| Summary: | Volume1/2000_Spring No Pain, Great Gain Hip Implants Restore Activity for Fighter Pilot, Octogenarian Whether you're a fighter pilot, anxious to get back into the cockpit, or a 79- year- old who wants to travel and walk his dogs, artificial hip implants can make it possible. Col. Rick Odegard's flight in an ejection- seat plane on Jan. 14 was a special joy, even though he's been flying for a quarter of a century. He made the flight just a little more than 90 days after the second of two surgeries to replace both his right and left hips at University of Utah Hospital, and one day after the Air Force permitted him to fly again. Sidney Seftel, who turns 80 in May, received his hip implant at University Hospital in June 1996. Six months later, he was back on his skis- enjoying the sport that brought him from New York City to Utah in 1973. Both men are patients of Aaron A. Hofmann, M. D., professor of orthopedics at the University of Utah School of Medicine, and both have metal- on- metal hip implants, a technology that has been available in Europe for more than 12 years but was not approved by the Food and Drug Administration ( FDA) for use in the United States until August 1999. University Hospital was one of 10 U. S. centers that participated in the three- year FDA clinical trial. Odegard, deputy commander of the 366t h Operations Group, Mountain Home Air Force Base, Idaho, is the first Air Force pilot to receive an unrestricted ejection- seat waiver following a bilateral hip replacement. Previously, pilots had been permitted to fly after total hip replacement, but were restricted to non- ejection seat airplanes. The Air Force changed its flying waiver policy on hip replacement based on analysis of new technology provided by the orthopedic consult- Col. Rick Odegard took his first flight after hip replacement surgeries in the front seat of an F- 15D, an ejection- seat plane. ant to the Air Force Surgeon General. Hofmann was delighted to hear elated " thank yous" from Odegard, 46, and marvels at Seftel, who's out and about, busy with various activities. Hofmann has no reservations about the new prosthesis, which features a metal head or " ball" of the hip joint fitting into a metal-lined socket. The problem with the long- used metal- on- polyethylene ( plastic) implant is that particles of the plastic wear off and cause the hip to ultimately loosen and possibly require a " revision" surgery to replace the failed hip, he said. " The longevity of the metal- on-metal implants is expected to be 30 years, because the amount of particles it produces is 25 to 100 times less than with traditional implants." Hofmann has received international awards for his innova-tive clinical studies on the human bone response to the various materials used in total joint replace-ment. He recently endowed a chair for orthopedic research at the U of U, and co- directs the Bone and Joint Research Laboratory at the Salt Lake Veterans Affairs Medical Center. Hip replacement technology has progressed from the first, and only, option, fusing the hip, to the metal-on- metal implants and, most recently, to a new plastic liner that is now being investigated in a multi- center study, including the U of U. According to Hofmann, a sure sign that a hip problem exists is pain that awakens a person at night and inability to perform the 2 Aaron Hofmann, M. D., implanted metal- on- metal hip protheses in 47 patients during FDA clinical trial. Model was approved last August. activities of daily living. Delaying medical attention often makes matters worse. People in such pain gain weight because they can't exercise or move about freely. Eventually, it's not only the hip that deteriorates; the entire body is affected. Odegard had painful hips for years. He attributed this to " a whole lot of wear and tear" on his body from sports ( football in high school and the Air Force Academy) and an airplane ejection in 1980. During the year before his surgeries in 1999 ( the left hip, Sept. 3; the right, Oct. 8) he relied on over- the-counter products to battle constant pain. When X- rays showed his hips severely disintegrated, he was grounded from flying. Thinking about all the non-prescription pain medications he took to make it through the day, Odegard, who normally flies a single- seat F- 15C, says it would have been " very stupid to delay the surgery to the point where I would have never flown again." Seftel has been active his entire life, playing tennis, racquetball, and " lots of handball." He thought the trouble he was having getting around and the pain, which seemed to emanate from his knee, was normal- just aging- and maybe aggravated by the handball. Things came to a head during a trip when he had to use a wheelchair to get to and from the airport gate. His hip problem was diagnosed and he opted for surgery. He had an uneventful recovery and no trouble skiing after his surgery, but gave up the sport last year. " I just got tired of it. After all, I've skied for more than half my life," he said. Now, Seftel enjoys walks with Sam and Harry, his Samoyeds who vie for his petting hand, and spends some of the winter in Arizona. He still runs his business as a distributor of promo-tional products and also has an interest in a helicopter skiing guide