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Jerry Sloan; one of my first famous athlete patients

5/22/2020: I saw in the press that Jerry Sloan, famous basketball player passed away. www.msn.com/en-us/sports/nba/hall-of-fame-nba-coach-jerry-sloan-dies-at-78-he-led-utah-jazz-for-23-seasons/ar-BB14sWMI He was one of my first famous athlete patients to undergo arthroscopy in the mid 70’s. I remember it well as I was lecturing at a meeting in Chicago suburb and his agent arranged for me to come down town and perform a diagnostic arthroscopy under local anesthesia. I did not tell anyone where I went and as my custom I created no publicity. I forgot about it until today.

Incomplete data analysis on Coronavirus Incidence

5/20/2020: The incidence of coronavirus cases are increasing because the frequency of testing is increasing. That should not be surprising nor unexpected. The magnitude of the condition is not reported; asymptomatic or symptomatic patient, just positive or negative test. The incidence of coronavirus cases with hospital admissions are high perhaps for this contributing reason. Reimbursement has always been the name of the game in medical economics. Now there is bonus money for coding as COVID-19 for billing purposes. Medicare will pay hospitals a 20% “add-on” to the regular DRG payment for a billing coding of a patient with the new government COVID-19 billing codes. Medicare has determined that a hospital gets paid $13,000 more if a COVID-19 patient on Medicare is admitted and $39,000 more if the patient goes on a ventilator with the coronavirus diagnosis. www.statesman.com/news/20200422/fact-check-do-hospitals-get-paid-more-to-list-patients-as-having-coronavirus This is in addition to the base reimbursement. What you incentivize you will get more of. Ever wonder why the high incidence of COVID-19 patients? The real numbers may never be known.

Malaria drug evaluation: some facts

5/8/2020: There are many factors to be considered in evaluation of a drug. The first issue is safety. Hydroxychloroquine has met that standard for 50 years in treatment of malaria, lupus and rheumatoid arthritis. The main potential side effect is adverse effect on the heart and that is infrequent. A prescription for any treatment selects the intended patient based upon certain criteria. Is the patient without the disease? In this case the treatment is called preventative or prophylactic. The treatment should be disease specific and in this case the physicians considering the use of hydroxychlorquine for the coronavirus symptoms is called “off label (not FDA approved for this use). It is not being proposed as virilcidal for SARS CoV 2. There is no such certified drug at present. It is being prescribed to affect the symptoms of a specific patient. The next consideration for a use of a drug is for those presently affected by the disease is the disease stage at time of onset. Did it just start or is the disease progressive? The magnitude of the disease in the patient is the next factor. So why all the controversy concerning reports of hydroxychloroquine? So far the answer appears simple and logical. There is a difference in severity of the condition and the amount of the drug given. The success reports have a patient population that are at the early stage of the disease and treated with low dose. The failure reports are the use of those advanced to hospitalization and/or very high doses known to be toxic. The complication in the negative reports are related to the amount of the dose. Those taking 200 mg twice day are not as sick and have fewer complications than those taking greater amounts. There also is the caveat that those getting the higher dose are those most severely effected and with other conditions. For emphasis, the patients not likely to get a benefit are those in the hospitalized group. They are those (recent New England Journal Medicine) who are the sickest and those with most comorbidity (other disease conditions) and on the highest doses. This is not unexpected adverse result. The two opposing views, may be agenda driven, but both have credible logical medical rationale. However, but each is based upon different patient selection and treatment parameters. Bottom Line: It is legal for a patient and their doctor to decide on the individual’s treatment and/or prescription. You may decide with the advice of your physician.

