Proliance Surgeons Outlook v5i14

2 PROLIANCE SURGEONS OUTLOOK

www.proliancesurgeons.com 3

In this issue...Ski Season...or Knee Season?It’s winter, time to review the best methods to get in shapefor the ski season. Explanations, exercises and illustrationshelp you understand the differences between preventionand rehabilitation.

Abu Ghraib PrisonAn orthopedic surgeon’s experiencesDr. Mark Berkowitz shares his military experiences as anorthopedic surgeon, focusing on his 2005 deployment toAbu Ghraib prison. His participation and obvservationswere defining moments for him.

Hearing Aids:Exciting new technologyImprovements in hearing aid products and techniques are delineated as well as the positive effects that using one can bring.

In Every Issue...4 Letter from the CEO

Welcoming remarks from theCEO of Proliance Surgeons

10 Proliance Surgeons’ Directory

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Volume 5 • Issue 14

Welcome to another edition of Proliance Surgeons Outlook! We appreciatethe time you take from your busy schedule to see what our surgeons haveto offer.

One of the issues we have been following for several years is a lawsuit filedby a physical therapy group against an orthopedic group, who also havelicensed physical therapists working for the group. The issues are broadand the results could be very far-reaching into all medical practices in thestate of Washington.

On November 17, 2009 oral arguments on the case were heard by the Supreme Court ofWashington. It was a very interesting experience to listen to the arguments (limited to 20minutes per side in totality) presented to the court. The issue boils down to a few items:

Does the law allow a physician to employ a physical therapist?

Does the law allow a physician who employs a physical therapist to profit from his/herprofessional services?

Is a consumer disadvantaged because a physician employs a physical therapist?

Both sides did a very good job of presenting their arguments and we will await the decisionby the court. Obviously, Proliance Surgeons disagrees with the lawsuit and supports theposition of the orthopedic group who was sued.

That said, I’d like to comment on the process as a whole. Lawsuits such as this do NOTHINGto further medical care and do NOTHING to keep healthcare costs down. This is just a “turfbattle.” The physical therapy group cannot even show direct “damages” to them from thephysicians group, but feel they need to “clarify” the law. For what reason? Regardless ofyour leanings, when the medical community fights among itself, regulators feel authorizedand even obligated to make rules so that the fights do not occur.

I am disappointed that this case went all the way to the Supreme Court and that physicaltherapists are so intent on being “independent” that they bring so much damage to themedical community as a whole.

Thanks for “listening.” Hopefully everyone learns that in-fighting only breeds regulation.All the best to each of you as we go through 2010!

David G. Fitzgerald, CEO


A publication from

Proliance Surgeons, Inc., P.S.Central Office

805 Madison St., Suite 901Seattle, WA 98104

(206) 264-8100(206) 264-8689 Fax

www.proliancesurgeons.com

President Jeffrey Remington, MD

CEO David G. Fitzgerald

CFO Gary Mayberry

Proliance Surgeons Outlook, apublication from Proliance Surgeons,is an educational resource for healthcare professionals as well as thegeneral public. The publicationcommunicates educational newsand trends involving bothorthopedic and general surgerytopics and contains various health-oriented articles of interest. ProlianceSurgeons’ goal is to increase publicawareness of surgical techniquesand innovations and their significantroles in orthopedic and generalhealth care.

The information contained in thispublication is not intended to re-place a physician’s professionalconsultation and assessment. Pleaseconsult your physician on mattersrelated to your personal health.

Proliance Surgeons Outlook is published by Oser-BentleyCustom Publishers, LLC, a division of Oser CommunicationsGroup, Inc., 1877 N. Kolb Road, Tucson, AZ 85715. Phone (972)687-9035 or (520) 721-1300, fax (520) 721-6300, www.oser.com. Oser-Bentley Custom Publishers, LLC specializes increating and publishing custom magazines. Editorial comments:Karrie Welborn, [email protected]. Please call or fax for a newsubscription, change of address, or single copy. This publicationmay not be reproduced in part or in whole without the expresswritten permission of Oser-Bentley Custom Publishers, LLC. Toadvertise in an upcoming issue of this publication, please contactus at (972) 687-9035 or (520) 721-1300 or visit us on the Webat www.oser-bentley.com. January 2010

Letter from the CEO



We have a joke in the physical therapyclinic that once the snow falls, it isn’t skiseason…it’s knee season! Unfortunatelyfor many that choose to hit the slopes toski or snowboard, knee, foot or ankle in-juries are an all too common end to theseason. Whether you are an avid skier orone who is taking your first ride on thechairlift, there are some easy things to doto get yourself ready to enjoy the wintersport of your choice.

Just because you played in the fall softballleague alongside your co-workers does notmean you are conditioned to ski withoutpreparation. As Benjamin Franklin wiselystated, “An ounce of prevention is wortha pound of cure.” Applying the sameprinciples physical therapists do during arehabilitative plan after injury, you canwork towards having the best chance of aninjury-free ski season.

When designing a rehabilitation program,the positions, demands and forces placedupon the body during the athlete’s sportare paramount in guiding exercise choices.The same can be said from a conditioningor preventative standpoint when training

the body to function at peak performance.

Skiing is largely a lateral sport as the par-ticipant moves from side to side while for-ward motion is provided by gravity downthe hill. It also requires rotational strengthand sharp balance to keep the body stableon the skis. Considering this, my approachto rehabilitating the skier of any competi-tive level always involves exercises thatstrengthen and challenge the core, hips,knees and the foot/ankle complex in theseprimary directions.

