As spring blends into summer, people enjoy returning to active-outdoor mode"”from golf courses and soccer fields to yard work.
It's also a season for moans and grimaces.

Tossing one spade of mulch the wrong way can produce a lifetime of back pain. Emergency rooms and doctors' offices fill with people of all ages who tried to swing into athletic action too fast or too hard. According to one survey cited recently in The New York Times, sports injuries have become the second-leading cause of visits to doctors' offices, right behind the common cold.

"Eighty percent of the population experiences neck and back pain," notes Dr. Charles Kuntz IV of the Mayfield Clinic in Walnut Hills, and Director of Spine and Peripheral Nerve Surgery at the University of Cincinnati.

For area orthopedic specialists, it's not uncommon to treat three generations in the same family. A 45-year-old executive whose elbow and back problems are hindering her golf game might have a dad with a rotator cuff tear in his shoulder and a 17-year-old daughter who "blew" a knee with a bad swivel in soccer practice.

The bad news: as Americans live longer, more active lives, the moving parts are more likely to cause trouble. As The Times reported, baby boomers are fueling a jump in visits to orthopedists, a phenomenon termed "boomeritis" by Philadelphia orthopedic surgeon Dr. Nicholas A. DiNubile.

The good news:
"¢ More varied and fun ways are out there to help prevent injuries and slow the rate of degeneration. Check out the education, wellness and therapy programs offered at health facilities operated by area hospitals, orthopedic and sports medicine clinics, and fitness centers.
"¢ The range of treatment options, many non-surgical, keeps growing.
"¢ Surgical procedures keep advancing to minimize trauma, reduce pain, shorten recovery and enhance mobility.
Don't put off seeing a specialist because you fear it automatically means going under the scalpel. "Eighty percent of our patients don't have surgery," notes Cindy Starr, spokesperson for the Mayfield Clinic, a world-renowned neurosurgical group noted for diagnosis and treatment of spinal disorders.

Conservative management rules, say local orthopedic surgeons. Exercise, physical therapy and medication usually come first, surgery much later, if at all. There's the paradox, however. Too many people who could forestall surgery wait too long, or keep up bad habits, and finally see a doctor when too much damage is done.

There's one consensus among all medical professionals in this field: patient compliance is the key. Heed the doctor's guidance on exercise, diet and activities to avoid, and you most likely will get more miles from your back or joints, with less pain. Following instructions from doctors and therapists is essential to successful recovery after surgery"”whether it's an arthroscopic procedure done on an outpatient basis or a full joint replacement.

How do you know when it's time to see a specialist? The guiding measures are pain, mobility and stability. When that throbbing knee is awaking you, giving out or locking up. When that aching hip or shooting sciatic pain in your leg makes a routine stop at the supermarket almost unbearable.

CENTERS AND SPECIALISTS
Where do you seek help? Greater Cincinnati boasts several major orthopedic and sports medicine groups"”including Beacon Orthopaedics & Sports Medicine, Cincinnati SportsMedicine and Orthopaedic Center, Freiberg Orthopaedics & Sports Medicine, and Wellington Orthopaedic & Sports Medicine"”with physicians who are leaders in their specialties and engaged in the latest scientific research. Many individual doctors and smaller groups in the Tristate are well-regarded, too.

Larger groups incorporate research, advanced diagnostics, outpatient procedures and physical therapy into their facilities. In 2004, Freiberg built a $7.8-million ambulatory surgery center and clinic in Kenwood. Freiberg has a Spine Institute, on-site physical therapy and conducts research through the Cincinnati Orthopaedic Research Institute (CORI).

Dr. Michael Swank, managing partner of the Freiberg group, has an international reputation for reconstructive and spine surgery. He was one of the first surgeons in the country to use a computer-guided system to perform a total knee replacement. As medical director of The Jewish Hospital Joint Replacement Center, he helped open its $1.5-million operating room dedicated to computer-assisted orthopedic surgery"”the first of its kind in the world.

