Throughout my early training program, one of the catch phrases was “When you hear hoofbeats, don’t think of zebras.” It’s sort of a corollary of Occam’s Razor, which states that the simplest explanation for any phenomenon is usually the truth. And, for the most part, that has proved to be the case. But regardless of what field we’re in, all of us train continually to deal with the unusual, the seldom seen, the rare.
 
That’s really what separates the great from the merely competent, isn’t it? The expert who knows enough to recognize the truly rare occurence when it does finally show up is considered by the rest of his/her colleagues to be in that rarified stratum of “the best.” 

My old professor, Broadway Bill Fielding, was a world class expert in the cervical spine (neck). And he fell into that quite by accident. HIS boss (when he was just a young attending surgeon at St. Luke’s) was a guy named David Bosworth. And he was considered by many to be THE  most powerful man in American orthopaedics, at that time. He TOLD you where you were going for your position after training–you didn’t ask, because you wouldn’t get his recommendation for anywhere else. I’m not saying that was right, or fair, or reasonable, just that he could do it and make it stick. That’s power.
 
Anyway, one day Dr. Bosworth came across a 16mm film lying in a desk drawer that my Professor, BB, had made. He looked at it and said, “When did you do this?” And BB answered, “just something I was fooling around with, as part of my research on the cervical spine.”  “Well, you’re going to present this to the Academy!”– statement, not a request, from Dr. Bosworth. Turns out this little film was a cineroentgenographic study (x-ray movie–don’t worry, I can barely pronounce that, too) of the cervical spine. In other words, a moving picture of the neck bones, in motion. Seems no one had ever done that before, so it was a big deal.
 
Well, that little movie reportedly electrifed the audience, which was orthopaedists from all over the world. And it launched Dr. Fielding’s career as a world expert in the cervical spine. He admitted to me once that it was ten years after that that he was REALLY as good as they all assumed he was. In the process of trying to become what they all thought he WAS, he literally “created” himself as a true expert. He knew all about the rarities in orthopaedics, because he had SEEN them all before.

In my own practice, I was the only orthopaedist I know of who gave prophylactic heparin (a blood thinner) to patients who were having arthoscopic surgery, to prevent clots from forming in their legs during the procedure. Now, the other surgeons thought I was crazy for doing this. “Just not necessary,” they said. And I admit it was done on the theoretical basis that this COULD happen.
 
Then, one day, a patient who had arthroscopic surgery of the knee came in for pain in her calf. After checking her myself, I was worried enough to refer her immediately to the vascular surgeon. He in turn, got a venogram (x-rays of the legs, after injecting iodone dye, so you can see the veins). And it turned out she had this ENORMOUS long clot in her deep popliteal vein (deep vein thrombosis or DVT). If we hadn’t found it and it broke free, she would have been killed. 

You see, sometimes it IS zebras. And if you don’t at least think of them, you’re going to miss the diagnosis, sometimes with dire consequences.
 
As it was, my clinical paranoia (we call that “a high index of suspicion”) actually got her treated in time and saved her life. And those guys who laughed at me weren’t laughing then. This had happened despite my prophylaxis. So it showed that it CAN happen.
 
Sometimes people develop this problem for other reasons, like long plane flights, or long car trips. It’s just one of the rarer causes of posterior knee pain that I explain for you in my newest program, HOW TO AVOID KNEE SURGERY
http://drbillsclinic.com/avoid_knee_surgery.html

Yes, it’s almost ready. We expect the first shipment this Wednesday. But the link is active on my website right now. So head on over and grab your copy NOW.  If you ever wanted to know how you could relieve your knee pain, but stay OUT of the operating room, THIS IS IT! Don’t miss out. Click on the link to get yours NOW:  http://drbillsclinic.com/avoid_knee_surgery.html

Til next time, my friend, be well.
 
Dr. Bill

P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

May 30, 2008

As I promised yesterday, today I’m going to tll you how my love affair with knees began. Once again, it was during my formative years in the St. Luke’s residency program, in the mid-seventies. One of our favorite professors, smartest diagnosticians and all around good guys was Dr. Robert E. Zickel, or “Zick,” as pretty much everyone called him. He was a completely self-made world authority in trauma, having invented a unique nail for fixing subtrochanteric hip fractures (a particularly nasty and difficult-to-fix broken hip), while still in his own residency. This device was so good that most surgeons around the world adopted its use.
 
By the time I met him, he was a Full Professor of Orthopaedic Surgery at Columbia, which was the academic affiliate of St. Luke’s Hospital and Deputy Director of the Department of Orthopaedics at St. Luke’s, under Bill Fielding. His was always the voice of reason, keeping Fielding (who was a bit of a wild man) under some kind of control. More than that, he had common sense, an all too rare commodity in academic circles. He was one of two professors who really taught me how to think about what I was doing.
 