Rehabilitation following injury focuses onstretching and strengthening muscles thatsurround the affected joint. Muscles areconnected to bones via tendons, connec-tive tissue that transfers the force of amuscle contraction (or shortening) inorder to move the joint. Joints arereinforced by ligaments, which span thespace between the bones (like a suspen-sion bridge) to limit motion in the wrongdirection. Ligaments don’t have muchelastic tissue, so once they are pulled totheir limit, they will abnormally lengthen,tear or pull part of their bony attachmentaway—all leading to a joint that has lost

its primary supporting structure and onethat becomes unstable.

The most common ligament injury duringthe activity of skiing is an Anterior Cru-ciate Ligament (ACL) tear. Once torn,surgical repair or reconstruction of theACL is typically recommended by yourorthopedic surgeon, especially if youwould like to return to an active lifestyle.Rehabilitation after an ACL reconstruc-tion focuses on restoring range of mo-tion, strength and the stability needed toreturn to your normal activities.

Strength is an important component to anypreventative or rehabilitation plan. Mus-cles can help support the joint through en-suring proper position of the body duringactivity, which limits improper forcesthrough the ligaments. This is also helpedby proprioception, a system of feedback inthe body that helps tell our brain whereour limbs are positioned in space—itallows us to walk in the dark and knowthat our foot will hit the ground just as wethink it should. Rehabilitation focuses onimproving muscle function and proprio-ception to help speed return to sport.

Ski Season...or Knee Season?

By Michelle Kuether, MPT


While each patient presents with theirown unique limitations following an in-jury, there are certainly common themesin the exercise plan. Following are excel-lent exercises for individuals looking tocondition and train during the off-seasonor those who have suffered knee, foot orankle injuries.

Balance is an important feature of any knee,foot or ankle rehab plan. The best mode ofexercise to restore balance is challengedpractice. Here’s a simple progression ofexercises to put your balance to the test.

Single Leg BalanceStand on one leg with the knee slightly bentand your arms apart. Hold for at least 10seconds to one minute.

If you can do this, try pulling your armsclose to your side.

If you are still standing, close your eyes(now think with your ears, not your eyes!)

If you are STILL standing, tilt your head back(think with nothing more than your ankle.)

The Single Leg ReachStand on your left foot.

Reach forward and touch the ground 2 feet infront of your left foot with your right hand.

Stand up straight again.

Repeat 10 times and switch legs.

The Medicine Ball Do the Single Leg Reach by picking up andreplacing a medicine ball. (Fig. 1)

With a partner, stand on one leg and tossthe ball back and forth—throw the ball inall quadrants of available reach range,catch the ball with both hands tochallenge rotation.

To train your lower leg in the stance de-manded during skiing, perform simplesquats to flex your body weight over theankle. This helps to restore the propermotion in the joints of your lower leg toallow the posture needed to positionyourself in the binding. It also allows youto keep your knees “soft,” properly dis-tributing the force as you respond to anybumps in the hill.

Start by performing repetitions of sitting tostanding from a hard chair.

Progress to doing wall sits—lean against awall, slide down to bend your knees toabout 90 degrees.

Keep your feet away from the wall so youcan still see your toes over your kneecapsand your shins stay perpendicular to thefloor. (Fig. 2)

Hold this position as long as you can,

progressing to 5–10 minutes. A minimumgoal should be to last for the duration ofyour desired run the next time you are onthe slopes. If you can only last oneminute, what will you do when you are atthe top of the double diamond run?

To combine lower body strength and bal-ance, perform the clock jump.

Stand on one leg and imagine you are in themiddle of a clock face

Start by jumping to 12:00, then back tocenter. Repeat, going to each numberonce clockwise, then counterclockwise,each time keeping your shoulders andupper body in the middle of the clock andyour knee soft to absorb impact.

To challenge the lateral motions needed tomaneuver the skis, lateral lunges help tocontrol your body motion over your cen-ter of gravity as well as reposition yourbody to an upright posture.

Stand with your hands on your hips, stepoutward sideways and lunge your bodyover your foot.

Work to control your momentum slowingyour motion, and then switch directions toreturn to the starting position.

Alternate sides to reproduce the side to sidemotion performed down the ski hill.

Fig. 1 Single Leg Reach plus Medicine Ball Fig. 2 Wall Sits


Progress to double leg hops side to side in a ski crouch.

Core exercises involve abdominal and pelvic muscle strengthen-ing. Side planks offer an efficient way to strengthen both areas.

For the beginner, start by lying on your side with your hips straight,knees bent to 90 degrees. Place your bottom elbow directly underyour shoulder with your hand in front of you. Your top arm canrest at your side or lightly rest on the floor in front of you.

Lift your hips toward the ceiling so your body is suspended,keeping your stomach tight by pulling your belly button towardyour spine.

Hold this position for 30 seconds, progressing to one minute.

Once this is easy, straighten your knees and prop yourself up withonly your elbow and feet contacting the floor. (Fig. 3)

To progress further, hold your core still as you raise your upperleg upward for 15 repetitions (Fig. 4) or add rotation by reach-ing your upper hand under your opposite armpit, then up to theceiling. (Fig. 5)

Technique is critical when doing any exercise program. If you feellike you are “all over the place” when performing your exercises,do them in front of a mirror to provide feedback and determinewhere you are weak. Flexibility is as important as strength—so besure to stretch your shoulders, hamstrings, quads and calf musclesbefore performing your exercises or your activity.

