Dr. Swanson (left) & Colleagues

I had been looking for a way to give back to society for quite some time.  I wanted to do a medical mission to an underserved part of the world, but being a hip and knee replacement surgeon, I had not found an organization that would allow me to use my area of expertise to help others until I found Operation Walk.  Operation Walk is a non-for profit organization founded by Dr. Larry Dorr in 1995 to allow surgeons to go into underserved parts of the world and perform hip and knee replacement surgeries on patients who would otherwise not be able to receive these treatments.  Currently there are nine sites throughout North America who assemble medical teams to travel to various parts of the world to perform hip and knee replacements in underserved areas.

I discovered Operation Walk online while looking for an opportunity to donate my time and skills where they could be best utilized.  I learned that Operation Walk had a team based in Los Angeles, California going to Ho Chi Minh City, Vietnam in January of 2010.  I therefore contacted the coordinator to offer my services.

After arranging transportation and various supplies donated by our hospital, my scrub tech, Lois, and myself departed for Ho Chi Minh City on January 13, 2010.

We arrived just after midnight the morning of January 15, 2010, the day we were to start.  After checking into our hotel and getting a few hours of sleep, we ate a quick breakfast and boarded a bus with 61 other volunteers to the Hospital for Traumatology and Orthopedics.  Arriving at the hospital it was apparent that the facility was just barely adequate to perform hip and knee replacement surgeries.  There were people everywhere.  The main form of transportation in Ho Chi Minh City is by motorcycle or scooter, and the streets looked like sheets of two-wheeled vehicles.  Entering the hospital at seven in the morning we saw swarms of patients all waiting to see a physician.  I wondered if there was any way they would all be seen before the day ended.

Our first morning was spent screening patients for surgery.  Eighty patients had been pre-selected based on their orthopedic problems and general health prior to our arrival.  After breaking up into four teams each with two orthopedic surgeons, a physician assistant, an anesthesiologist, and an internist, we each screen 20 patients for suitability for surgery.  We worked quickly and used university students as interpreters to get accurate histories from the patients. Nurses, scrub techs, and other volunteers unpacked supplies and readied the operating rooms and patient care wards for our patients.

By noon we were done screening our 20 patients each.  We convened in a conference room where sack lunches were served, and we took turns presenting each of our 20 patients to the entire group recommending suitability for total hip or total knee replacement surgery.  Of the 80, 62 arthritic hips and knees were selected as suitable candidates for surgery.

Once the conference concluded, we all quickly changed into our surgical scrubs, which we had brought from home, and went to the operating room where we again grouped in 4 teams each having an anesthesiologist, a scrub tech, a physician’s assistant, and two orthopedic surgeons.  Each team did one case that afternoon to ensure that all operating room systems were in place.

The operating rooms were small but relatively clean.  Zimmer Orthopedics had donated the implants to be used in our surgeries, and the orthopedic representatives were there at all times being very helpful in ensuring we had appropriate implants for our surgical cases. A mountain of supplies had been donated by various entities and shipped over prior to our arrival.  Our storage room was so full of sterile supplies, instruments, gowns, gloves, drapes, etc., that there was barely any room to move when we started.  By the end of the mission, the room was nearly empty.

At the end of day one we all met for a group dinner to discuss the day and to relax in preparation for the next three days which would be more demanding.

We again met for breakfast at 6am the following morning, day two.  We took a bus back to the hospital where each team was assigned patients by number that we would operate on that day.  All four teams worked throughout the day accomplishing our goals and performing the cases which we had been assigned.   The backup crews were incredible.  We had volunteers from the United States, Canada, and Vietnam helping to clean instruments, deliver supplies to the operating rooms, and direct the flow of patients so that things ran efficiently.  We occasionally had to make due when we didn’t have everything we needed, but we completed all the cases that were assigned.   Again that night we met to discuss the day over a group dinner donated by the Vietnamese people.

Days three and four went the same as day two.  We completed our 62^nd total joint on day four by 6pm. Our recovery room nurses were superb in caring for the patients as they came out of their anesthetic, and the internal medicine doctors were there all day long ensuring that patients recovered from their anesthetics safely and without complication.  An excellent group of floor nurses and physical therapists who came with us took great care of the patients once they left the recovery room and were transferred to the patient wards.  Each room generally had 4 orthopedic patients, and the doors were so narrow that patients coming up on gurneys had to be hand lifted from the doorway into their beds.  Our physical therapists worked diligently with our patients, teaching them the proper exercises and getting them up walking the day of surgery.