Prevention is getting attention, too. Area hospitals with orthopedic units, affiliated health facilities, physical therapy practices and individual practitioners offer information to help people manage osteoarthritis, prevent osteoporosis, avoid injuries, and explore options for injuries or diseases. The Joint Replacement Center at Deaconess Hospital, for example, offers regular free, public seminars on hip and knee pain.

Hospital orthopedic and physical rehabilitation programs have become more technologically advanced, but also more connected to patients and their families. At Deaconess, the patient and the family or friends who will support them before and after joint surgery attend a class led by Orthopedic Resource Director Brenda Hilger, a physical therapist. With live demonstrations she teaches the supporters how to be the "family coach, the go-fer, the cheerleader" for the patient. "I think the families almost appreciate it more than the patients do," she comments.

After knee replacement surgery, 75 percent of patients go home in three to four days, 10 percent stay longer in the hospital's rehab center, and the others spend time in an intermediate skilled-nursing facility.

HIPS, BACKS AND KNEES
As proportionately more people advance from middle age into the senior years, orthopedists see a steady rise in cases involving hand, wrist, elbow and shoulder ailments. But hip, back, neck and knee disorders and injuries tend to dominate, in part because those joints, bones and ligaments bear so much weight.

Each year, more than 350,000 Americans experience hip fractures, with the rate for women running two to three times that of men, according to the American Academy of Orthopaedic Surgeons. Only 25 percent fully recover. Nearly one in four die within a year due to complications.

Doctors and other healthcare providers are dedicating more resources to educating people about reducing the risk of hip fractures (which doubles about every five years past age 50)"”and especially about prevention of osteoporosis, the bone-thinning disease that is more common in post-menopausal women, but affects men, too.

For those who need a hip implant, advances in materials"”especially metals and ceramics"”are extending the lifetime of the prostheses. Some newer versions could last 25 to 30 years, according to lab studies.

"With most degenerative diseases of the spine, the best way to start is with conservative management," says Dr. Charles Kuntz IV of the Mayfield Clinic. The regimen ranges from physical therapy and weight control to epidural injections of cortisone to relieve inflammation and promote healing, and even chiropractic manipulation.

When surgery is justified, Mayfield's group is among the local leaders in new techniques. The clinic's Dr. William Tobler, who also is Director of Neurosurgery at Christ Hospital, was the first neurosurgeon in Cincinnati to perform an advanced surgical procedure"”called the Axial Lumbar Interbody Fusion, or AxiaLIF"”to stabilize the lower spine. Typically, this kind of surgery required cutting through the abdomen. This minimally invasive technique, requiring only a small incision at the end of the tailbone, can offer faster recovery with less discomfort.

For decades, spinal fusion was the most common surgery for patients with degenerative disease of the lower vertebrae. Fusing or locking vertebrae together can relieve daily pain but also lessen mobility, and often hastens deterioration of adjoining spinal discs. Artificial spinal discs are one possible alternative. Kuntz, Tobler and Mayfield colleagues were investigators in a national clinical trial, authorized by the U.S. Food and Drug Administration (FDA), using an all-metal disc.

TOTAL REPLACEMENT
In the mid-1990s, about 250,000 total knee replacements (known as total knee arthroplasty, or TKA) were performed each year in the United States. That rate will soon pass 1 million annually, says Dr. Michael Welch, a member of the Wellington Orthopaedic group wh'™s on staff at Deaconess.

Why so many? One factor is simple aging: as people get older, they're more prone to develop osteoarthritis, rheumatoid arthritis and other conditions that deteriorate cartilage. A common malady is degeneration of the meniscus, the cartilage that acts as the shock absorber between the ends of knee bones. Injections of synovial fluid (Synvisc) ease the friction, and can buy some time, as do arthroscopic procedures (getting "scoped") to repair damaged or torn meniscal tissue.

Dr. Frank Noyes is an internationally respected orthopedic surgeon and expert on knee problems, especially complex ligament injuries and knee biomechanics. He founded the Cincinnati SportsMedicine and Orthopaedic Center in 1981, where he still serves as chairman and medical directory, and later started a research and education foundation. More than 130 specialists have graduated from the  sports medicine fellowship program Noyes initiated, one of the first in the U.S.