To be clear, there is prevention and there is rehabilitation. Follow-ing an injury, it is important to regain proper joint mobility, functionand stability to minimize the risk of repeat injury, chronic stiffnessand loss of proprioceptive abilities. Your physician and physicaltherapist will work together as a team to identify how skilled carecan help you in ways your exercises cannot. For example, manualtherapy techniques are an essential tool that your physical therapistwill employ to ensure proper joint function following an injury.

If you aren’t able to “walk off” an injury, continue to have pain orthink you should have been able to return to sport sooner, make anappointment with your health care practitioner to help rule outsomething more serious. It’s better to be safe than sorry in order tomaximize your time on the slopes, get the most out of your seasonpass and ensure that you don’t spend your time in the lodge!

Michelle Kuether, MPT is the clinic director at Pro-liance Sports Therapy & Rehabilitation in Is-saquah. She graduated with a master’s degree inPhysical Therapy from The University of PugetSound after completing her Bachelor of Science de-gree in Biopsychology at Grand Valley State Uni-versity in Allendale, Mich. She specializes in theevaluation of lower extremity biomechanics alongwith the fabrication of custom foot orthotics to aid

in the treatment of acute and chronic impairment or dysfunction.

Fig. 3 Core Exercise – Level 1




As one of the country’s largestsurgical practices, ProlianceSurgeons, Inc., P.S., performsemergency and elective operations,treating illnesses and injuries thataffect us all. Proliance’s orthopedicsurgeons have expert knowledge ofgeneral orthopedics and additionalspecialized training in sportsmedicine, joint reconstruction,arthroscopic surgery, spine surgery,hand surgery, foot surgery, fracturecare, and major orthopedictrauma. Our general surgeons havefurther specialized training inotolaryngology ENT), vascular,bariatric, and colorectal surgery.

CARE CENTERS

Bellevue Ear, Nose andThroat Clinic1135 116th Ave. N.E., Suite 500Bellevue, WA 98004(425) 454-3938

450 N.W. Gilman Blvd., Suite 203Issaquah, WA 98027(425) 454-3938

Cynthia K. Anonsen, MDThomas A. Knipe, MDAlice Lee Kuntz, MDSamson J. Lee, MDDaniel R. Seely, MDRoger S. Zundel, MD

Cedar Surgical3124 S. 19th St., Suite 220Tacoma, WA 98405(253) 301-5050

Leaza M. Dierwechter, MDW. Michael Johnson, MDJames J. Schopp, MDVirginia A. Stowell, MD

Edmonds Orthopedic Center7320 216th St. S.W., Suite 320Edmonds, WA 98026(425) 673-3900

James R. Alberts, MDBrian D. Cameron, MDDarcy S. Foral, MDLawrence J. Fowler, MDMichael B. Lee, MDWren V. McCallister, MDJeffrey P. Remington, MD

Everett Bone and Joint1100 Pacific Ave., Suite 300Everett, WA 98201(425) 339-2433

Howard B. Barker, MDLawrence J. Fowler, MDRalph T. Haller, MDTodd W. Havener, MDBill K. Huang, MDPeter J. Kinahan, MDJeff R. Mason, MDClay M. Wertheimer, MD

Evergreen Orthopedic Clinic12911 120th Ave. N.E., Suite H-210Kirkland, WA 98034(425) 823-4000

14841 179th Ave. S.E., Suite 330Monroe, WA 98272(360) 794-3300

8301 161st Ave. N.E., Suite 102Redmond, WA 98052(425) 882-1661

Richard L. Angelo, MDJames A. Champoux, MDCamille M. Clinton, MDMark A. Freeborn, MDRobin R. Fuchs, MDRonald V. Gregush, MDKenneth C. Lin, MDCraig M. McAllister, MDGregory J. Norling, MDJ. Scott Price, MDJames R. Robbins, MDJeffrey L. Stickney, MDJames D. Swenson, MD

Evergreen Surgical Clinic12333 N.E. 130th Lane, Suite 420Kirkland, WA 98034(425) 250-4700

Kelly A. Clinch, MDJohn S. Ebisu, MDMarion C. Johnson, MDHarry A. Kahn, MDJames G. Mhyre, MDMichael A. Towbin, MD

Northwest Orthopaedic Clinic10330 Meridian Ave. N., Suite 270Seattle, WA 98133(206) 526-8444

2409 North 45th St.Seattle, WA 98103(206) 633-8100

Herbert R. Clark, MDRobert S. Clawson, MDTimothy P. Daly, MDAllen W. Jackson, MD

Northwest Surgical Specialists1560 N. 115th St., Suite 102Seattle, WA 98133(206) 363-2882

Mark T. Brakstad, MDPaula L. Denevan, MDAlison L. Perrin, MDTerence M. Quigley, MD

Orthopedic Physician Associates601 BroadwaySeattle, WA 98122(206) 386-2600

1600 E. Jefferson St., Suite 600Seattle, WA 98122(206) 325-4464

M. Kevin Auld, MDJames P. Crutcher Jr., MD

Justin L. Esterberg, MDAlexis Falicov, MDJeffery L. Garr, MDK. Elizabeth Garr, MDLawrence E. Holland, MDScott E. Hormel, MDE. Edward Khalfayan, MDRichard M. Kirby, MDMartin G. Mankey, MDMichael K. McAdam, MDSt. Elmo Newton III, MDCharles A. Peterson, MDJohn W. Robertson, MDTodd J. Seidner, MDEugene “Pepper” Toomey, MDSean D. Toomey, MDJay B. Williams, MDWilliam J. Wilson, MDRobert A. Winquist, MDEva Young, MDRichard A. Zorn, MD

Orthopedic Specialists of Seattle1801 N.W. Market St., Suite 403Seattle, WA 98107(206) 784-8833

