology to antici- pletely new design as a “foundation platform” for large

G that people will buy more and

and smog turned out to be the last- n That’s the necessary ingredient of pate the next vehicular trends (see sidebar). automakers to consider. That way, Hypercar can have a g i more. ing legacy of Ford’s vision. s e a captured public fancy. piece of the pie when some of these futuristic features

D The gist of that kind of entrepreneurship is this: to To illuminate these principles of g That’s a compelling enough rea- become part of the auto-making present. n Production | To take best advan- i know both your industry and your audience is to h entrepreneurship, one need look no son to make something new. s i tage of this growing interest, Honda l realize success in selling new ideas. b further than the development of the To revolutionize the automobile industry takes two fac- u The first electric car, believe it or expedited development of its P hybrid car. tors: time and money. For example, to set up 500 hydro- m not, was created way back in 1835 Insight HEV (Hybrid Electric o t gen-refueling stations around California (the minimum s

u History | Back in the early years in the Netherlands by Professor Vehicle). That car hit the American C

required to enable fuel cell car travel around the state)

5 of the 20th century, the power of Sibrandus Stratingh. Others devel- market in 2000, followed soon after 0

0 would cost about $235 million, according to the inde-

2 the internal combustion engine cap- oped the first road-practical ver- by the Toyota Prius. Nearly every

© tured the public imagination. With sions in the 1840s. At the turn of other major automobile manufac- pendent California Fuel Cell Partnership. the advent of Henry Ford’s land- the century, hybrid cars that com- turer, including General Motors and So the price can be prohibitive, but as with all techno- mark assembly-line production bined electric batteries with internal Daimler Chrysler has followed suit, logical advances, it will be overcome with time. 24 www.JOIonline.net JOI Journal creating prototypes and introducing consumer mod- els in rapid succession. The Revolution The difficulties encountered have included appear- ance, size, and most importantly, cost. But HEV The hydrogen fuel cell represents one dynamic break- manufacturers have taken their cues from one Henry Ford, recognizing that cost-savings come through through in automotive technology. But a company in the the process of mass marketing. small town of Basalt, Colorado has incorporated the cell into a car that is different and new in virtually every way. And, as a result of high quality products at lower prices, consumers buy more and more. The design group? Hypercar. The design? Fittingly enough, it’s called the Revolution. The three keys are fulfilled. Lessons Learned | Of course, it’s a significant Company spokesman Michael Brylawski says, “If you bonus for any entrepreneur when the developed want to achieve results, then you must use a completely product significantly improves the world, as is the new methodology.” case with the HEV car. That moral advantage even Hypercar has. gains an economic aspect when governments, such as that of the United States, gets behind a product The hydrogen fuel cell is just one new component – one line, helping to incite the consumer culture. that offers more than 90 miles to the average gallon. As of 2002, manufactured passenger cars must Another feature of the Revolution is how the car is driv- meet a mandated requirement of 27.5 miles-per-gal- en. No steering wheel greets the driver. Instead, what lon. Light trucks, mini-vans and sport utility vehi- amount to joysticks positioned on either side of the body cles must average 20.7 miles-per-gallon. Legislators control the car’s direction and braking. That helps regularly argue for highly heightened standards, improve the safety of the vehicle, for the steering wheel even suggesting an 80 miles-per-gallon minimum itself is the most common cause of injury in accidents. within the next two decades. The body of the car itself is made of an advanced com- What these requirements mean for major manufac- posite – a polymer matrix with carbon fiber reinforce- turers is simply a change in focus to meet the stan- ments. This extremely lightweight material replaces the dards. But it also opens the door to the next wave of entrepreneurs, who can follow the formula and steel traditionally used in a car’s body. Even though the trends in public consciousness to reach business vehicle weighs less than one ton, it is still safe for passen- success. gers in crashes up to 35 miles-per-hour – 5 miles-per-hour better than the U.S. safety requirement. In the automotive industry, hybrids are only one example. Vehicles can also be powered by hydrogen “Licensing the whole car would be the Holy Grail of our fuel cells, which create electricity by combining efforts,” says Brylawski from his office in the mountains gaseous hydrogen extracted from fuel with oxygen near Aspen. “But it’s not necessarily feasible at this taken from the air. In fact, in early 2002 the federal point.” government pushed for increased research into this concept with a program called Freedom CAR Because of the company’s limited resources, instead of (Cooperative Auto Research). Companies such as trying to sell the Revolution, Hypercar presents its com- Hypercar, Inc. are using that technology to antici- pletely new design as a “foundation platform” for large pate the next vehicular trends (see sidebar). automakers to consider. That way, Hypercar can have a The gist of that kind of entrepreneurship is this: to piece of the pie when some of these futuristic features know both your industry and your audience is to become part of the auto-making present. realize success in selling new ideas. To revolutionize the automobile industry takes two fac- tors: time and money. For example, to set up 500 hydro- gen-refueling stations around California (the minimum required to enable fuel cell car travel around the state) would cost about $235 million, according to the inde- pendent California Fuel Cell Partnership. So the price can be prohibitive, but as with all techno- logical advances, it will be overcome with time. Jacksonville Orthopaedic Institute 25 “Arthritis pain doesn’t have Ask your orthopaedic surgeon about the knee replacement that’s designed to bend and rotate.