"The key is diagnosis," Noyes says about knee problems. "Sometimes it requires two or three visits to find out what's really wrong."

Like other orthopedists interviewed, Noyes doesn't push patients toward surgery. He says he is one of the first in his fields to join surgeons with physical therapists in the same practice. "The holistic approach is really important," he says. Weight control is one example. In a typical cycle of damage, a patient cuts back on exercise because of knee pain, then gains weight that worsens the wear on the knees, and reduces activity even more. And that can affect cardiovascular health. "For a businessman, healthy knees equal a healthy heart."

Noyes was one of the first surgeons to perform meniscus transplants using allografts, or donor tissue, and is now doing them with autografts, or tissue from the patient's body, which he calls "retread lining." Meniscus transplants usually are reserved for younger people with relatively healthy knees who suffer knee injuries. Noyes began doing the transplants in 1987, and 10 years later performed one for Olympic gold medal gymnast Jaycie Phelps.

Inevitably, however, when knee bones are grinding together, joint replacement becomes a logical option.

Welch at Wellington is the first surgeon here, and one of the first in the country, to be certified to use the Oxford® Unicompartmental Knee System, approved by the FDA in 2004 after being used in Europe for more than 20 years. A unicompartmental device replaces only one side of the knee joint, usually the medial (inside) compartment that bears the most weight, and where most osteoarthritis damage occurs. The Oxford device features an artificial, floating meniscal bearing that permits a more normal range of motion.

By allowing the rest of the knee and ligaments to remain intact, the patient retains more mobility and recovers faster. "There's less of a hospital stay, about one-third of that for a TKA," Welch comments. But the unicompartmental knee is an option only for some select patients.

Dr. Francis Florez, a member of the Freiberg group who practices at Mercy Health Partners hospitals, is considered a local leader in the minimally invasive approach to knee replacements.

Traditionally, a TKA can require an incision of 12 to 15 inches. Using new instrumentation, surgeons can perform the replacement with a cut under three inches. With a smaller cut, minimally invasive TKA can reduce bleeding, damage to ligaments and the duration of pain during the recovery period, and patients can gain a fuller range of motion faster. With this approach, the worst pain may last only two to three weeks instead of a month or longer, Florez says.

Critics content that by going too far in shrinking the interior view of the knee"”think keyhole view instead of porthole"”surgeons may compromise the precision necessary for long-term success.

Florez believes he has found a satisfactory medium between the large and mini incisions, typically using a cut of around six inches. "Everyone in general is trying to do smaller wounds," he says.

HIGH EXPECTATIONS
It's not uncommon to hear someone complain after having joint replacement surgery. Quite often, however, a 70-year-old is expecting to get the knees of an 18-year-old, when the medical objective is to alleviate severe pain and restore reasonable mobility for a senior citizen.
"For whatever reason, people are not aware of, or don't accept the fact that there's more to surgery than putting it [the artificial joint] in," Welch observes. "They're demanding a higher level of activity later in life, and there's pressure on technology to restore a certain level of function. For younger people, implants are not designed to do what younger people want to d'

Dr. Florez agrees. "I tell patients it's a mechanical joint to decrease pain and increase function. If you think I could put in what the good Lord put in 60 or 70 years ago, we're not there yet."

Florez adds that he sees too many people waiting too long for knee replacements, such those in their 70s and older who suffered through years of pain that restricted the most basic of normal activities.

Noyes feels the pressure to perform knee replacements on younger patients, and recently did one for a 35-year-old nurse. But about 90 percent of these replacements are "sedentary knees," he says, meant for about four to six hours of standing per day.

OUT TO THE FUTURE
Noyes believes much more can be done to prevent sports injuries, such as torn ACLs (arterior cruciate ligaments), that guarantee future knee deterioration problems. That's why he developed the Sportsmetrics program at his center in 1992. It combines specialized conditioning with changes in athletes' habits and techniques.

