WINCHESTER Greg Grau, MD, had decided before he even went to medical school that he wanted a career in orthopedic surgery. With a degree in mechanical engineering in hand, he needed a few pre-med courses to apply to medical school. During this time, he worked as an ER technician and got to see the orthopedic residents and attendings realigning broken bones and thought, “I think I could be really happy as an orthopedic surgeon.” How much he was influenced by having a mechanical engineering degree is not certain, but Grau uses the problem-solving skills he first honed as an engineer every day in his practice at Kentucky Orthopedic Associates.
When Grau joined an existing practice in Winchester, Ky., 10 years ago, he was joining a single orthopedic surgeon – Michael Heilig, MD. He saw the potential for development of a robust practice as the patient population included many towns and cities close to the Mountain Parkway. He adds jokingly, “During training I heard my attendings say, 90 percent of orthopedic surgeons end up practicing within 20 miles of where their wives grew up. Coincidentally, my wife grew up in Winchester.”
Grau was clearly correct about the potential in the Winchester location. The practice has grown rapidly and now includes four associate orthopedic surgeons – Grau, Heilig, James Rice, MD, and David Waespe, MD – and five physician assistants, with satellite offices in Richmond, Georgetown, and Paris.
While some of the other associates have done subspecialty fellowships, Grau finds that general orthopedics suits him best. “I see patients ranging in age from seven months to 85 years, and I implement treatment programs ranging from conservative medical management to state-of-the art joint replacement,” he says.
On a typical day, Grau and two physician assistants will see 60 to 70 patients, 90 percent of whom are at some stage of conservative management, including physiotherapy, nonsteroidal anti-inflammatory medications, cortisone injections, and some with bracing. An average of about 10 percent of patients seen in the clinic are candidates for surgery.
Over the last decade, joint replacement materials and computer-assisted technology have advanced the field, as have products and procedures to put off the need for joint replacement. Grau uses a product called Accufill, by Zimmer, as a bone filler because it not only retains its shape and position but also it allows ingrowth of the surrounding bone. It is particularly useful in a procedure called subchondroplasty, where bone defects can be filled and knee replacement can be put off for an extended period of time.
Another recent advancement is a procedure for severe rotator cuff tears. “I have found a procedure called superior capsular reconstruction effective in treating severe rotator cuff tears that would otherwise require shoulder replacement, especially for relatively young patients with little or no arthritis,” says Grau.
Like his partner Grau, James Rice, MD, felt a strong pull towards a career in orthopedic surgery Rice’s exposure came while watching the repair of an extremely complex bone fracture when he was at the University of Louisville School of Medicine. It was during residency at the University of Florida in Gainesville when Rice worked with a pioneering spine surgeon, Michael MacMillan, MD, that his interest turned to that subspecialty. This was reinforced by his very next rotation on pediatric orthopedics, where a number of congenital spinal deformities were treated.
After completing his spine fellowship in Morgantown, W.Va., Rice returned to his hometown of Ashland, Ky. After three years at King’s Daughters in Ashland, the opportunity to join Grau and Heilig at Kentucky Orthopedic Associates arose. After the first visit, Rice was sure it was the right move.
Rice has a practice philosophy of using the most up-to-date techniques that have been proven to be of lasting value. “The procedures I do and the implants I use are cutting-edge technology, but they are not untested or unproven. I do not devote my practice to being the first one through the door with a brand-new technique or device. The reason is simple. A lot of those brand-new ideas don’t work out, and patients end up having to go back to have another surgery with a more time-tested technique,” he says.
Patient selection is key to achieving optimal outcomes with these procedures. For example, the direct lateral interbody fusion is one of Rice’s most utilized procedures because it has many advantages over the traditional posterior incision technique in the right patients, including a smaller incision with faster healing and less scar tissue, and a larger, more stable, bone graft.
“This is not a technique that most orthopedic surgeons use yet, although I learned it first in my residency program 10 years ago, and throughout my spine fellowship,” says Rice. “However, if confronted by significant osteoarthritis, with large bone spurs, I am still going to do the traditional posterior approach because it is the only way I can address the stenosis.”
The direct lateral approach is also a good choice for patients with spondylolisthesis, a condition where the spine is not stable and the vertebrae can slip back and forth on each other.
A lot of back pain in our society is caused by obesity, sedentary lifestyle, and poor postural habits. Rice knows these patients have been inundated with advice on diet and exercise, so his focus is on correctable pathology in the spine.
“If I find something that I think is amenable to surgery, I recommend surgery. I make sure patients understand my surgery is not going to take away chronic back pain, and they may have to take an active role in their back pain treatment plan,” he says.
Rice works closely with pain management physicians for medicines or injections. Those physicians often refer patients back to Rice for implanted spinal cord stimulators.
Whatever the condition, the surgeons of Kentucky Orthopedic Associates use their training and expertise to select the right treatment for the right patient to get the best outcome possible.