Dr. Fauci’s argument critique

4/14/2020: Dr. Fauci’s argument discrediting the malaria drug for coronavirus patients is somewhat misleading. It is true that the randomized double blinded studies are the gold standard in medical science research. It is also true the hydroxychloroquine has been used for more than 50 years in other conditions with minimal complications. There are published studies in peer reviewed journals from France of the successful use in COVID-19 patients. However, Fauci knows better, but ignores the fact that historical controls are a valid means of producing valid reliable data. For example, if it is known that a given condition results in 100% mortality in 6 weeks even with the present treatments. This forms a historical control. The result is that everyone dies. With his historical control, a known medicine is given according to law where the doctor patient relationship allows a licensed doctor to prescribe an “off label” drug. An “off label” drug is one approved for another condition. In the best judgement of the doctor and the informed consent of the patient the medicine is given. This is legal and medically ethical. That is what is being done with hydroxychloroquine for COVID-19. Back to my example. When a series of medically well-defined patients have been followed for 6 weeks with the “off label” drug and 50% live it is accepted as valid research based upon the historical control. Only bureaucratic doctors who do not or perhaps never went face to face with a patient would withhold a potential safe reasonable treatment waiting for FDA approval. What is being done in practice and benefiting patients with “off label” drug is legal, ethical and scientifically sound.

Medical Technology New to Me.

9/11/2019: Medical Technology New to Me. Yesterday I was asked by two different professional athletes to give my opinion on two different medical treatments previously unknown to me. You must remember I concluded by clinical practice 24 years ago. The first one was about ARP wave therapy. My Internet search learned it is primarily a commercial entity. See www.arpwave.com/ It is based upon an electrical input that reduces the “charge of injury”. I could not readily find a definition for this term. There is before and after MRI evidence on the Internet promotion showing rapid repair of torn anterior cruciate ligament. It is advocated for nerve and muscle treatment in a wide variety of conditions. The second one was ozone injection therapy for spinal disc degeneration. See www.ijssurgery.com/content/8/17 They both appeared to be safe. The ARP lacks histological evidence, but search for such from the promoter results in opportunity to purchase the equipment. There is more supporting literature for the ozone treatments. The general effectiveness although promoted, the specific uses and outcomes remain unclear.