Knee injuries among females active in sports"”especially soccer, basketball and volleyball"”increased in recent years as more girls became involved. But females are sustaining knee injuries at a much higher rate than males, and most of those injuries are non-contact. The Sportsmetrics program is offered at several area high schools, with more in line. In one study, Noyes and colleagues found the girls who completed the Sportsmetrics program lowered injuries to rates comparable to male athletes.

On the scientific side, watch for progress in molecular and genetic biology. Regenerating healthy nerve cells, for instance, could be a huge breakthrough for people who suffer traumatic head and spinal injuries. Orthopedic surgeon Welch points out that meniscal cartilage has been cultured, grown and re-implanted, but we're years away from making it an easy, widely available alternative. He believes much will depend on what happens with stem cell research. "Hopefully, we're at the end of the prosthesis era and at the beginning of the regeneration era."


George Shybut, M.D., F.A.C.S.
SPECIALTIES: Orthopaedic surgery
EDUCATION-TRAINING: B.S. in chemistry, Grinnell College. M.D., the University of Chicago. Residency in orthopaedic surgery, the University of Chicago. Fellowship in clinical biomechanics and sports medicine, Harvard University. Sports medicine fellowship, Children's Hospital Medical Center/Boston. Operative arthroscopy and sports medicine fellowship, Newton-Wellesley Hospital. Chief of Staff at Mercy Hospital Clermont. Faculty volunteer, University of Cincinnati College of Medicine. Chair, Sports Medicine Program, United States Figure Skating Team.
PHYSICIAN GROUP AFFILIATION: Wellington Orthopaedic & Sports Medicine
LOCAL HOSPITAL AFFILIATION(S): Mercy Hospital Clermont, Mercy Hospital Anderson
PROFESSIONAL/BOARD CERTIFICATIONS: Certified by the American Board of Orthopaedic Surgeons.
MEMBERSHIP: Academy of Medicine of Cincinnati, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Academy of Sports Physicians, American Heart Association, American Medical Association, Association for the Study and Application of the Methods of Ilizarov, Clermont County Medical Society, Illinois Orthopaedic Society, Ohio Medical Society, Ohio Orthopaedic Society, Performing Arts Medical Association.

Wellington Orthopaedic & Sports Medicine
11 locations in the Tristate
Telephone:  (513) 232-BONE
Web site: www.wellingtonortho.com

Francis Flores, M.D.
SPECIALTIES: Hip and knee reconstruction.
EDUCATION-TRAINING: B.S., Johns Hopkins University. M.D., Case Western Reserve University School of Medicine. Internship and orthopaedic surgery residency, University Hospitals of Cleveland. Fellowship in joint replacement and adult reconstruction, University Hospitals of Cleveland. Team physician for the Mt. Healthy High School football team.
PHYSICIAN GROUP AFFILIATION: Freiberg Orthopaedics & Sports Medicine
LOCAL HOSPITAL AFFILIATION(S): Mercy Hospitals
PROFESSIONAL/BOARD CERTIFICATION(S): Certified in orthopaedic surgery by the American Board of Orthopaedic Surgery.
MEMBERSHIPS: Academy of Medicine of Cincinnati, American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, Cincinnati Othopaedic Club, Mid-American Orthopaedic Society, Ohio State Medical Association, Ohio State Orthopaedic Society.

Freiberg Orthopaedics & Sports Medicine
9825 Kenwood Rd.
Cincinnati, OH 45242
Telephone: (513) 221-5500
E-mail: jayk@freibergortho.com
Web site: www.freibergortho.com 

