Tag - Mansfield Orthopaedics

1
Pain Management from a Physician’s Perspective
2
Anterior Cruciate Ligament (ACL) Injuries and Reconstruction
3
Osteoporosis and Our Aging Population
4
Expect Some Pain

Pain Management from a Physician’s Perspective

Nicholas Antell, MD, one of Copley Hospital’s orthopaedic specialists, recently testified in front of the Vermont Senate Health and Welfare Committee. Dr. Antell was invited as part of the Committee’s request for feedback from providers on legislation that went into effect last year. The Vermont legislation limited prescribing and increased required education and communication in a statewide effort to address opioid addiction. Below is a transcription of Dr. Antell’s testimony. 

Over the past several days I’ve talked to most of the prescribers in our practice, Mansfield Orthopaedics, including physicians, but more importantly our Physician Assistants (PAs) and Nurse Practitioners (NPs) who do most of the prescribing and fielding of patient phone calls. The overwhelming consensus is that we are able to control our patient’s pain under these rules and that we were likely prescribing more opioids than necessary prior to their implementation. My subspecialty training is in orthopaedic trauma, taking care of patients that have complex fractures. I started with Mansfield Orthopaedics in August of 2016, and the NP I work with and I adopted these rules well ahead of the go-live date to see how it went. There were, of course, a few exceptions, but we were pleasantly surprised with how few patients were calling back requesting more pain medications. Now, I had the benefit of a developing practice, with a little more time to talk to our patients and manage expectations, which I feel was a huge benefit.

There are certainly times where I prescribe less, but most of my fracture patients are prescribed an amount of opioid that falls into the “severe” pain category in addition to recommending other medications such as Tylenol and Advil. My colleagues that perform joint replacement surgeries, such as total hip and total knee replacements, prescribe an amount of opioid that falls into the “extreme” category, and this was a significant cut from what they were used to. The PAs that work closely on that service tell me less than half of patients call back asking for more pain medications, but some still do. My colleagues that specialize in hand surgery, shoulder surgery, and foot and ankle surgery also feel they are able to control their patient’s pain under the current rules.

A point that was brought up by many was that we can use these regulations to help us limit the amount of opioids given to patients we do not feel really need them but are requesting them. In essence, we can blame the rules and the burden does not fall on the provider.

There are concerns amongst physicians in my group about legislation directing medical practice.  We must be allowed to use our clinical judgment when determining how many opioids are prescribed on an individual basis. We do not feel that it is up to lawmakers to decide if our patients fall into the minor, moderate, severe, or extreme pain categories. Although good as guidelines, we should be allowed to place our patients into which category we feel will adequately, and safely, control our patient’s pain so they can successfully recover from their orthopaedic procedure.

The most common complaint I received from our practice was with the Vermont Prescription Monitoring System (VPMS). We all appreciate the need to know if other prescribers are providing our patients with regulated medications, but the prescribers and delegates that use it most find it cumbersome and time-consuming to use. One provider suggested being provided with a reference number for each query that can be placed in the patient’s chart to confirm on our end that a query had been done. Another has found the customer service hours inconvenient while trying to get a password reset. We have also talked about a requirement to check VPMS before the first prescription is given, but then the system notifies us, for example by email, when another provider prescribes a controlled substance to this patient outside of our practice. Then instead of having to spend time rechecking VPMS in the rare circumstance a patient needs a refill, we can either quickly provide a refill knowing we are the only provider prescribing for them, or be able to have a conversation with that patient about the other prescription we are aware has been filled under their name. Most of us think there is certainly room for improvement with VPMS.

The consent form does add time to our preoperative routine, but the majority of the providers in our group don’t find it to be a nuisance, and with a few exceptions, we feel patients appreciate the discussion. A few patients have even taken this opportunity to tell us they don’t want a narcotic prescription following their procedure.

In our group, we have decided to prescribe Narcan to all patients that receive a narcotic prescription. This saves the hassle of having to figure out who needs one and who doesn’t. To save time we had a stamp made for our Narcan prescriptions, which lives in our perioperative area. However, we have noticed that the majority of our patients do not fill this Narcan prescription.