Despite his fame for and his contributions to hip surgery, he was the first one to bring arthroscopy to St. Luke’s. Up to that time, we only had indirect means of diagnosis, like x-rays, arthrograms (a kind of x-ray taken after iodine-containing dye is injected, to make normally invisible structures, visible) or CT scans. All these studies require interpretation–meaning someone has to look at them and decide what those shadows mean. These are all great, but what arthroscopy did was allow us to see directly into the joint for the very first time.
 
The idea was developed by a Japanese surgeon, Dr. Watanabe. He had the idea to take the cystoscope, a thin telescope used to look inside the bladder, and stick it into a knee. It’s one of those ideas that after the fact, everyone says, “Oh, how obvious!” But no one did it before him. After his initial success peering into the knee joint, to see all the structures in real life, he had the cystoscope modified to better serve his purpose. Thus, the arthroscope (an endoscope specifically for joints) was born.
 
Anyway, Zick had read about this great new instrument, seen its potential and decided to get on board this great new idea. I remember when he first brought his brand new arthroscope into the St. Luke’s OR. All the residents crowded around to see this shiny little steel tube, with a black plastic eye piece. It was about 8 or 9 inches long and 5 mm thick. We all watched in fascination, as he showed us how it worked on his patient. 

Wow! You could see everything inside! Just like a movie, but live. In those days, that meant you had to stick your capped (but still non-sterile) head down into the surgical field, to look through the eyepiece, which turned, so you could fine tune the focus. The scope was inserted through a little 1/4 inch stab wound, and another little stab wound was made on the other side of the knee, to allow the insertion of a steel probe, so you could touch those structures and examine them for pathology.
 
I still remember Zick saying proudly “Best orthopaedic surgery in North America,” as he taught us how to use the scope. Sure enough, it confirmed that the patient had torn his meniscus, just like the arthrogram said. But this was LIVE–you could actually move the torn fragment around. Well, at that time, the scope was considered just a diagnostic tool, so after we had confirmed the diagnosis, we re-prepped and re-draped the patient for a standard open surgery to fix the problem. I loved it! I was hooked on scopes from that time on.
 
But, it never occurred to us that the probe could be replaced with special cutting instruments and the entire business could be done with only those tiny little stab wounds, instead of a real knee incision. And if it had, we wouldn’t have believed it possible. That’s the real
difference between those that are true visionaries and the rest of us.
 
That same Dr. Watanabe DID make that intuitive leap, that seems so obvious to us, now. He and his colleagues developed the concepts, the instruments and the techniques that eventually became arthroscopic surgery. It took until the early 1980′s before the techniques became more and more accepted by orthopaedists. Old dogs don’t like new tricks, and many feel intimidated by new technology,
especially when the old methods worked just fine for them. This was especially true for arthroscopy, which involves an entirely different set of skills from those of normal surgery.
 
When I first started my practice, years later, even I was skeptical at first, when tales were told of same day surgery. “Just a gimmick,” I thought. Then, Dr. Turner, one of my other profesors from my fellowship, asked if I had gotten into arthroscopy yet. When I told him my
reservations, he laughed at me. “Bill, this is the greatest thing since sliced bread. You oughtta look into it.”
 
So, I did. Initially borrowing long thin instruments from the neurosurgeons, I started to remove loose bodies through the scope. Then, I went to Salt Lake City for a hands-on course to learn the latest techniques and see what equipment was needed. When I came back, I spent my own personal funds to purchase the first camera, recorder, arthroscope and instruments at my hospital. And that was the beginning….
 
Despite my original claim to fame as a fellowship-trained expert in joint reconstruction, my love for arthroscopy expanded over the years. By the time of my forced retirement, fully half my practice was arthroscopic surgery. It’s funny how life works out. Originally trained to do some of the biggest, most invasive open surgeries, arthroscopy led me further and further away from open procedures, and now, here I am, doing no surgery at all and teaching all the many methods I know for healing knees without surgery (see what I mean at
http://drbillsclinic.com/eliminate_knee_pain.html ).
 
So, my love affair with knees continues to this day, just in a different form. From the latest in cutting edge surgical techniques to the best conservative, conventional treatments, to the alternative methods that work, I teach it all at Dr. Bill’s Clinic. And I’m grateful that you’re along for the ride, my friend. Til next time, have a great weekend, and be well.
 
Yours for a pain-free tomorrow,
 
Dr. Bill
P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION

Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved