Few people in the country, arguably the world, know more about joint replacement than C. Lowry Barnes, M.D., chairman of the Department of Orthopedic Surgery at the University of Arkansas for Medical Science (UAMS). One of the country’s foremost authorities on joint replacement, Dr. Barnes has patented four orthopedic surgery devices, designed numerous hip and knee implants and written and lectured widely on the subject of total joint replacement surgery.
But with all of these accolades, the thing that still drives Dr. Barnes daily is the goal of making Arkansas the nation’s center of excellence when it comes to orthopedic medicine. And there’s ample evidence that his efforts are headed in the right direction.
“There is not a single orthopedic problem that cannot be managed in our state now. I should say that includes replantation of hands and fingers,” asserts Dr. Barnes. “For years, we have struggled with how do we manage that population of patients. We now have four fellowship-trained hand surgeons at UAMS and they are on call 24-7, 365. We’re the center to replant fingers now.”
In addition to patient-facing advancements, Arkansas is a national model for other states in terms of managing the business of orthopedic care.
“We’re at the forefront of the economics of joint replacement,” he says. “We’ve already been a part of bundled care; Arkansas has been one of the leaders as far as having a commercial and state government combination between Blue Cross Blue Shield, QualChoice and Medicaid for bundled care and joint replacements.”
Despite these intricacies and the continued tug-of-war over health care policy going on in Washington, medical students continue to flock to the specialty. According to Dr. Barnes, UAMS receives about 500 applications for its five residency positions every year.
One of the things setting Arkansas apart is the access rural areas get to specialized expertise through telemedicine, says Theresa Wyrick-Glover, M.D., an orthopedic surgeon with UAMS specializing in the hand, wrist and elbow.
“We’re a typical Southern state in that we have a couple centers of population and the rest of the state is largely rural,” she says. “Some of the bigger population centers like Little Rock and Fayetteville have quite a few orthopedic surgeons, including lots of subspecialists. As you get into smaller towns, like Batesville and Russellville, you may have one or two general orthopedists but you don’t have access to subspecialty care.”
Piggybacking off a 2014 grant that helped set up long-distance diagnosis for stroke patients, orthopedic emergencies can now be evaluated in real time by a specialist from any emergency room in the state using high-resolution cameras.
“If it’s just a cut, it may be ‘suture it up and they can follow up in my clinic tomorrow,’” says Wyrick-Glover. “Or, if it’s a true amputation and we’re thinking about reattachment, we would say ‘treat the finger like this, give the patient antibiotics and tetanus and put them on a helicopter or ambulance to Little Rock so we can work on reattachment.’”
The system has garnered national attention and more importantly, it helps more than 400 patients annually realize better outcomes.
“We’re getting patients where they need to go in a more timely manner,” says Wyrick-Glover. “It’s very progressive for a little rural state like Arkansas to pull off something like that.”
Orthopedic technology is bringing patients other benefits as well says W. Scott Bowen, M.D., chairman of Arkansas Surgical Hospital. A primary benefit is procedures that are less invasive.
“We have seen growth in treatments for sports medicine and ligament injuries. With these, we are able to use small incisions and repair the torn or injured ligaments using arthroscopic surgery in an outpatient setting,” he explains. “In the past, these procedures were considered major surgeries that included large incisions and required lengthy hospital stays.”
The future is no less exciting, given some of the research being done that could one day replace metal replacement components, says Dr. Bowen.
“Utilization of biologics — the use of a patient’s own tissue to help in the healing process — is a type of treatment that has experienced tremendous growth in the last few years,” says Dr. Bowen. “Sometime in the future, the use of biologics may change the nature of what we do as far as joint replacement parts.
“Typically, replacement parts are metal and plastic. Biologics are created using the patient’s own tissue or possibly tissue growing in a tissue bank, which is transplanted into the patient. We are a few years away from routine use, but biologic implants will likely become available sometime in the future.”
Such advancements are not just limited to the state’s hospitals, either. The forthcoming merger between Arkansas Specialty Orthopedics and Ortho Arkansas, official on Jan. 1, 2018, is a model for the future: a large clinic offering a comprehensive battery of specialists and surgeons performing thousands of procedures annually.
“What I’m most excited about the firepower we’ll have going together is we’ll have a lot more brains thinking about things,” says Tad Pruitt, M.D., president of Ortho Arkansas and co-president of the new, as-yet-unnamed entity. “I really believe physicians should lead health care because physicians are the ones closest to patients. We want to try to stay plugged in at that leadership level as much as we can.”
Being big for big’s sake isn’t particularly important, says Dr. Pruitt, but as clinic-based practices get larger they gain the ability to bring services to people outside of major metro areas.