Initially, the morphine milligram equivalent requirement was confusing. We worked with our pharmacy department who put together a table to help guide how much of each specific narcotic medication could be prescribed to comply with these rules. This was extremely helpful in determining our new prescribing habits. I encourage the other providers here today to do the same if they haven’t already.

In conclusion, I want to thank this committee on behalf of Mansfield Orthopaedics for being given the chance to testify today, and for your continued interest in making these rules as operational and functional as possible, while not inhibiting our ability to practice medicine in a thorough and efficient manner.


Dr. Nicholas Antell of Mansfield Orthopaedics at Copley Hospital specializes in treating acute musculoskeletal injuries and total joint replacement.

Anterior Cruciate Ligament (ACL) Injuries and Reconstruction

By: Leah Morse, MS, PA-C

The Anterior Cruciate Ligament, the “ACL”, is an important stabilizing ligament in the middle of the knee. It is at risk of being torn in skiers, soccer players, and other athletes who commonly use cutting or twisting movements. About half of the time, an ACL tear will be accompanied by a meniscal tear and/or medial collateral ligament tear due to the overwhelming rotational or hyperextension force to the knee. Patients with ACL tears typically experience sudden pain and giving way of the knee, sometimes with an audible “pop” at the time of injury.  The knee will typically swell with fluid, become painful and unstable.

If this happens to you, initial treatment includes a period of rest, ice, compression, elevation (RICE), bracing, crutches, and anti-inflammatories. Early range of motion of the knee as tolerated with a trained physical therapist is also helpful. Then, an MRI is usually ordered to better visualize the ACL and further assess the knee injury.

Definitive treatment of an ACL tear depends on the patient’s age, desired activity level, and associated injuries. For young, active patients, ACL reconstruction offers a good chance of a successful return to sports and the pre-surgery level of activity.

Like many things in medicine, ACL reconstruction has advanced over the years. Mansfield Orthopaedics at Copley Hospital offers patients a minimally invasive “double-bundle” ACL reconstruction done arthroscopically. This reproduces the two naturally occurring components of the ACL, the anteriomedial and posterolateral bundles, through a few small incisions. Our orthopaedic suregeons can restore the location and orientation of the two ACL bundles using cadaver tissue or the patient’s own tissue to build a new ACL. Surgery usually takes 60-90 minutes, and any meniscal or cartilage injury can also be addressed arthroscopically at that time. (You can learn more here.)

Patients who undergo ACL reconstruction take on the small risks of surgery to regain knee stability and the ability to return to sports. Surgery is done on an outpatient basis and physical therapy is restarted one week after surgery. Rehabilitation after ACL reconstruction is a lengthy process – it takes many months for the body to reincorporate the new tissue into the knee. Patients who have undergone ACL reconstruction may start sports-specific agility training and drills five to six months after surgery, and running four months after surgery. It does take one year for full recovery and to properly rebuild muscle strength.


Leah Morse is a Certified Physician Assistant with Mansfield Orthopaedics at Copley Hospital. After completing Physician Assistant School and her Master’s Degree at Wagner College in New York City, Morse worked with the Neurointerventional Surgery team at Roosevelt Hospital in mid-town Manhattan. She relocated to her native Vermont in 2010 to work at Mansfield Orthopaedics, specializing in Hip and Knee joint replacement and sports medicine. Morse coordinates both the research program and the inpatient total joint replacement team.

Osteoporosis and Our Aging Population

By: Nella Wennberg, PA-C

Osteoporosis is a common diagnosis found in older patients. We are becoming more aware of the devastating consequences of fractures resulting from fragile bones. As the population continues to age, it is increasingly important for us to recognize the preventative measures and treatment options available to treat osteoporosis.

Over 40 million Americans have osteoporosis or low bone mass. This often develops unnoticed and can lead to fractures from a simple slip and fall. Hip, spine and wrist fractures are the most common type of fragility fractures associated with osteoporosis.  Osteoporosis_Live Well LamoilleThese fractures can lead to hospitalization, need for surgery and long periods of recoveries. These injuries are also associated with increased mortality in the elderly population.