G. James Sammarco, M.D. F.A.C.S.
SPECIALTIES: Orthopaedic surgery
EDUCATION-TRAINING: M.D., Tulane University School of Medicine. Internship, Philadelphia General Hospital. Orthopaedic residency, University Hospitals, Case Western Reserve University. NIH Fellowship, Orthopaedic Biomechanics, University Hospitals, Case Western Reserve University. Co-director, fellowship in Adult Reconstructive Foot and Ankle Orthopaedic Surgery. Surgeon, U.S. Public Health Service. Consulting orthopaedic surgeon and evaluating physician, NFL Players Association. Past team physician, U.S. Ski Team. Volunteer professor, Department of Orthopaedic Surgery, University of Cincinnati Medical Center.
PHYSICIAN GROUP AFFILIATION: Cincinnati SportsMedicine and Orthopaedic Center.
LOCAL HOSPITAL AFFILIATION: Deaconess Hospital.
PROFESSIONAL/BOARD CERTIFICATION(S): American Board of Orthopaedic Surgery. Diplomate, American Board of Orthopaedic Surgery.
MEMBERSHIPS: Member, American Orthopaedic Association. Member, American Medical Association. Fellow, American Academy of Orthopaedic Surgeons. Fellow, American College of Surgeons. Member, American Orthopaedic Society for Sports Medicine. Past president, American Orthopaedic Foot and Ankle Society. Past president, Clinical Orthopaedic Society.

Cincinnati SportsMedicine and Orthopaedic Center
10663 Montgomery Rd.
Cincinnati, OH 45242
Telephone: (513) 794-8468
Fax: (513) 792-3230
Web site: www.cincinnatisportsmed.com
www.sportsmetrics.net


Nicholas T. Gates, M.D.
SPECIALTIES: Orthopedics and sports medicine. Dr. Gate is the Foot and Ankle Consultant for Thomas More College Athletics, Florence Freedom Baseball, Highlands High School, and other area high schools.
EDUCATION-TRAINING: B.S. Xavier University, M.D. University of Cincinnati, orthopedic residency at Mount Carmel Medical Center, Orthopaedic Foot and Ankle Fellowship at the Cleveland Clinic Foundation.
PHYSICIAN GROUP AFFILIATION: Commonwealth Orthopaedic Centers, P.S.C., the only practice in Cincinnati that combines three specialties: an orthopedic surgeon, a non-surgical podiatrist, and an orthopic and brace specialist.
LOCAL HOSPITAL AFFILIATIONS: St. Elizabeth Medical Center and St. Luke Hospitals. Was chairman of the St. Elizabeth Department of Surgery, 2000 to 2001.
PROFESSIONAL/BOARD CERTIFICATION(S): Licensed State Board of Medical Examiners of Ohio and State Board of Medical Examiners of Kentucky. Crtified by the American Board of Orthopaedic Surgery.
MEMBERSHIPS: American Orthopaedic Foot and Ankle Society, American Academy of Orthopaedic Surgeons, Pedorthic Footwear Association, Northern Kentucky Medical Society, Academy of Medicine of Cincinnati.

Commonwealth Orthopaedic Centers, P.S.C.
500 Thomas More Pkwy.
Crestview Hills, KY 41017
Telephone: (859) 341-9300
Web site: www.commonwealthorthocenters.com

Francis R. Noyes, M.D.
SPECIALTIES: Sports medicine and orthopaedics
EDUCATION-TRAINING: A.B., Philosophy, University of Utah, M.D., George Washington University Medical School. Internship and assistant resident at University of Michigan Medical Center, residency at University of Michigan Medical Center's Division of Orthopaedic Surgery. Lieutenant Colonel, United States Air Force, joint assignment—Medical Center Staff, Orthopaedic Surgeon and Aerospace Medical Research. Laboratory Senior Research Associate, Division of Biodynamics and Bionics, Wright-Patterson Air Force Base. Adjunct associate professor, College of Medicine, Department of Physiology, Wright State University. Adjunct clinical professor, Department of Veterinary Medicine, Ohio State University. Assistant professor, Department of Orthopaedic Surgery, University of Cincinnati. Director, Sports Medicine Institute, director, Orthopaedic Research, co-director, Orthopaedic Biomechanics and Sports Medicine Laboratory, adjunct professor of biomechanics, Department of Engineering Analysis, College of Engineering, associate professor, Orthopaedic Surgery, professor, Department of Orthopaedic Surgery, adjunct professor, Department of Health, Physical Education and Nutrition. Team physician, University of Cincinnati (all athletic teams), 1975 — 1983. Cincinnati Bengals, 2000 — 2001. Cincinnati Riverhawks, 2001 - 2003. Orthopaedic Consultant, Cincinnati Gymnastics Academy, 1991 — present. Cincinnati Sizzle, 2005 - present.
PHYSICIAN GROUP AFFILIATION: Chairman and Medical Director, Cincinnati SportsMedicine and Orthopaedic Center. President, Cincinnati SportsMedicine Research and Education Foundation. Faculty appointment, University of Cincinnati, clinical professor, Department of Orthopaedic Surgery. Adjunct professor, Department of Biomedical Engineering, University of Cincinnati College of Medicine and College of Engineering.
LOCAL HOSPITAL AFFILIATION(S):, Deaconess Hospital, Jewish Hospitals, Bethesda Hospital, Christ Hospital, Children's Hospital Medical Center.
PROFESSIONAL/BOARD CERTIFICATION(S): American Board of Orthopaedic Surgery. Board examiner, American Board of Orthopaedic Surgeons, 1978—1985.
MEMBERSHIPS: Academy of Medicine of Cincinnati, Alpha Omega Alpha Honor Medical Society, American, British and Canadian Club, American Academy of Orthopedic Surgeons, American College of Sports Medicine, American Medical Association, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Association of Bone and Joint Surgeons, Cincinnati Orthopaedic Society, European Society of Sports Traumatology and Knee Surgery and Arthroscopy, Herodicus Society, International Society of the Knee, Michigan Orthopaedic Alumni Society, Mid- America Orthopaedic Association, Ohio Orthopaedic Society, Ohio State Medical Association, Orthopaedic Research Society.

Cincinnati SportsMedicine and Orthopaedic Center
10663 Montgomery Rd.
Cincinnati, OH 45242
Telephone: (513) 794-8468
(513) 346-7292, ext. 3115
E-mail: bkohake@csmoc.com
Web site: www.cincinnatisportsmed.com
www.sportsmetrics.net

Cincinnati Sportsmedicine Research and Education Foundation
10663 Montgomery Rd.
Cincinnati, OH 45242
Phone: (513) 792-3232
E-mail: sbwestin@csmref.org
Web site: www.cincinnatisportsmed.com
www.sportsmetrics.net


Pamela J. Petrocy, M.D.
SPECIALTIES: Orthopaedic surgery
EDUCATION-TRAINING: B.S. Miami University. M.D. Ohio State University. Research fellowship at Tulane University. Residency at Charity Hospital, New Orleans.
PHYSICIAN GROUP AFFILIATION: Freiberg Orthopaedics & Sports Medicine
LOCAL HOSPITAL AFFILIATION(S): Bethesda North, Good Samaritan, Mercy Franciscan Western Hills and Mount Airy, Jewish Hospital Kenwood, Kenwood Surgery Center.
PROFESSIONAL/BOARD CERTIFICATION(S): Certified in orthopaedic surgery by the American Board of Orthopaedic Surgery.
Glen Reinhart, M.D.
SPECIALTIES: Orthopaedic sports medicine, knee and shoulder surgery, pediatrics
EDUCATION-TRAINING: B.S. Princeton University. M.D. Northwestern University. Fellowship at Kerlan-Jobe Orthopaedic Clinic. Faculty member, Department of Orthopaedic Surgery, Northwestern University Medical School. Instructor for the Arthroscopy Association of North America. Team physician for the Los Angeles Lakers, Kings, Dodgers, Angels, Mighty Ducks and Rams.
PHYSICIAN GROUP AFFILIATION: Freiberg Orthopaedics & Sports Medicine
LOCAL HOSPITAL AFFILIATION(S): Jewish Hospital Kenwood, Bethesda North, Mercy Franciscan Western Hills, Kenwood Surgery Center, Children's Hospital
PROFESSIONAL/BOARD CERTIFICATION(S): Certified in orthopaedic surgery by the American Board of Orthopaedic Surgery. 


Freiberg Orthopaedics & Sports Medicine
9825 Kenwood Rd.
Cincinnati, OH 45242
Telephone: (513) 221-5500
Web site: www.freibergortho.com