On day five, we rounded on our patients that morning, and the patients were extremely grateful.  We were met smiles, handshakes, and even hugs from these very appreciative people who otherwise would have never had a chance to live a normal life again.  We changed dressings, checked wounds, and reviewed post operative x-rays of our work.  To our satisfaction, we had no significant complications in any of the 62 joint replacement surgeries performed.  The team worked together seamlessly to accomplish our goal.

On day six we again rounded and saw that all patients were doing well.  In fact on that day we all helped get all of the patients up in the hallway, which actually faced an outdoor courtyard, for a group picture.  Our 63 volunteers with our 62 patients were quite a sight, but everyone had smiles on their faces.  At that point we officially transferred care to the Vietnamese physicians and nurses who had been by our sides assisting and learning the entire time.

We also worked closely with the Vietnamese medical providers in teaching them the techniques and method we used in the United States for total joint replacements.  Each team had at least one if not two Vietnamese orthopedic surgeons assisting in surgery, and each room had at least one Vietnamese anesthesiologist learning from our anesthesiologists.  The Vietnamese nurses worked with our nurses as did the physical therapists.  On the final day we put on a symposium where we each presented a topic or research done in the area of joint replacement surgery to help educate the Vietnamese staff surgeons and surgeons in training.  We were well received, although we heard that some of the Vietnamese surgeons who were not accustomed to such rapid mobilization of patients after total joint replacements, were secretly telling the patients not to follow our instructions and that they should not be getting out of bed so early! However by the end of our mission, I think they were convinced that early mobilization of our patients was the right thing to do as they all seemed to be doing very well.

We had a few days at the end of our trip to see some of the sites of Vietnam.  We saw some of the war museums which were quite interesting, although naturally a bit biased against the United States.  However, seeing their perspective was much easier for me after speaking with them and visiting their museums.  The university students conducted the tours and were very interesting to speak with regarding their country and politics. Although acknowledging that they lived under a communist government, they seemed somewhat indifferent to the government, stating that they merely wanted to live full, fruitful lives.  They also went out of their way to ensure that we knew they were not angry with the United States for invading their country and urging us not to be sad by what we saw at the war museums.  They wanted us to know that they understood that most human beings are good people and what happened in the seventies was none of our fault.  They were very grateful young men and women, and I enjoyed all the time we were able to spend with them seeing their country.

My scrub nurse and I also had a chance to take a tour outside of Ho Chi Minh City to see the Cu-chi tunnels where the Viet Kong hid underground during the war.  They were a very innovative and hard working people, devising very effective means to counter attacks by our sophisticated war machinery with the most primitive but effective countermeasures.  It was a bit horrifying to actually crawl through the tunnels to see what our men were forced to do in the war, and it made it easier to see how difficult it would be to win this war.  After years of struggling with the questions of why we went to war with Vietnam, I left convinced that we did the right thing in leaving, but also with a much greater respect and gratitude for our men who served so courageously over there.

We boarded our plane back to the United States on January 23, 2010, stopping for two days in Shanghai, China where my son who is teaching English in China met us for my birthday.  We had a great birthday celebration not having seen him for several months and were able to tour Shanghai before departing to the United States.

I have to say that this was one of the most rewarding and fulfilling trips of my life.  I never realized how gratifying it could be to help people who are so poor that they could not even afford basic necessities let alone something we take for granted here in the United States–being able to walk painlessly.  I think if I didn’t have to worry about supporting a family here in the United States I might even consider doing this type of volunteer work full time.  But that not being the case, I expect I will at least donate my time yearly for many more of these medical missions as my duty and responsibility to mankind.  Wouldn’t it be nice if everyone could give in some way to those less fortunate than us.  This trip really made me realize how fortunate we are here in the United States regardless of what view we have of our own government.

People keep asking me what type of health care system I would support.  With some type of health care reform bill soon likely upon us, I suppose it is a timely question.  I hear many others in support of everything from the “do nothing” plan to full fledged socialized medicine.  I don’t know that either one is the answer, but then again, I’m not sure that I have the answer either.

I do know a few things that I see in my own practice.  The first is that physicians across the board over utilize health care resources.  It’s rare to find a physician who has been in practice for any length of time who has not been sued for some supposed act of omission.  When things go wrong, people need someone to blame—and to pay.  So when a patient comes into my office with hip or knee pain and no clear explanation, in spite of the fact that we all have hip or knee pain at some point, more commonly as we age—I order an MRI scan—even though I am 99% confident that it will not show anything of significance.  Sometimes the patient demands it!  There goes $1,000 for another test.  More often than not, the MRI shows some little this or that, but nothing that common sense wouldn’t have told me to treat with activity modification, anti-inflammatories and the usual gamut of conservative measures.

Physicians live in fear of malpractice lawsuits.  Lawyers have made it so easy for patients to file frivolous claims—and threaten not only to trigger an increase in our malpractice premiums, but threaten to exceed our malpractice limits thereby gaining access to personal assets.  With a legal system that makes lawsuits so easy, why not minimize the threat by ordering a test that doesn’t cost us anything—and usually doesn’t cost the patient either? So first, meaningful tort reform is necessary to control healthcare costs.

Second, private insurance companies, I suppose, are the epitome of capitalism in action.  They are businesses whose primary goal is to make a profit for themselves, not care for patients’ health.  But when insurers are allowed to fix prices where they want and make delivery of effective healthcare difficult in order to generate profits for themselves and their stockholders, healthcare suffers.  As much as I believe that capitalism is the key to a thriving economy, something has to be done about insurance companies that put profit before provision of affordable healthcare.

Socialized medicine?  Not so much.  There are so many things wrong with so many government-run bureaucracies that putting more programs into their hands is the last things we want.  Not only will government restrict and ration healthcare to a level not before seen in this country, but the delivery will become even more inefficient and costly.  Look at the per capita healthcare costs vs healthcare services citizens receive in countries that have socialized medicine.  It’s outrageous.  Yes, it all works great—until one gets sick!

So, yes, I do believe that we should have a safety net for all those who cannot get or afford healthcare.  Private insurance companies should not be allowed to profit at the expense of the health of our citizens.  But don’t throw out the baby with the bathwater.  Help physicians take care of patients without the hindrance if insurance companies or government.  And help patients needing care get it.  Control frivolous lawsuits.  And minimize bureaucracy.  Those changes will give us a good start.  And could we do it without that panic that it has to be done “yesterday”—so that we can take time to study the effects of these changes and make rational decisions?  I hope so.

Many surgeons are now using biology rather than surgical technology for treatment of a multitude of musculoskeletal problems.  Although stem cell therapy holds promise for the future, the use of Platelet Rich Plasma (PRP) is here today.

Platelet Rich Plasma is a concentrate of multiple growth factors normally found in the blood.  PRP can now be acquired in the office setting using the patient’s own blood and relatively simple equipment to centrifuge the blood and separate red blood cells from the plasma rich in platelets containing various growth factors.

Some of these factors include such proteins as Transforming Growth Factor-beta, Basic Fibroblast Growth Factor, Platelet Derived Growth Factor, Epidermal Growth Factor, Vascular Endothelial Growth Factor, and Connective Tissue Growth Factor.  There are likely many others that we have not yet identified, but these factors, when injected into an area of tissue damage (such as tendinitis, bursitis, or arthritis) stimulate the body to “jump start” the healing process.

Thus far, PRP has been used successfully in the treatment of such ailments as tennis elbow, plantar fasciitis, rotator cuff tendinitis and bursitis, muscle strains, and even arthritis.  Additionally, PRP can be used at the time of surgery to accelerate the healing process and sometimes reduce pain.

Although one of the remaining obstacles with use of PRP is getting insurance companies to pay for the procedures, PRP holds promise for the nonoperative treatment of multiple musculoskeletal ailments.

For more information, see this very thorough review:

http://www.prolotherapy.com/PPM_JanFeb2008_Crane_PRP.pdf.

Well, first, there are many ways to do a total hip replacement.  The surgeon can make an incision in the back of the hip (posterior approach), the side of the hip (anterolateral or direct lateral approach), the front of the hip (anterior approach) or using a combination such as in the 2-incision approach.  The anterior approach has recently been touted by many surgeons as being superior to other approaches because it “cuts no muscle,” implying that the other approaches must cut a lot of muscles.

So I decided to see if there was any data substantiating the superiority of the anterior approach over other approaches.  Woolson, et al recently showed a significantly higher complication rate using the anterior approach (http://tinyurl.com/nt7hnm, http://tinyurl.com/m4fcjh), and Hungerford, et al showed a significant learning curve for the anterior approach (http://tinyurl.com/l6y67g) at this years American Academy of Orthopedic Surgeons meeting in Las Vegas, NV.  Seng, et al published very similar results (http://tinyurl.com/ltvr58).  Jarrett, et al found no advantages to the anterior approach and noted some distinct disadvantages (http://tinyurl.com/nua37g). 

Although the proponents of the anterior approach are quick to point out the theoretical advantages of this approach, the facts do not support their claims, and in fact, some studies suggest that the approach may be inferior to others.  So as with all media hype of new technologies, surgical techniques, and drugs, don’t buy into things that sound too good to be true.  Many persons and companies profit from use of these products and will make unfounded statements to sell their product directly to consumers and to increase their profits.  So when the next new technology is hyped in the media, remember, Caveat Emptor.