2409 North 45th St.Seattle, WA 98103(206) 633-8100

Mark J. Berkowitz, MDPhilip R. Downer, MDJonathan L. Franklin, MDCharles A. Peterson II, MDJoel A. Shapiro, MDJ. Michael Watt, MDWayne M. Weil, MD

Proliance Eastside ENT1800 116th Ave. N.E., Suite 102Bellevue, WA 98004(425) 451-3710

8301 161st Ave. N.E., Suite 200Redmond, WA 98052(425) 869-4855

Tom F. Gumprecht, MDJennifer L. Heydt, MDEric F. Pinczower, MD

Proliance Eastside Surgeons6505 226th Place S.E., Suite 101Issaquah, WA 98027(425) 313-0775

Edward Freimanis, MDBrian J. Plaskon, MD

Proliance Orthopaedic and Sports Medicine1135 116th Ave., N.E., Suite 510Bellevue, WA 98004(425) 455-3600

510 8th Ave. N.E., Suite 200Issaquah, WA 98029(425) 392-3030

Clayton B. Brandes, MDJames D. Bruckner, MDThomas H. Castle Jr., MD

Thomas D. Chi, MDJeremy A. Idjadi, MDTodd E. Jackman, MDGregory A. Komenda, MDPeter R. Mandt, MDAshit C. Patel, MDSteven S. Ratcliffe, MDMatthew J. Robon, MDMichael J. Sailer, MDJohn L. Thayer, MD

Puget Sound Ear, Nose, and Throat21616 76th Ave. W., Ste. 112Edmonds, WA 98026(425) 775-6651

15021 Main St., Ste. KMill Creek, WA 98012(425) 337-4810

9730 3rd Ave., N.E., Ste. 201Seattle, WA 98115(206) 526-9999

Henry S. Chang, MDTyler G. Kimbrough, MDJohn T. Parker, MDDuncan A. Riddell, MDShawn E. Rogers, MD

Puget Sound Orthopaedics 7308 Bridgeport Way W., Suite 201Lakewood, WA 98499(253) 582-7257

1515 Martin Luther King Jr. WayTacoma, WA 98405(253) 572-2663

Julian S. Arroyo, MDW. Brandt Bede, MDJohn M. Blair, MDSpencer A. Coray, MDDale L. Hirz, MDMichael J. Martin, MDGavin H. Smith, DPMSteven M. Teeny, MDAlan B. Thomas, MD

Rainier Orthopedic Institute3801 5th Street S.E., Suite 110Puyallup, WA 98374(253) 845-9585

20920 SR 410 EBonney Lake, WA 98391(253) 845-9585

Wendall W. Adams Jr., MDSteven C. Brack, DOWendy L. Heusch, DOFrederic L. Johnstone II, MDEric G. Puttler, MDNeal H. Shonnard, MDJohn T. Steedman Jr., MDAnthony B. VanBergeyk, MDSteven K. Yamamoto, DO

Skagit Island Orthopedics1401 S. LaVenture Rd.Mt. Vernon, WA 98274(360) 424-2400


Proliance Surgeons’ Directory

2511 M- Ave., Suite DAnacortes, WA 98221(360) 424-2400

Jimmy Y. Cui, MDDaniel M. Hanesworth, MDCurtis W. Rodin, MDJonathan B. Shafer, MDRichard V. Williamson, MD

South Seattle Otolaryngology16259 Sylvester Rd. S.W., Ste. 505Burien, WA 98166(206) 242-3696

David C. Green, MDPeter F. Maurice, MDPatrick H. McClean, MD

Southwest Seattle Orthopaedic and Sports Medicine16259 Sylvester Road S.W., Ste. 501Burien, WA 98166(206) 243-1100

Alan D. Barronian, MDWilliam L. Clark, MDPaul S. Degenfelder, MDRoger Y. Wong, DO

Surgery Associates16122 8th Ave. S.W., Suite D-1Burien, WA 98166(206) 244-1680

Andrew J. Haputa, MDMichael M. Kennelly, MD

Surgical Associates of Edmonds7315 212th St. S.W., Suite 201Edmonds, WA 98026(425) 778-8116

Carol J. Cornejo, MDKurt E. Harmon, MDThomas J. Jurich, MDSteven D. MacFarlane, MDMichelle J. Sinnett, MD

Valley Orthopedic Associates4011 Talbot Rd. S., Suite 300Renton, WA 98055(425) 656-5060

27005 168th Pl. S.E., Suite 201Covington, WA 98042(253) 630-3660

Michael D. Allison, MDCraig T. Arntz, MDWilliam P. Barrett, MDTraci G. Barthel, MDSusan R. Cero, MDB. Daniel Chilczuk, MDKaya Y. Hasanoglu, MDJohn M. Hendrickson, MDChristopher R. Howe, MDJohn P. Howlett, MDFredrick S. Huang, MDEric J. Novak, MDMark C. Remington, MDNiket Shrivastava, MDJason H. Thompson, MDMartin S. Tullus, MDRobert G. Veith, MD

Washington Hand Surgery12911 120th Ave. N.E., Suite H-10Kirkland, WA 98034(425) 823-4224

1535 116th Ave. N.E., Suite 200Bellevue, WA 98004(425) 283-5230

Todd M. Guyette, MDAllison J. MacLennan, MDEdward R. North, MDSteven L. Reed, MDSteven D. Sun, MDLoryn P. Weinstein, MD

With 38 care centers, eight MRI cen-ters, six physical therapy clinics, and13 surgery centers conveniently lo-cated throughout Washington’sKing, Snohomish, Pierce, Island, SanJuan, and Skagit counties, Proliance’s164 physicians and its providers de-liver the highest quality care avail-able. For more information, includinga list of physicians and directions toour clinics and centers, please visitwww.proliancesurgeons.com.