Making a Difference May Include Being Different

3/7/2018: I was invited to write this short manuscript by the editor in chief of the Journal of Bone and Joint Surgery. What’s Important: Making a Difference May Include Being Different Johnson, Lanny L. MD JBJS: March 7, 2018 – Volume 100 – Issue 5 – p 443–444 doi: 10.2106/JBJS.18.00011 The Orthopaedic Forum I probably made a difference in orthopaedic surgery as one of the pioneers of arthroscopy and the inventor of the motorized shaver and other instruments. However, a recent review of the biographies of those chosen for the American Orthopaedic Association’s (AOA’s) Distinguished Contributions to Orthopaedics Award made it clear that my career path was very different from those who are acknowledged by organized medicine. Many of the AOA luminaries came from families with medical genealogies. There were no doctors in my family. We only knew our family doctor, E.E. Woods, MD, who removed my tonsils in his office under ether anesthesia in 1938. He was way ahead of his time in doing outpatient surgery. I had been an athlete in high school and had wanted to become a coach, but my high school coach thought that I should be a surgeon based on results from the Kuder Preference Test. I had rejected that idea, thinking I was not smart enough—my IQ was 112. Plus, my family had no money. Most of those chosen by the AOA for the Distinguished Contributions to Orthopaedics Award had attended elite private colleges. I had attended a state school (called Michigan State College at the time) on an athletic scholarship. My high school coach had convinced me to try veterinary science, which I did for 1 year, and then I changed my major to premed. My application to the prestigious University of Michigan Medical School was rejected. I graduated from Wayne State University Medical School in Detroit—without honors. Perhaps my only likeness with the AOA honorees was my residency at Barnes Hospital in St. Louis, which was then, and still is, a prestigious program. My mentors there were H. Relton McCarroll, MD, and Fred C. Reynolds, MD, who were both American Academy of Orthopaedic Surgeons (AAOS) presidents. Those chosen for honors by the AOA typically came from large university academic groups. I had a desire for academic medicine and had been offered opportunities right out of residency to head a program at Syracuse and a new program in Shreveport, Louisiana. However, I accepted a family member’s advice that I was not a good fit for academic medicine and declined. By contrast, I started a solo private practice in East Lansing, Michigan, where there was no medical school at the time. I was interested in sports medicine and went to all of the relevant continuing education courses, where I learned that the experts of the day were 100% correct in their clinical diagnoses, personally confirmed by them during surgery. I was not that good, and was looking for ways to improve. I heard a lecture by Bob Jackson, MD, in 1969 about arthroscopy with a large Watanabe scope. Then, at an AAOS technical exhibit, I saw a needle scope. I popularized the use of this scope in an outpatient setting using local anesthesia at a time when arthrograms were the diagnostic standard. Subsequently, I saw that hand debridement by arthroscopy was primitive, and I invented motorized instrumentation, including a shaver. Most of those honored by the AOA belong to multiple prestigious orthopaedic organizations, most of which initially rejected my applications for membership. The rejections arose partly because the orthopaedic surgeons in my community said I was performing an unethical and immoral operation. Today, those purportedly inappropriate procedures are among the most common and successful orthopaedic procedures that are performed. I was rejected from membership in the Michigan Orthopaedic Society for 11 years. Five years ago, I received that society’s inaugural Lifetime Achievement Award. I was a candidate for AOA membership on 4 occasions before finally being admitted at 60 years of age. Each application was sponsored by a different AAOS president. My practice received a site visit by the American Orthopaedic Society for Sports Medicine (AOSSM) president, Les Bodner, MD, and secretary, Royer Collins, MD. After their visit, they voluntarily submitted my application for membership, but I was blackballed. Three years later, I was asked to give a 2-hour program on arthroscopy at the AOSSM national meeting, and was then granted membership. From all of these initial rejections and subsequent recognitions, I learned that I must accept, weigh, be thankful for, and respond to legitimate criticism. Unlike those typically honored by the AOA, I was never a traveling fellow, nor do I have a long list of academic appointments or awards. I had published in The Journal of Bone & Joint Surgery while I was a resident, but had only 1 publication thereafter. Noting that, the former JBJS Editor-in-Chief, Paul Curtiss, MD, invited me to submit. The submissions were all rejected. Dr. Curtiss was kind enough to tell me why: a prominent Harvard professor who reviewed for JBJS said I was a known liar. I was never elected to a leadership position in organized medicine. To be fair, I was offered several opportunities to serve as president of large national orthopaedic associations, but the same family member mentioned above directed me to decline. I have never been named a “distinguished” anything. I have received no National Institutes of Health (NIH) or other prestigious grants; I have always funded my own research. So, with all of these differences from the mainstream orthopaedic leadership, how can someone like me make a difference? I was influenced by the 1958 AAOS presidential address by H. Relton McCarroll, MD, entitled, “What Good Thing Could Come Out of Nazareth?” The message was that an orthopaedic surgeon can make a contribution no matter where he or she practices. I practiced in a remodeled student-rental house across from an 80-acre cornfield. In the early days, there were no traffic lights between my home and my office. Without the usual academic

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Fun to see I am still quoted from 1979 publication

11/29/2017: It was fun to see work I published 38 years ago is still quoted in the medical literature. The original publication was: Johnson LL: Lateral capsular ligament complex: Anatomical and surgical considerations. Am J Sports Med 7:156-160, 1979 This was reference in Oper Tech Orthop by Jorge Chahla as in press 2017 Elsevier Inc. Chahla J, Moatshe G, LaPrade RF. Biomechanical Role of Lateral Structures in Controlling Anterolateral Rotatory Laxity: The Anterolateral Ligament Biomechanical Role of Lateral Structures in Controlling Anterolateral Rotatory Laxity – The Anterolateral Ligament. Available from: www.researchgate.net/publication/314031553_Biomechanical_Role_of_Lateral_Structures_in_Controlling_Anterolateral_Rotatory_Laxity_-_The_Anterolateral_Ligament [accessed Nov 29 2017].