Osteoporosis, which literally means “porous bones”, is an age-related decrease in bone mass. The cells in our bones are constantly being reabsorbed and replaced as we age. For some people, the new bone is less dense, which results in weaker bone structure increasing one’s risk for fracture.

Risk factors that increase your likelihood of developing osteoporosis include smoking, female gender, post-menopausal status, small body frame, White or Asian ancestry,  low calcium intake, excessive alcohol use, sedentary lifestyle, post-menopausal status and long-term use of certain drugs.

Most providers recommend Bone Density Testing (DEXA scan) in women over the age of 65 and men over the age of 70. This painless scan looks at the density of your bone and compares this to the bone density of the same gender and ethnicity, but at the age of peak bone density, typically when we are 20 to 25 years old. Blood work such as Calcium and Vitamin D levels may also be checked to help formulate a treatment plan.

Treatment is multifaceted and should be discussed with your primary care provider. Common treatments include calcium and vitamin D supplements, medications that increase your bone density, and weight-bearing exercises that emphasize balance training.

Prevention of osteoporosis is incredibly important. This involves living a healthy lifestyle that includes regular weight-bearing exercise, smoking cessation, low alcohol consumption, and a diet rich in calcium and vitamin D. People under the age of 50 should consume at least 1000mg of calcium and 400-600 international units (IUs) of vitamin D daily. Those amounts increase to 1200mg of calcium and 800-1000 IUs of vitamin D daily in folks over the age of 50. There are exercise programs designed to increase your bone density such as Bone Builders at Sterling View Community Center.  You could also contact your local gym or senior center for other options in your community.

Osteoporosis is a preventable disease. If you are concerned about whether you are developing weaker bones that increase your risk of fractures, discuss this with your primary care provider. They will be able to do some simple tests and review your individual risk factors to help determine if you will benefit from treatment.


Nella Wennberg_Mansfield OrthopaedicsNella Wennberg is a certified orthopaedic Physician Assistant with Mansfield Orthopaedics. She sees patients with a variety of orthopaedic issues. Wennberg holds a Master of Health Professions from Northeastern University and holds an undergraduate degree in psychology from the University of Vermont. She has been with Mansfield Orthopaedics since 2001.

Expect Some Pain

By: Leah Hollenberger

I recently listened to an interview on NPR about how doctors are wrestling with helping their patients who are in pain without contributing to the growing levels of opioid-addiction.

pain medicineIt was interesting because they spoke with a physician from Massachusetts who commented that he has changed how he prescribes pain medication. It’s now understood that even a short course of opioids (morphine or Dilaudid for example) for a few days can put some patients at risk for developing drug abuse. Now he tends to try NSAIDs first – ibuprofen or Toradol – and has found them to often be effective for his patients.

The interview finished with him saying “a little pain is going to be necessary,” which the radio host then rephrased as “pain is a part of healing.”

It made me think of Copley’s total joint replacement surgery program, during which it is clearly explained that day two and day three post surgery will be the toughest days. Where each patient signs a narcotic contract that clearly spells out when and how clinicians will prescribe along with when they will not. That, while clinicians will try as much as they can, there will be pain and the goal is to keep each patient’s pain managed in the 1-3 level on a scale of 1-10. So, yes, in this case, pain is part of the healing.

However, I think the radio host did a dis-service by continuing the misconception that everything can be healed, that everyone can be pain free. Certainly, that is true much of the time, but not all of the time. And the truth is, if we as a society are going to really reduce opioid-drug addiction, we are going to have to stop believing that a pill is going to be able to solve everything. We are going to have to expect some pain.

So where does that leave us? As a patient what is our responsibility in managing our pain?
Copley encourages you to:

  • Ask your doctor or nurse what to expect regarding pain and pain management
  • Discuss pain relief options with your doctors and nurses
  • Work with your doctor and nurse to develop a pain management plan
  • Ask for pain relief when pain first begins
  • Help your doctor and nurse assess your pain
  • Tell your doctor or nurse if your pain is not relieved, and
  • Tell your doctor or nurse about any worries you have about taking pain medication

Every clinician wants you to be pain-free, but they cannot guarantee it. Accepting that, expecting a little pain, may help you experience a better outcome in the long run.