Additional Services

AMBULATORYSURGERY CENTERS

Edmonds Center forOutpatient Surgery7320 216th Street S.W., Suite 140Edmonds, WA 98026(425) 673-3750

Everett Bone and JointSurgery Center1100 Pacific Ave., Suite 100Everett, WA 98201(425) 317-8535

Evergreen OrthopedicSurgery Center12911 120th Ave. N.E., Suite H-110Kirkland, WA 98034(425) 216-7000

Evergreen Surgical Clinic Ambula-tory Surgery Center12333 N.E. 130th Lane, Suite 420Kirkland, WA 98034(425) 250-4700

Issaquah Surgery Center6505 226th Place S.E., Suite 102Issaquah, WA 98027(425) 313-0776

Lakewood Surgery Center7308 Bridgeport Way S.W., Suite 102Lakewood, WA 98499(253) 584-5252

Proliance Highlands Surgery Center510 8th Ave. N.E., Suite 100Issaquah, WA 98029(425) 507-0800

Seattle Orthopedic Center Surgery2409 N. 45th St.Seattle, WA 98103(206) 633-8100

Seattle Surgery Center900 Terry Ave., 3rd FloorSeattle, WA 98104(206) 382-1021

Skagit Island Orthopedic Surgery Center1401 S. LaVenture Rd.Mt. Vernon, WA 98274(360) 434-2480

Southwest Seattle Ambulatory Surgery Center275 Southwest 160th St., Ste. 200Burien, WA 98166(206) 988-0927

The Surgery Center at Rainier3801 5th St. S.E., Suite 210Puyallup, WA 98374(253) 445-4285

Valley Orthopedic Associates Ambulatory Surgery Center4033 Talbot Road S., Suite 270Renton, WA 98055(425) 226-2041

MRI

Eastside MRI12911 120th Ave. N.E., Suite H-120Kirkland, WA 98034(425) 823-4226

Edmonds Orthopedic Center MRI7320 216th St SW, Suite 320Edmonds, WA 98026(425) 673-3900

Everett Bone and Joint MRI3102 Colby Ave.Everett, WA 98201(425) 258-8110

Orthopedic Physician Associates MRI900 Terry Ave, Suite 100Seattle, WA 98104(206) 694-6665

Proliance Highlands MRI510 8th Ave. N.E., Suite 110Issaquah, WA 98029(425) 507-0810

ProSports Imaging N.W.3801 5th St. S.E., Suite 120Puyallup, WA 98374(253) 864-4106

Seattle Orthopedic Center MRI2409 N. 45th St.Seattle, WA 98103(206) 633-8100

STAR MRI8009 S. 180th St., Suite 105Kent, WA 98032(425) 656-0711

PHYSICAL THERAPY

Edmonds Orthopedic Therapy7320 216th St. S.W., Suite 320Edmonds, WA 98026(425) 673-3916

Evergreen Orthopedic Physical Therapy12911 120th Ave. N.E., Suite H-220Kirkland, WA 98034(425) 216-7075

Proliance Sports Therapy and Rehab of Bellevue1200 112th Ave. N.E., Suite C-260Bellevue, WA 98004(425) 462-5006

Proliance Sports Therapy and Rehab of Issaquah510 8th Ave. N.E., Suite 340Issaquah, WA 98029(425) 313-3055

Seattle Orthopedic Center Physical Therapy2409 N. 45th St.Seattle, WA 98103(206) 633-8100

Skagit Island Orthopedic Physical Therapy1401 S. LaVenture Rd.Mt Vernon, WA 98274(360) 424-2400



After nearly a decade in the U.S. military, inNovember 2009 I began my civilian orthope-dic surgery practice with Orthopedic Special-ists of Seattle. As I meet more and morepeople within the vibrant Seattle medicalcommunity, I have tried to introduce bothwho I am as a person and as a physician. In sodoing I have found myself reflecting back towhat is most certainly the defining experienceof my orthopedic career, my deployment toAbu Ghraib prison in support of OperationIraqi Freedom. Although it has now been fiveyears since this occurred, this experience con-tinues to influence my interactions with pa-tients and how I practice medicine, and in thiscontext it reflects many of the values that areimportant to me.

The medical care that has been provided toAmerican soldiers injured in Iraq has, withfew exceptions, been widely praised. Thispraise has come from academic institutionssuch as the New England Journal of Medi-cine, which has written several articles laud-ing America’s care of its wounded. It has alsocome from the popular media which hasbeen quick to highlight the drama of the airevacuation process. HBO’s documentary,

“Baghdad ER,” in particular, received greatcritical reviews for its depiction of Americannurses, medics and doctors caring for thewounded. Other documentaries on CNNand NPR have been equally well received,and YouTube contains more than 100 videoclips of similar life-saving heroics.

This praise is truly well deserved. During theVietnam War it took an average of 45 daysto return an injured soldier from theaterback to the U.S. for medical care; today, ittakes only four days. Even more impor-tantly, wound fatality rates have decreasedto 10 percent, a level far below thatachieved in any prior military conflict. Inessence, we are truly doing a better job ofcaring for injured soldiers than at any timein our history.

Standing in contrast to these accomplish-ments is the perception of how America hastreated the prisoners and detainees of thewar on terror. The same New England Jour-nal of Medicine suggested that physiciansactually contributed to the abuse of de-tainees at Abu Ghraib. The overall impres-sion seems to be that American physicians

have at times failed to carry out their oathto care for the sick and injured when thosesick and injured are enemy combatants.

It was in this context that I received myassignment in 2005 to serve as the orthopedicsurgeon for detainees at Abu Ghraib prison.This was a particularly volatile time for theprison. My deployment occurred less than ayear after the prisoner abuse scandal be-came public and within months of the bru-tal second Fallujah offensive that occurredadjacent to Abu Ghraib.

For these and numerous other reasons, AbuGhraib inherently posed several distinctchallenges. The first was strategic. AbuGhraib is only 20 miles west of Baghdadand adjacent to Fallujah in the Sunni Tri-angle, so it was situated in a rather unstablelocation. It also measures less than onesquare mile and is surrounded by highwayson all sides, making it an ideal target for animprovised explosive device (IED) and mor-tar attacks. During my time at the prison, itgarnered the dubious distinction of beingthe most frequently attacked U.S. forwardoperating base in theater.

Abu Ghraib PrisonAn orthopedic surgeon’s experiencesBy Mark J. Berkowitz, MD


The second challenge was psychological. Itwas impossible not to be reminded of theabuse that had gone on at this place. Thisincludes not just the U.S. prisoner abusescandal but also the thousands executed bySaddam Hussein before the conflict. I sawthe actual death chamber within the prisonwhere prisoners were hanged in an old-stylegallows. These images served as constant re-minders of the violent history of this place.

The third challenge was the weather. Todescribe it as having a biblical quality isnot hyperbole. In the winter when I ar-rived, it was cold, the rain was torrentialand flooding was widespread. In spring,insects invaded the prison in droves andwithin a few months, the place turned intoa desert with temperatures reaching 130degrees. All of these tended to sap one’senthusiasm for the mission.

The fourth challenge was the accommo-dations. In the wake of the prisoner abusescandal, the prisoners had been movedoutside into a tent city named CampRedemption. This opened up the actualprison, and due to the relative safety ofliving in concrete structures, we werehoused in the prison cells. But the ameni-ties were somewhat lacking as you mightexpect. Air conditioning was unreliable,windows nonexistent, and privacy therarest of commodities.

The fifth and final challenge involved thehospital and its surgical equipment. Unlikethe large Combat Support Hospitals orCSHs profiled on HBO and CNN, whichoperated in commandeered Iraqi civilian

facilities, Army Field Hospitals work out oftents, so a tent was set up within one of theprison’s buildings and served as the inpatientward. The operating theater is contained ina mobile trailer which could not be placedwithin the concrete structures of the prisonso it was set up just outside the ward tent.These OR trailers are actually quite impres-sive units with two OR beds and anesthesiamachines that can function simultaneouslyif necessary. But being outside the concreteprotection of the prison structures and com-posed of lightweight metal, these trailersprovided little in the way of protection, so itwasn’t uncommon to don Kevlar helmetsand vests during surgical procedures.

Lastly, the equipment available was min-imalist, to say the least. Again, whereasthe CSHs in Baghdad and Balad wereequipped much like a U.S. civilian hospi-tal with mobile radiographic C-arms,intramedullary nails, locking peri-articularplates and pretty much anything else onecould want, the prison facility had noC-arm, no intra-operative X-ray capabil-ity and really limited power or implantsother than external fixation.

With this limited armamentarium, myprimary task was to provide orthopedicsurgical care for enemy combatants anddetainees of the war who sustained high-velocity penetrating trauma. This consistedprimarily of amputations, fracture treat-ment, soft tissue management and traumareconstruction, each of which posed its ownunique challenges.

My first recollection of my initial days on

the job was how quickly I realized just howunprepared I was for military penetratingtrauma. I had performed my orthopedictrauma training at Los Angeles County hos-pital where gunshot injuries were a routineoccurrence, but it became clear prettyquickly how drastically wartime trauma dif-fers from civilian trauma. Besides mortarsand IEDs, I was impressed at the sheer sizeof the projectiles. I took a photo of a 9mmround, an M-16 round and a round from a.50 caliber machine gun. Once this visualsunk in, I was no longer surprised at theseverity of the injuries that resulted fromthese weapons.

All too often, in the face of a mangling ex-tremity injury, amputation became a pri-mary mode of treatment. Although the rulesfor managing amputations are different onthe battlefield than in civilian practice, thegoals are the same—namely, a stable resid-ual limb that can accommodate a functionalprosthesis. Through contracting with localprosthetists, we were able to obtain func-tional prosthetic limbs for virtually everydetainee who underwent amputation. Infact, all efforts were made toward salvagingas much of the limb as possible to allowprosthetic use. At the time, this requireduse of external fixation to stabilize a moreproximal fracture, as in a patient with atranshumeral amputation.

Unfortunately, many of the more severe,proximal injuries were not amenable to pros-thetic fitting. Two of my more memorablecases involved proximal extremity amputa-tions. In one case, it was ultimately necessaryto perform the very uncommon procedure of

Gallows in Abu Ghraib prison used by Saddam Hussein

External entrance to my living quarters at Abu Ghraib

Entrance to my cell at Abu Ghraib


total scapulectomy in order to achieve heal-ing of a massive draining wound. In anotherinstance, three months of wound care andmore than 25 surgical procedures were re-quired to achieve closure of an infected hipdisarticulation. These cases will always rep-resent for me the horrific damage that warinflicts on the human body.

It was in doing a transfemoral amputationthat I obtained an interesting glimpse into thephilosophy of many of the Islamic detainees.This individual was assembling an IED whenit detonated, creating a mangling, unsalvage-able injury to his thigh. Because of the acuityof the situation, I wasn’t able to speak withhim before the surgery and I felt very badlythat I had amputated his leg without ex-plaining why. After the surgery, when he wasrecovering I went and spoke with himthrough a translator and explained why thesurgery had to be done. I had anticipated thatthis would be quite an emotional situation,but this individual betrayed no emotion, noanger toward me or toward his situation.The translators explained to me that theIslamic philosophy is much more fatalisticthan in the West and that he had simplyaccepted this as Allah’s will for him and wasat peace. Such interactions with the detaineesform some of my strongest memories.

When the limb was able to be salvaged,fracture treatment became the next high-est priority and this was accomplished pri-marily using external fixation. In general,the method of fracture treatment we useddrew on principles of previous armed conflicts. H. Winnett Orr was a Nebraskaorthopedic surgeon who observed

firsthand the heyday of the Carel-Dakinsmethod of wound irrigation during histime spent overseas during World War I.The Carel-Dakins method attempts to ster-ilize the wound by frequent dressingchanges and constant instillation ofhypochlorite solution. Orr felt this tech-nique actually impeded tissue healing andinstead recommended aggressive debride-ment followed by infrequent dressingchanges and tissue rest using plaster im-mobilization, thus allowing the body’sown homeostatic mechanisms to begin thehealing process. He was ridiculed in theU.S., but supported by the famous Britishorthopedic surgeon Sir Robert Jones,among others, whose own technique wassimilar in philosophy. My feeling was thatexternal fixation and use of a vacuum-assisted wound dressing updated but stayedtrue to the principles of Orr’s technique.

Experiences in World War II and Vietnamalso demonstrated the importance of func-tional rehabilitation for fractured longbones, and we tried to stay true to thismaxim as well. External fixation frameswere gradually deconstructed and loosenedin a process called dynamization which al-lowed more and more stress to be supportedby the bone and less by the external fixatorframe. During this dynamization process,patients were encouraged to bear increasingamounts of weight on the injured leg. Thiswas beneficial not only to the fracture butto the patient’s overall disposition and re-habilitation as well.

The limits of external fixation quickly be-came apparent, though, for certain

fractures. Forearm fractures did ex-tremely poorly with external fixation andso whenever possible I would use our lim-ited small fragment set to treat these withOpen Reduction Internal Fixation(ORIF). Fractures about the elbow alsopredictably developed ankylosis and lim-ited function. Probably the most vexinginjury to treat with external fixation werefractures of the proximal femur or hip re-gion. These were incredibly frustrating totreat in the sense that just miles down theroad at the CSH in Baghdad, patientswith these fractures received modern in-tramedullary devices just as patients inAmerica with similar injuries would re-ceive. In contrast, I had no option but totreat these injuries with external fixatorsattached to the pelvis and thigh, immobi-lizing the hip. This is a photo of one ofmy proximal femur fracture patients on atilt table, really the only activity these pa-tients could do for the 12 or so weeks thatthe fixator was in place.

Virtually 100 percent of the fractures Itreated were high-grade open fractures in-volving severe trauma to the skin and mus-cle as well as the bone. Soft tissuemanagement was often just as challengingas fracture treatment. As you can tell bynow, most of the equipment we had wasfairly rudimentary but the one exception tothat was the VAC (KCI). We had several ofthese devices available, and they proved tobe the single most valuable piece of equip-ment. I never tired of watching wounds thatinitially appeared massive, transform intomanageable ones with use of the VAC. TheVAC creates what is called a negative

Interior of my cell at Abu Ghraib shared with three other soldiers

Protective Kevlar helmet during surgerywithin surgical trailer

Pre-operative radiograph of patient with nonunion of humeral fracture


pressure dressing that continuously removesfluid and debris from the wound and en-courages increased blood flow, thus pro-moting granulation. This proximal femurfracture presented with a gaping soft tissuedefect with bone visible in the depths andafter 45 days of negative pressure therapyhad filled in almost completely with healthygranulation tissue that eventually supporteda successful split thickness graft.

Unfortunately, at times more VAC machineswere needed than we physically possessed. Inthese situations, we used a portable NG suc-tion machine, a JP drain, a surgical scrub brushand Ioban to create an improvised negativepressure dressing. In fact, in the aftermath of amass casualty situation, we once had severalpatients hooked up in series to an industrialvacuum machine providing a communal neg-ative pressure dressing. This technique waseventually published in the peer-reviewed jour-nal, Foot and Ankle International.

The other technique we adopted to helpwith soft tissue management was modifyingthe external fixator frame with a kickstand.I first did this when I inherited a patient’sfull-thickness decubitus heel ulcer. It becameclear that patients with multiple injuries,treated with rigid external fixators, on un-forgiving beds, with a language barrier, wereextremely susceptible to decubiti. The kick-stand also facilitated the frequent VACdressing changes that most of these patientsrequired. Eventually this technique waspublished in the peer-reviewed journal,American Journal of Orthopedics.

The last aspect of war surgery that I engaged ininvolved late reconstruction of post-traumaticinjuries. These were the most difficult toperform in the detainee population becausethey essentially involved asking a prisoner ofwar to have elective surgery by an enemysurgeon who speaks a different language. Butthey were also real opportunities to helpindividuals with debilitating injuries.

Most cases came from outpatient clinics.Medics would identify detainees with prob-lems during sick-call sessions in the prisoncamp and bring them up for evaluation.Translators were critical in establishing a vi-able relationship with the prisoners, and Ihave an incredible amount of respect for

these individuals. Most wore masks andsunglasses at all times to protect their iden-tities. The threat of death to themselves andtheir families was all too real if it becameknown that they were assisting Americans.

My most memorable patient interactionoccurred in the context of treating a post-traumatic nonunion of a humerus fracture.The surgery proved extremely challenging.Despite a great deal of preoperative counselingregarding the risks of surgery, it is hard todescribe just how uncomfortable it was for meto face him when he initially developed a post-operative radial nerve palsy and again whenhe developed a purulent deep infection that re-quired several additional surgeries. Complica-tions strain the doctor-patient relationshipunder the best of circumstances, but this strainwas multiplied tenfold in the prison setting.Yet despite the friction that developed betweenhim and me, at three months after surgery henow had a solid arm, infection-free, goodrange of motion and return of his radial nervefunction. I think in the end he and I came tounderstand each other somewhat, and he felthe had been treated fairly, if not well.

In conclusion, I hope you’ve found this ma-terial interesting and thought-provoking.Although I am in a very different place rightnow, personally and professionally, I continueto draw lessons from this experience that in-fluence my practice of medicine and my caringfor patients. I think my experiences at AbuGhraib in many ways accurately reflect whatI am about, and hopefully they will serve as astarting point as you get to know me as a newmember of the Proliance community.

Dr. Mark J. Berkowitz is aboard certified orthopedicsurgeon with expertise inall aspects of foot andankle surgery and non-operative care includingarthroscopy, sports-relatedconditions, bunions, arth-ritis and trauma. He

obtained his medical degree from CaseWestern Reserve University and completedhis residency at Tripler Army Medical Cen-ter in Hawaii. Dr. Berkowitz has completednumerous marathons and triathlons andalso enjoys tennis, running, biking andplaying with his two young children.

TOP: External fixator modified with“kickstand” to prevent decubitus ulceration

MIDDLE: Clinical photo of detainee withproximal femur fracture treated withexternal fixation on tilt table. This was theonly activity these patients could perform forthe 10-12 weeks that the frame was in place.

BOTTOM: Clinical photo of patient beingtreated with functional rehabilitation andearly weightbearing on bilateral lowerextremity injuries



Consider this: one in 10 Americans, more than 31 million people,experience some degree of hearing loss. As baby boomers transitioninto their 60s, one in three can expect some hearing loss.

How do the hearing aids of today differ from yesterday’s hearingaids? “A great deal of research and development has gone into en-hancing hearing devices,” explained Dale Flynn and Beth Kopyar,audiologists with Puget Sound Ear, Nose and Throat. Hearing aidstoday feature digital, multi-channel circuits that are computer pro-grammable. This allows more flexibility in making sound adjust-ments and fine-tuning the instruments. Hearing aid circuits featurefrom one to 32 channels, which are frequency bands of amp-lification. Tuning flexibility increases with the number of channels.Most hearing aids also offer leading technologies such as directionalmicrophone system, which enhances speech understanding in noisyplaces, and feedback cancellation, which eliminates, or reduces, feedback (whistling). Many current hearing aids are equipped withmultiple memories or programs designed for specific listening situa-tions such as noise-filled rooms or TV/music. Some hearing deviceseven come with remote controls and rechargeable batteries.

For certain types of hearing loss, a new and very popular device iscalled the “thin-tube, open ear” hearing aid. A small, featherweightinstrument tucks behind the ear and is connected to a thin tube lead-ing into the ear canal. This style of hearing aid is virtually invisible.An open-fitting hearing aid allows wearers to hear their own voicenaturally, and eliminates the sensation of a plugged ear. Effective,new feedback control systems allow more people than ever to wearthin–tube, open ear devices.

Advances in hearing aid technology are occurring quickly, paralleling advances in computers and robotic science. The latesthearing devices have artificial intelligence in the form of aDataLearning system. This system learns the user’s preferred vol-ume in specific environments and programs the hearing aid auto-matically to the preferred setting. SoundSmoothing reduces theannoyance of sharp, impulse sounds like silverware and dishesclattering or paper rattling. Amplified sound is quite comfortable.

Patients with hearing aids describe many positive effects of improvedhearing. One patient, an avid golfer, told of feeling isolated and left outduring biweekly rounds of golf with her friends before being fit witha hearing aid. With her new hearing aid, she reports the pleasure ofconversation with the other three ladies in her foursome. Another pa-tient strained to hear the teacher in a class he was taking. His newhearing instrument enabled him to hear easily and he could take notes,since he did not have to read the instructor’s lips! Most hearing aidusers appreciate being able to listen without straining to catch words

and are no longer exhausted by that effort at the end of each day. With today’s new hearing devices, patients are able to comfortably hearinformation that is too important to miss.

Dale Flynn, MSPA, CCCA, attended the University of Washington forboth undergraduate and master's degrees in audiology. He joined PugetSound Ear, Nose & Throat in 1978. He is certified by the AmericanSpeech-Language-Hearing Association and is a Fellow of the AmericanAcademy of Audiology. Besides dispensing hearing aids, he does vestibu-lar (balance) testing and diagnostic hearing tests.

Beth Kopyar, Ph.D., CCCA, received her master's degree in audiologyfrom Kent State University in Ohio and her Ph.D. from the University ofWashington. She joined Puget Sound Ear, Nose & Throat in 1996. Herareas of clinical service are diagnostic audiometry and hearing aid fit-ting. Dr. Kopyar is certified by the American Speech-Language-HearingAssociation and is a Fellow of the American Academy of Audiology.

Hearing Aids:Exciting new technologyBy Dale Flynn, MSPA, CCCA and Beth Kopyar, Ph.D., CCCA


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