Surgery goes outpatient route

It was a surgeon's shopping spot recently at Flathead Valley Orthopedic Center's conference room.

Orthopedic surgeons Rod Brandt, Bill Butcher, Stan Makman and Al Olszewski circled a table piled high with gleaming tools and implants brought by salesman for their consideration.

The banquet of precision instruments reflects the evolution of minimally invasive procedures such as arthroscopic shoulder surgery.

"The technology has really come of age," Butcher said.

Butcher, Brandt and Makman use these tools with a special camera to repair shoulder problems such as torn rotator cuffs - through just a few tiny incisions.

"We've done over 80 of them," Brandt said.

Although it's been available now for about two years, he said, many patients don't know they have an outpatient alternative to open surgery.

Along with avoiding a hospital stay, arthroscopic repairs bring fewer complications and reduced post-operative pain due to the small incision and less soft-tissue damage.

Butcher, Makman and Brandt committed to a tough training regimen to master the techniques of operating through tiny portals made in the shoulder.

"I put in a whole year of extra training," Butcher said. "There's a long learning curve."

Olszewski held up a large pair of retractors to contrast to the 6- to 10-centimeter opening used in open surgery on shoulders.

He said that as recently as four to five years ago, orthopedic surgeons laughed at the idea of making complex shoulder repairs through the tiny openings of arthroscopic procedures.

"These three guys are on the forefront," Olszewski said. "They really learned a valuable skill."

Rotator cuff and labral tears (related to dislocations) represent some of the most common shoulder problems that bring patients to orthopedic specialists.

According to Brandt, people in their 50s, 60s and 70s most often suffer rotator cuff tears. In some people, decades of shoulder muscles and tendons rubbing or impinging against bone result in the tears.

"It can be from trauma but most cases are chronic," he said.

Young people, mainly men 17 to 25, most often suffer shoulder dislocations. Extreme sports and other risky behaviors account for these painful injuries.

"Recently we've seen some 40- and 50-year-olds with dislocated shoulders," Brandt said. "But they were behaving like teenagers on wake boards."

Diagnosing the source of shoulder pain begins with an appointment with the orthopedic specialist.

The physician gathers a history, performs an exam and, if necessary, orders studies such as an MRI. Most shoulder problems don't require surgery.

"At least 70 percent of patients can be treated with therapy," Brandt said. Butcher said that surgery becomes an option if the pain doesn't go away and if the patient suffers a loss of function. He as well as Brandt and Makman use the arthroscopic approach most often.

"The vast majority, 95 percent, I'm doing with a scope- from very large tears to smaller tears," Butcher said.

Along with the advantage of less scarring and trauma to surrounding areas, the arthroscopic approach gives the surgeon a clear view of the injury on a high-definition monitor.

Butcher, Brandt and Makman perform the procedure at the outpatient facility of the patient's choice.

Options include HealthCenter Northwest, Kalispell Regional Medical Center or North Valley Hospital. By next spring, Flathead Valley Orthopedic will offer a fourth option at its own outpatient surgery center.

When patients arrive for their arthroscopic procedure, they receive either a shoulder block and sedation or go completely under anesthesia.

Makman said the procedure begins by inserting plastic tubes called cannulas in small incisions to form portals for the camera and instruments.

"You start with three incisions," he said. "But you may end up with five or six."

Makman begins with a thorough inspection of the injured shoulder from every angle.

In rotator cuff repairs, he said the work includes mobilizing the cuff which sometimes pulls into the shoulder and gets scarred down. Surgeons then attach sutures to bone and repair tears and damaged tendons.

Following the surgery, the patient stays at the surgery center for several hours for pain monitoring. Normally, a patient takes a narcotic pain killer for a week or so, then switches to an over-the-counter medication.

"It varies from patient to patient," Makman said. "People can feel pretty good that night."

Makman and the other surgeons warn patients that their bodies need several months to mend even though they feel good in hurry.

"For three months, you rely on sutures," Makman said. "It's healing."

Shoulder muscles and tendons take the same time to heal whether repaired arthroscopically or by open surgery.

According to Brandt, the cost is also comparable. Although arthroscopic surgical fees are higher than those for open surgery, patients save on hospitalizations for complications and pain control.

Medicare has approved the arthroscopic shoulder procedures.

"It's not experimental by any means," Brandt said.

Makman points out that the procedure remains the same. It's just a method of reaching the repair site that causes less damage and trauma to the body.

"When I was in residency 12 to 15 years ago, they told me that in 10 years you will be doing everything differently," he said. "It's true."

Reporter Candace Chase may be reached at 758-4436 or by e-mail at cchase@dailyinterlake.com.