to be the end of your life. Jeanne’s knee arthritis had gotten so bad, even simple everyday activities – like walking and getting into her car – were difficult. So she talked to her Surgery can be the orthopaedic surgeon. He told her about a range of options from DePuy Orthopaedics, Inc., a Johnson & Johnson company, including a beginning of your life.” knee replacement that’s designed to bend and rotate. Encouraged, and committed to working hard at rehabilitation, Jeanne decided to go ahead with surgery. One year later, she is no longer letting life pass her by. -Jeanne, DePuy knee replacement patient. If you suffer from osteoarthritis of the knee, talk to your orthopaedic surgeon about taking steps towards getting your life back. Just like Jeanne. Visit www.kneereplacement.com

Important Safety Information:

The performance of knee replacements depends on age, weight, activity level, and other factors. There are potential risks and recovery takes time. People with conditions limiting rehabilitation should not have this surgery. Only an orthopaedic surgeon can tell if knee replacement is right for you.

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26 www.JOIonline.net JOI Journal © 2006 Custom Publishing Design Group akovleOtoadcIsiuewwJInient27 www.JOIonline.net Jacksonville Orthopaedic Institute Corporate SocialResponsibility uligaBte opn en en etrCitizen CompanyMeansBeingaBetter Building aBetter It’s hardtoargue againstdoingtherightthing. That meanstrying resources, havethepotentialtodomoregoodthanmanyofworld’s governments. to maketheworldabetterplace.Successfulcompanies,withtheirstrong B shareholders musttaketop priority. es. ate profitswhilepursuingnoblecaus- balance mustbemaintainedtogener- poses, itwouldappearthatadelicate a corporation.Forallintentsandpur- purposesinrunning company leaders’ question thatmustbebalancedwith ly onthebottomline?Certainly, it’s a Purely forthesakeofsurvival, responsibility reflectpositive- this: Doescorporatesocial ut forCFOsitcomesdownto tant. apparent purpose. that willnotbeacompany’s most measured withNASDAQ-likezeal, socially consciousinvestingisnot attended toconstantly. Solongas craps table,profitabilitymustbe thoughtfulness assomanychipsona exchanges withasmuchcareand ny stocksareoftentradedin But inthisdayandage,whencompa- Still, thatmakesitnoless impor- By MilesEldridge two ideologiesblendseamlessly. America’s strongestcorporations,the intertwined. And formanyof consciousness can,andshould, be like Enron. toppled inthewakeofmega-scams unscrupulous housesofcardsthat ty underscrutiny, unlikethe tion ofaccountabilityleadstostabili- it maynotbeovert,thesolidfounda- consider theirnoblepurpose. Though leaders oftengobehindthescenesto The factisprofitabilityandsocial To besociallyresponsible,company TheThe fascinating Bottom thing is Linethis: companies with a conscience “The DePaul University study offers evidence that good outperform their counterparts. A DePaul University study corporate citizenship is a superior form of management,” found that the overall financial performance of the most said Business Ethics Editor and Publisher Marjorie Kelly. socially responsible companies was significantly better than “These top companies perform substantially better than that of other companies in the S&P 500 index. their S&P 500 peers, in strictly financial terms. It simply makes sense: managing a company for one measure alone – The companies in the study were gleaned from Business shareholder value – is like flying a 747 solely for maximum Ethics Magazine’s 100 Best Corporate Citizens. The top speed. You can shake the plane apart in the process.” choices balanced corporate responsibility toward stakehold- ers with environmental and community concerns. So that, in itself, should settle the score. But what does it mean to be a socially responsible company? Examining “This may be the most concrete evidence now available some of the efforts of the top three shows it’s through a that good citizenship really does pay off on the bottom variety of means. line,” said Professor Curtis C. Verschoor, coauthor of the study. #1Just about– IBM every year, IBM tops the list of good corporate Professor Verschoor worked with Assistant Professor citizens. That’s because of a conscientious objective to Elizabeth A. Murphy to consider a variety of criteria critical improve the world in ways its product line and interests to social interests as well as shareholders. These included make possible. eight statistical factors, such as net profit margins and return on equity. Verschoor reported that “the difference In late 2002, for example, IBM joined Oxford University between the performance of the Best Citizens and the others and the United Kingdom in building a computing grid to was strikingly large.” In fact, the “Best Citizens” scored ten enable early screening and diagnosis of breast cancer. The percentile points higher than the mean ranking of the company jointly donated some $6 million with the British remaining S&P 500 Companies. Department of Trade and Industry to found “eDiamond”,

28 www.JOIonline.net JOI Journal The Top 100 Socially which is hoped to help radiologists compare and evaluate mammography scans, even when conducted at different Conscious Corporations locations. IBM’s contribution includes servers, storage sys- Business Ethics Magazine measures the social conscious- tems, workstations and other computing hardware. ness of international corporations in efforts to promote the greater good. The following companies set the standards Lord Sainsbury of Turville, Parliamentary Under- for improving the well being of its employees, the envi- Secretary of State for Science and Innovation, said, ronment, local communities and the world at large. “This project shows that investment in knowledge transfer enables effective partnerships between IBM Eastman Kodak companies and universities or research insti- Hewlett-Packard Tennant Company tutes.” It is expected to be fully-implemented Fannie Mae Eli Lilly and Company St. Paul Company Northwest Natural Gas by the middle of the decade. Procter & Gamble Merix Corporation Motorola Inc. Network Appliance The technology giant’s social efforts Cummins Engine Nucor go much further. One potentially criti- Herman Miller Sonoco Products cal arena in which the company has General Mills, Inc. Wells Fargo made efforts is in computer recycling pro- Avon Products MBNA Corporation grams. For a nominal fee, IBM directs any manu- Intel Corporation Clorox facturer’s PCs, monitors and other equipment State Street Corporation Modine Manufacturing Home Depot through a designated recycling center. Certain hard- H B Fuller Timberland Deere & Company ware goes to charities in need of equipment. Bank of America New York Times Amgen Peoplesoft “As customers have invested in new technology to Lucent Technologies Arrow Electronics better serve their needs, there has been an increase in Qualcomm Autodesk the amount of older IT equipment that is either obso- Sun Microsystems Apache lete or that they no longer want,” said Wayne Balta, Southwest Airlines Dephi Automotive Director of Corporate Environmental Affairs. “IBM’s Starbucks Microsoft Fed Ex Corporation Harman International “The DePaul University study offers evidence that good services help facilitate the recycling of this equipment. TheThe fascinating Bottom thing is Linethis: companies with a conscience Brady Corporation Devry Inc. outperform their counterparts. A DePaul University study corporate citizenship is a superior form of management,” They also help ensure equipment that is still of value is Northern Trust Corporation FirstFed Financial found that the overall financial performance of the most said Business Ethics Editor and Publisher Marjorie Kelly. made available to others who can benefit from it.” UnumProvident Airproducts & Chemicals socially responsible companies was significantly better than “These top companies perform substantially better than Freddie Mac Rouse Company Nordson Corporation that of other companies in the S&P 500 index. their S&P 500 peers, in strictly financial terms. It simply In a given year, IBM recycles 120 million pounds of JP Morgan Chase makes sense: managing a company for one measure alone – equipment, with less than four percent deemed unsalvage- Adolph Coors Tektronix shareholder value – is like flying a 747 solely for maximum able. Whirlpool CIGNA Corporation The companies in the study were gleaned from Business Charles Schwab speed. You can shake the plane apart in the process.” Tellabs Ethics Magazine’s 100 Best Corporate Citizens. The top Corning Inc. Energen choices balanced corporate responsibility toward stakehold- Medtronic Inc. Guidant ers with environmental and community concerns. So that, in itself, should settle the score. But what does it #2Hewlett-Packard – HP originated the idea of mass-recycling Cisco Systems PNC Financial Services mean to be a socially responsible company? Examining computer hardware. Each month, it’s worldwide recycling 3M Oracle Corporation “This may be the most concrete evidence now available some of the efforts of the top three shows it’s through a centers process more than four million pounds of products. Pitney Bowes Analog Devices Oxford Health Plans that good citizenship really does pay off on the bottom variety of means. AT&T Corporation American Express McDonalds Corporation The corporation works to better the world in more person- line,” said Professor Curtis C. Verschoor, coauthor of the Gillette Graco al ways as well. For HP that means involving itself in study. #1 – IBM Symantec Corporation Marriott International Just about every year, IBM tops the list of good corporate underdeveloped nations to create opportunity that will ben- Baxter International Xilinx Professor Verschoor worked with Assistant Professor citizens. That’s because of a conscientious objective to efit people there as well as HP shareholders down the line. Merck & Company MBIA Inc. Elizabeth A. Murphy to consider a variety of criteria critical improve the world in ways its product line and interests Solectron Inc. Washington Gas & Light to social interests as well as shareholders. These included make possible. “We’re working to define the role companies can and Golden West Financial Safeco eight statistical factors, such as net profit margins and should play working in collaboration with other sectors to Scholastic Corporation Emerson Electric PPG Industries return on equity. Verschoor reported that “the difference In late 2002, for example, IBM joined Oxford University solve some of the fundamental problems in the world,” said Oneok 3Com Corporation Adobe Systems between the performance of the Best Citizens and the others and the United Kingdom in building a computing grid to Senior Vice President Debra Dunn. “My aspiration is that Lexmark International Wendy’s International was strikingly large.” In fact, the “Best Citizens” scored ten enable early screening and diagnosis of breast cancer. The HP be viewed as a real leader in this space – a leader in Compaq Computer Tribune Company percentile points higher than the mean ranking of the company jointly donated some $6 million with the British forging new kinds of relationships with nonprofit organiza- Ecolab Kroger remaining S&P 500 Companies. Department of Trade and Industry to found “eDiamond”, tions and governments.” Texas Instruments Applied Materials Jacksonville Orthopaedic Institute www.JOIonline.net 29 That effort has taken the company American Dream Commitment” to places like Dikhatole, South works to increase home ownership Africa, an impoverished communi- rates for young families, new immi- ty with 30 percent unemployment, grants, minorities and members of that lacks basics such as running low-income communities. water, electricity and basic housing. HP is part of a business consortium “When we meet our new $2 tril- trying to break the poverty cycle by lion goal at the end of this decade, teaching citizens of the township we will have helped create stronger, computer, Internet and business safer, and healthier communities; skills. The Dikhatole Digital built wealth and savings among Village features about 100 Internet- millions of families; stabilized enabled workstations, provided by neighborhoods; and eradicated dis- HP as part of its e-Inclusion proj- crimination and unfair practices in ect. the mortgage marketplace,” said Chairman Franklin D. Raines.

# More than half of all Fannie Mae 3 Fannie Mae financing now goes to help these This private company has a targeted groups, making this com- unique federal charter to put more pany’s work greatly beneficial for Americans in homes. Since 1968, society at large. That policy has Fannie Mae has done that for 43 paid tremendous dividends, as the million families. Now a ten-year, company has turned record profits $2 trillion project called “the for fifteen consecutive years.

30 www.JOIonline.net JOI Journal Suzanne: Back pain sufferer Dance partner

REHABILITATION REHABILITATION

What makes you, you? The people you love? The passions you pursue? At Brooks, we think it’s all these things. We offer the region’s only rehabilitation hospital as well as a full range of outpatient therapies. With a highly trained staff experienced in every aspect of recovery. So you can be you again. brooksrehab.org

SIMPLIFY YOUR COMMUNICATIONS Misys Healthcare Systems VOICE AND DATA SOLUTIONS FOR is proud to be the ANY SIZE BUSINESS preferred practice management system of Jacksonville Orthopaedic Institute.

One Industry… One Company… One Call! • World Class Communications Technology • Design & Implementation of Voice & Data Networks • Structured Cabling Systems • Avaya Certified Design Engineers & Technicians • Emergency Service – 24hrs/7 days a week • Adds, Moves or Changes of Existing Systems Misys is the leading provider of practice management software, electronic medical records, and E-Commerce services to physicians nationwide. 886-0080 6316 Greenland Road, Jacksonville, Florida For more information, please call (800) 334-8534, or www.convergedcommunications.com visit our web site at www.misyshealthcare.com.

Jacksonville Orthopaedic Institute www.JOIonline.net 31 “Treat Your Patients To The Ultimate In Comfort & Convenience!”

The Shortest, Most OPEN, High-Field MRI (1.5T) Available!

The Largest, Most Comfortable, Patient-Friendly OPEN MRI!

The Most Relaxing & Calming Environment! “High-Field MRI Has Never Been This OPEN!”

350 10th Avenue S. • Jacksonville Beach, FL 904-247-2220