service, which he co- founded in 1973. Generally, all patients go through three phases of rehabilita-tion after surgery, Hofmann said. During the first six weeks, the patient's energy is lowest, the muscles weakest and the pain moderate. Between six weeks and three months, the patient's leg strength rapidly improves and discomfort gradually disappears. There may be some limping during that time as long as muscle and bone are healing. The patient gains maximum strength and pain relief during the third phase, beginning at about three months post- op. Patients who are willing to walk and do simple exercises on their own do not require formal physical therapy after hip replacements. Osteoarthritis, sometimes called degenerative arthritis, is a natural part of the aging process and is the reason for 60 percent of hip replacements. Rheumatoid arthritis and fractures and dislocations are the other top reasons for the procedure. Approxi-mately 85 percent of hip replace-ments are performed on adults 55 and older. In 1998, there were more than 250,000 hip replacements in the U. S. Ill For more information or an appointment, call Pam Foote in the Department of Orthopedics, 801- 585- 1098. On the cover. Sidney Seftel with his Samoyeds, Sam and Harry, had a hip replacement in 1996 and resumed skiing six months later. 3 A Word to the Wise Woman with Incontinence: Check Variety of Approaches to Stay Dry Active Urogynecologist Peggy Norton, M. D., explains treatment options to patient in Urodynamic Testing Laboratory. Incontinence is to women's health what impotence is to men's: an embarrassing, seldom- discussed problem, only now emerging from the closet, which many people endure needlessly. Urinary leakage and a serious companion problem, pelvic organ prolapse, can be treated with a variety of approaches ranging from behavior modification to surgery, according to Peggy A. Norton, M. D., associate professor of obstetrics and gynecology at the University of Utah School of Medicine. Norton, who heads the department's Urogynecology and Pelvic Reconstructive Surgery Division and is one of only two fellowship- trained urogynecologists in Utah, said many women wait years after their symptoms become troublesome before consulting a doctor. An estimated 21 million Americans suffer from urinary incontinence. Three times more common in women than in men, it affects 10- 25 percent of the general female population and up to 40 percent of elderly women. Some $ 1.3 billion is spent annually on pads- the most common method for managing incontinence. Norton and her colleague, clinical/ research nurse practitioner Jan Baker, APRN, screen patients for the cause or causes of their incontinence. Thorough medical histories to elicit information about illnesses, surgeries and medications, as well as patients diaries that record liquid intake and voiding frequency and circumstances, aid in diagnosis and treatment decisions. Some patients benefit from an evaluation of urinary tract function with state- of- the- art equipment in the department's Urodynamic Testing Laboratory. The type of incontinence diagnosed- stress, urge, overflow or a mixed form- determines the treatment of choice. Urge incontinence, most common in older people, is the sudden urge to void, accompanied by the loss of large volumes of urine. Drug therapy can reduce the frequency of urination but many patients benefit from additional therapies for overactive bladder problems. Norton suggests bladder drills to help patients gradually increase the time between trips to the bathroom. " Bladder re- training requires habit- changing, putting the brain rather than the bladder in the driver's seat," she said. Stress exerted on the pelvic floor is thought to be the main culprit in stress incontinence, which can be precipitated by laughing, coughing or lifting. It can respond to muscle-strengthening exercises or electrical stimulation to trigger muscle contraction, medication to increase bladder tone, or the use of a pessary ( a device worn in the vagina to support a sagging uterus). Childbirth, and the decreased estrogen levels of aging that can cause organs to atrophy and tissues to thin, are considered the major causal factors in both incontinence and prolapse. Bladder suspension surgery for stress incontinence is successful in 85- 95 percent of cases, although Norton cautioned that any geni-tourinary surgery is risky and can result in serious complications. " Besides," she said, " if you're 35 years old and have three kids, you don't have time for surgery." Surgery for prolapse is roughly three times more common than surgery for incontinence and is the more difficult surgical problem, Female pelvic anatomy with one- third of prolapse surgeries being " re- dos," according to Norton. She performs approxi-mately 70 leakage surgeries and 150 major prolapse surgeries annually. Norton commonly uses a sling procedure to help patients in whom the usual anti- incontinence proce-dures have not worked. It involves placing a strip of material- either the patient's fascia or that of a donor, or synthetic materials such as polyethylene or polypropylene mesh ( which the patient's own tissue weaves itself into) underneath the organ. This sling is then grafted to the abdominal wall or, in the case of pelvic organ prolapse, to the vagina. Norton's prolapse patients fit the national profile in age, number of births and the complex nature of their problems. One, a 47- year- old mother of six from Sandy, Utah, has had two surgeries with Norton. Her problems with prolapse started in 1985, after the birth of her fourth child. " He was my largest child- 8- 1/ 2 pounds, and I hemor-rhaged a lot afterward," she said. She went to three doctors. One told her to come back when she was through having children, another performed a hysterectomy and vaginal bladder repair that failed and the third one referred her to Norton. Norton used donor fascia in the woman's first surgery two years ago but the patient developed a new unusual prolapse of the intestines behind the bladder. Mesh was used to reinforce her second surgery last December. As she does with most of her patients, Norton told the woman that, " We won't know for at least five years if this is going to last the rest of your life." But the woman and her husband, who accompanies her to all her appointments, have put their trust in the doctor who " explains things so well, and can draw diagrams from 2- 3 different views." At their first post- op clinic visit in January, the patient received a clean bill of health. Another 47- year- old, from Helper, Utah, describes a similar history. In the 1987 birth of her fifth and last child, a son, " all the muscles were torn during the delivery." She went to several different doctors before learning the reason for her unremitting pain. A trusted physician performed several operations, but sometime later, while she was mowing the lawn, the prolapse of her pelvic organs recurred. In 1997 she began using guided imagery and hypnotherapy " to get ready for another surgery," one that Norton would do in March 1999. " Every day, I visualized the OR and invoked prayers of healing." Using polypropylene mesh, Norton reconstructed a new top and backside of the vaginal canal, then attached the sling to the woman's pelvis. " I'm on my treadmill every morning now, doing my 2 1/ 2 miles- I feel like a whole new woman," said the patient, who plans a healing pilgrimage to Peru in May. For more information or an appointment, call Dr. Norton's office, 801- 581- 3565. . bladder sags into the vagina . vaginal walls fall in on themselves 5 URETHRAL SPHINCTER CYSTOCELE Mood Disorders Clinic Participates in National Research For Psychiatric Disorders- from AADD to Schizophrenia Like many mental health patients, Bill Fechisin felt he was running out of options. The 41- year- old had tried a variety of medications to treat his bipolar disorder ( formerly known as manic depression) but nothing really seemed to work. His visits with a psychiatrist were no longer covered by Medicare and he was unem-ployed. Help came in the form of a television commercial. " I was pretty desperate when I saw the ad for the university's Mood Disorders Clinic. I'm feeling a lot better now," he said. Fechisin is participating in a 20- week study evaluating the effectiveness of a new drug for his disorder. The study provides him a weekly appointment with one of the center's three psychiatrists and a daily dose of the new medication, and it's all free. " I've been on a lot of medica-tions; some have worked and some haven't," he said. " I'm in this study because I want to find a medication that will help me live a better life." If selected to participate in the second phase of the study, he could continue receiving care for an additional 60- 70 weeks. The University of Utah's Mood Disorders Clinic, which is part of the medical school's Department of Psychiatry, was established 20 years ago to conduct FDA- approved research on a variety of psychiatric disorders including depression, bipolar disorder, anxiety, mania, adult attention deficit disorder, panic disorder, bulimia, social phobia and schizophrenia. The clinic often runs as many as six studies concurrently, each with 40- 50 participants. " Most of our patients are suffering from chronic psychiatric disorders. They have tried numer-ous medications, have not re-sponded, and are interested in trying a new medication," said Frederick Reimherr, M. D., associ-ate professor of psychiatry and clinic director. " The real advantage we offer is much more closely supervised care, and at times, access to medications that are not available elsewhere." Patients receive weekly visits with a psychiatrist and follow- up care after completion of the study. " The studies give us an opportunity to see patients much more frequently than most clinicians would. They also allow us to watch patients more closely, which can be very meaningful," he said. " We find that most patients are doing better four to six months later, even if they were on a placebo initially, than they would be if they were being seen in another clinic." Reimherr believes the follow- up care university patients receive sets the clinic apart from many commu-nity- based research programs. Patients return for continuing care after the study is complete to stabilize them on a medication and establish a plan for long- term care. He says many patients are still being seen by the clinic's psychia-trists six months after completion of a study. In addition to Reimherr, the clinic is staffed by psychiatrists Robert E. Strong, D. O., and Michael L. Smith, M. D., both assistant professors of psychiatry, a Frederick Reimherr, M. D., consults with social worker Erika Williams, M. S. W. on follow- up care for a patient who recently participated in a drug study. social worker, a research analyst and two study coordinators. Depression is the disorder most frequently studied in clinic trials. " We always have a depression study open," said Reimherr. " Our typical patient often has a childhood onset of the disease, recurrent episodes during the teenage years and chronic symptoms through adult-hood." Approximately 17 million Americans suffer from the disease. While studies involving depression are usually easy to fill, other disorders can often pose a challenge, according to Erika Williams, M. S. W., diagnostic intake coordinator. She is respon-sible for screening patients to determine whether they are eligible for a study. Approximately 60 percent of people who call the clinic interested in a specific study are selected for that study. Those deemed ineligible are counseled by Williams about other treatment options, including referral to the Department of Psychiatry's Resi-dents' Psychotherapy Clinic, the university's Family Counseling Center, or Valley Mental Health. As part of the screening process, patients receive a detailed explana-tion of the study and what the research is designed to achieve. Reimherr says while some patients express concerns about receiving a placebo for their disorder, their biggest concern is usually that they have access to the medication once the research is complete, something that hasn't always been possible. " Recently, there has been much discussion in the university commu-nity about the use of placebos. In reality, access to new treatments, even if delayed, is a much more important issue than exposure to placebos," he said. Some of the clinic's studies now have a provision guaranteeing that patients will have access to the medications if/ when the drug is approved by the FDA. While Reimherr admits that recruiting patients occasionally is made more difficult by the presence of private research groups in the Salt Lake area, he welcomes the growing competition. " Commercial research plays an important part in the development of new medica-tions. Certain kinds of studies tend to gravitate toward commercial centers. They are more production-line type of operations and there is much less physician/ patient con-tact," he said. " The more exacting the requirements, the more physi-cian involvement is needed, and the more likely the study should be done in an academic setting." The other advantage of research in an academic setting is the collaboration among researchers in various specialties, something that Reimherr hopes to build on. " More and more we're finding a real commonality of interests among practitioners in gastroenterology, arthritis, pain management, high blood pressure and psychiatry," he said. Bill Fechisin is just glad he found help. " As new medications come along it's important for people to participate in these studies so doctors can find better ways to treat mental illness," he said. To learn more about the Univer-sity of Utah's Mood Disorders Clinic and studies currently available, call 801- 585- 6663 or toll- free in Utah 1- 888- 633- 4363. Clinical Studies Endocrinology: Men and women with inadequately controlled type two diabetes, from 18- 75 years of age, are needed for a 26- week, double- blind study to evaluate a combination of 45 mg of Pioglitazone ( ACTOS) taken in combination with Metformin ( glucophage) compared to 30 mg of ACTOS and glucophage. Qualified participants will be reimbursed for their time and will receive free study medication. Contact Richard Swope at 801- 585- 5115. University of Utah Hospitals & Clinics toll- free referral and consultation numbers: in Utah 1- 800- 662- 0052 outside Utah 1- 800- 453- 0122 www. med. utah. edu 7 University of Utah School of Medicine Continuing Medical Education Various Dates: Administration for Physician Executives: An Intensive Program Audience: All specialties Site: University of Utah, Salt Lake City Planned by: David Eccles School of Business, the Matheson Center for Health Care Studies, School of Medicine Meeting chairs: Robert Huefner, Ph. D., Debra Scammon, Ph. D., David Bjorkman, M. D., M. S. P. H. Mtg. id# 2000- 039; fee, dates, and number of AMA Category 1 hours vary with each of four modules: Acquiring and Allocating Funds, Structuring and Leading the Organization, Strategic Planning, Communicating with Customers. March 23- 25: Sexual Health Across the Generations Audience: Primary care providers Site: Olpin Union, University of Utah Planned by: Department of Psychiatry June 18- 22: University of Utah 49t h Annual School on Alcoholism and Other Drug Dependencies Audience: Physicians, physician assistants, nurse practitioners Site: Olpin Union, University of Utah Planned by: Division of Physical Medicine and Rehabilitation, School of Medicine Meeting chair: John Speed, M. D. Mtg. id# 2000- 011; Fee $ 325 25 AMA Category 1 hours For information on CME offerings, call 801- 581- 8664, or visit http:// medstat. med. utah. edu/ som/ education/ cme FILE COPY DO NOT REMOVE
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