“Over the last 20 years we’ve put a lot of emphasis on access,” he says. “We do that by our various clinic locations — we’re at nine different places around the state. We have a nighttime urgent care clinic, and we’ve always tried to just make it easy to get in to see us.”
Jimmy Tucker, M.D., president of Arkansas Specialty Orthopedics and co-president of the new entity, says another advantage the practice will have is the ability to better measure patient outcomes.
“Outcome measurements help us decide how well patients are doing and how much procedures help people,” he explains. “If I do a particular surgery and patients only come back to see me one time and they say they’re doing great, I assume the surgery is really beneficial. But if they just decided to go somewhere else, the doctor never gets a clear understanding of whether patients are benefiting from the treatment.
“One of the things that’s important in the future is to collect data on these people long-term and [by] analyzing it, we’ll be able to tailor our treatment based on what affects the patient the best,” he adds.
Some surgeons are blazing new trails by introducing advanced procedures to the Arkansas market. Tod Ghormley, M.D., of Conway Orthopedics and Sports Medicine, is introducing one such technique, called direct superior approach, used in hip replacement.
“You used to see patients experiencing a lot pain, they stayed in the hospital two to three days and were on a walker for six weeks,” he says. “This new approach goes through the gluteus maximus muscle, then directly into the hip joint. It’s a smaller incision. You don’t violate the abductor tendons, the IT band.”
After performing the procedure just a handful of times, Dr. Ghormley was immediately sold on its benefits.
“Normal hip replacements take 2 to 2.5 hours and the guys that trained me in New York City do their operations routinely in 1 to 1.5 hours,” he said. “Patients have much less pain, they go home the next day, they’re on a walker for two to three weeks and a cane for a week or two afterward. It’s a game-changer.”
John Yocum, M.D., an orthopedic surgeon with Baptist Health in Little Rock, says the pace of innovation in orthopedics rivals most other medical fields.
“In shoulder, knee and hip ligament surgery and hip, shoulder and knee arthroscopy, we’ve developed some techniques to treat conditions that previously we really didn’t have an answer for,” he says.
In a specialty that already boasts patient-specific implants generated from CT scans, the future sounds like something bordering on science fiction.
“I think in the near future, we’re going to see another revolutionary change that’s going to involve robot-assisted surgery in knee and hip replacement,” he says. “We’re really excited about that and what that offers the patients in the way of improvement and the function of implanted joint replacements.”
One downside of all of these technological advancements is knowing where to invest the considerable resources it takes to acquire them. Kris Hanby, M.D., director of the Total Joint Center at Washington Regional Medical Center in Fayetteville, says it’s important to look after the interests of patients while not getting too far ahead of yourself.
“You do have to be careful because of the cost,” he says. “A new piece of technology is a pretty big capital outlay. There’s definitely some things there that we’ve looked at and we’ve decided not to use yet. I think we’re maybe a little more, I wouldn’t say cautious exactly, but we really want to see a benefit in exchange for the cost of implementation.”
One significant trend Dr. Hanby points to is that Arkansas continues to benefit from the import of physicians from other parts of the country and native surgeons who were trained elsewhere. This diversity of experience adds up to a more well-rounded collective skillset.
“A lot of us in this field have Arkansas ties, but a lot of us did our training outside of Arkansas,” says Dr. Hanby, an Arkansas native who did his residency in Oklahoma and his fellowship in Utah. “The people in my group trained in probably six or eight different states. You think about bringing that training back to Northwest Arkansas, you’re getting a lot of different ideas and approaches to problems.”
The versatility of treatment options in the orthopedics field has also given physicians the flexibility to adapt to the needs of various demographics within their individual markets.
“I would say in Hot Springs specifically, especially with Hot Springs Village being so close to us, our whole medical community has evolved,” says Christopher Young, M.D., an orthopedic surgeon with CHI Hot Springs. “We’re now a fairly seasoned group of medical professionals in terms of taking care of t
he geriatric population. We’ve been doing it for so long that I think we’re particularly well-positioned for this patient group.”
Young says that like any subset, dealing with aging Baby Boomers as a patient population requires specific skills and methodologies to be effective.
“It’s different because their soft tissues are less forgiving,” he explains. “That’s a variable you have to take into account. Something simple like wrapping dressings, for instance; you have to take those dressings off in such a way that it doesn’t cause skin tears. Once you’ve done it long enough, you just sort of develop those habits.”
Photography by Jamison Mosley
CORRECTION: A previous version of this story stated that Tod Ghormley, M.D., works at Conway Regional Medical Center. Ghormley is employed by Conway Orthopedics and Sports Medicine.