Total hip replacements have come a long way, and Dr. Todd Swanson, Las Vegas, NV, pioneered many of the advances including the mini-incision total hip replacement that utilizes a mere 3-4 inch incision and has patients up and putting weight on the hip immediately. Full recovery takes a fraction of the time compared to older techniques, and many people return to sedentary jobs in 1-2 weeks.

“We were so excited about the mini-incision results, the greatly reduced recovery time and the increased longevity of the ceramic-on-ceramic hip replacements. Then, after implanting around 50 ceramic hips of a particular brand in 2004, we began noticing loud squeaking in some of them,” says Todd Swanson, MD, innovator of the mini-incision total hip replacement surgical procedure and director of the Desert Orthopaedic Research Foundation. “As the number of squeaky hips began to escalate, it became important to isolate the cause and relieve the concern for patients,” Dr. Swanson comments.

From November 1999, to February 2007 Dr. Swanson implanted 306 ceramic-on-ceramic total hip replacements in 267 patients utilizing 4 different brands: 1) Plus Orthopedics, 2) Stryker Orthopedics, 3) Wright Medical and 4) Encore Orthopedics. In the study, 233 patients with 270 total hips were contacted by telephone to complete a survey regarding squeaking of their hip replacement.

Frequency and severity as well as other independent variables were surveyed and rated. Frequency ranged from a squeak less than once per week to daily and severity ranged from perceptible only to the patient to loud–creating a social problem for patient. The study found problem squeaking was associated with only the Stryker Trident acetabular design used with their Accolade hip stem. Based on the findings of this study, the authors recommend against using the Stryker Trident cup with the Accolade stem.  More information on the study can be found at:

http://www.minitotalhip.com/webpages/squeakyceramichipposter2009aaos.pdf   http://www.minitotalhip.com/webpages/aaossqueakythahandout.pdf

Dr. Todd Swanson conducted the study at his Las Vegas research facility with his fellows and medical students: Raghavendran Seethala, MS, David J. Peterson, PharmD, DO, Ryan Bliss, BBA, and Calvin Spellmon, BS.

Todd Swanson, Las Vegas, is the director of the Desert Orthopaedic Research Foundation and is one of the country’s leading Mini-incision Total Joint Replacement surgeons. Since 1997 he has performed over 3000 minimally invasive total hip procedures and has traveled the world teaching this new technique to other surgeons. Research reports demonstrating these procedures and benefits are available at http://www.minitotalhip.com/webpages/PublicationsPresentations.htm. Dr. Swanson is also the Director of the Desert Orthopaedic Center Adult Reconstruction Fellowship Program in Las Vegas.

Phone Number: 702.731.1616

Fax: 702.221.9186

E-Mail: toddswanson.orthopedics@gmail.com

My name is Todd Swanson and I am a Total Joint Replacement surgeon in Las Vegas, Nevada. Since 1997 I have performed over 4000 minimally invasive total hip and knee procedures. I teach these techniques to surgeons around the world and report my own research demonstrating the benefits of these procedures.

I graduated from Augustana College in Sioux Falls, South Dakota and attended Washington University Medical School in St. Louis, Missouri. I completed my general orthopedic training at the University of California, Davis in Sacramento, California and specialized in total joint replacement of the hip and knee during a fellowship at the Metropolitan/Mount Sinai Medical Center in Minneapolis, Minnesota.

Since finishing my fellowship in 1991, I have practiced with Desert Orthopedic Center in Las Vegas, Nevada. I direct the Desert Orthopedic Research Foundation, a not-for-profit research organization working to benefit patients with hip and knee problems. Additionally, I direct the Desert Orthopedic Center Adult Reconstructive Fellowship program, a post-residency training program that prepares orthopedic surgery graduates for a career in total joint replacement surgery. I am also serving as a consultant for orthopedic implant companies and I’ve developed several patents for joint implants and instrumentation.

Board certified and a Fellow of the American Academy of Orthopedic Surgeons, I focus my practice on total joint replacements and joint preserving procedures for the hip and knee. As head of the Swanson Hip and Knee Center of Excellence and Research Institute, an organization located in Las Vegas, Nevada I’ve recently launched a program to develop and promote cutting edge techniques and technologies to alleviate hip and knee pain.

Websites: http://www.minitotalhip.com/webpages/index.htm

http://www.minitotalknee.com/webpages/index.htm

http://www.doclv.com/

http://www.americanjointsurgery.com/

http://www.swansonhipandknee.com/

Todd Swanson is also on: