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Image created by RRY Publications, LLC. Sources: Wikimedia and hss.gov
Image created by RRY Publications, LLC. Sources: Wikimedia and hss.gov

Pills for Disc Health? // Is Total Ankle Replacement the Next TKA?

Elizabeth Hofheinz, M.P.H., M.Ed. • Mon, June 3rd, 2013

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HSS Prepares for 2014 World Cup and 2016 Olympics in Brazil

The race is on in Rio as the country prepares for the 2014 World Cup and the 2016 Olympics. And Hospital for Special Surgery (HSS) in New York is helping to pave the way for quality management and outcomes in the orthopedic arena. Laura Robbins is senior vice president for education and academic affairs at Hospital for Special Surgery. She has coordinated a major international effort recently, namely, a new partnership between HSS and Amil Par, the largest managed healthcare organization in Brazil, on behalf of Hospitalys Ortopedia, its newly opened orthopedic center in Rio de Janeiro. She tells OTW, “The team at Amil Par is focused on quality improvement, so we are setting up a Quality Advisory Council that is made up of key players from Hospitalys Ortopedia and HSS—five individuals from each facility. They are in the process of deciding what the quality measures should be for this hospital, examining how they want to address them, and collecting data for benchmarking. At present they are looking at several measures: because HSS has one of the lowest infection rates in the world, they want to examine how they can ensure that infection rates are as low as possible and what systems need to be in place to make this happen. They are also looking at length of stay, especially as related to knee and hip replacement.”

“HSS is approached by many countries who want to collaborate, and what’s very appealing to us about Brazil’s Amil Par is that their core mission and values are so similar to ours that it felt like kinship…a very natural synergy. As for the macro picture, Brazil has a booming economy and is faced with many of the same issues that we are—such as an active baby boomer population.”

“There is also a research component to this project. A team of Brazilian physicians is already conducting research; on our end, Dr. Scott Rodeo is taking the leadership roles in this area. Dr. Rodeo will soon be meeting with the scientist in Brazil and we will hold a round table discussion to decide on appropriate topics for research. They will also identify a research fellow who will come to HSS to work with Dr. Rodeo in his lab. Mathias Bostrom, M.D. is providing leadership on arthroplasty initiatives.”

Robert Anderson, M.D. is an orthopedic surgeon with OrthoCarolina, and is a past president of the AOFAS [American Orthopaedic Foot & Ankle Society]. When asked about the latest developments in the foot and ankle universe, Dr. Anderson told OTW, “We are seeing a burgeoning popularity of total ankles, largely due to the anecdotally good short term results we are seeing (at about three years). While the INBONE and SALTO are gaining in popularity, the newest to hit the market is the Zimmer total ankle. This implant is ‘hot’ because it utilizes a lateral transfibular approach to implantation versus a standard anterior approach. It’s intriguing because it will preserve the anterior soft tissue sleeve and decrease potential complications related to wound healing. Obviously, the lateral transfibular approach is being received with enthusiasm by patients who can’t have an incision over the front of the ankle.”

“The total ankle has gone through a lot of generations, but we’re finding that the instrumentation is much improved and the biomechanical aspects of implants are more natural. This means that we are getting better results (better motion and less pain). The problem is that we don’t know how long these implants will last. For those patients over 55 who have had prior hindfoot fusions this may be an opportunity to maintain motion in the ankle and have a more natural gait, while removing stress from the adjacent joints. The good news is that total ankles are the most researched area in foot and ankle. For example, my team and I are doing a prospective study on the INBONE device, while Ned Amendola, M.D. and his team in Iowa are working on how the vascular supply may be affected by a total ankle replacement.”

“As for what we are telling patients, we let them know that there is a tremendous biomechanical advantage over replacement versus fusion, but that it is more than likely that they will outlive the device. Despite hearing this information, two-thirds of our patients go forward with the replacement surgery.”

Take a Pill for Disc Health?

Tim Yoon, M.D. is a professor at Emory University in Atlanta. Dr. Yoon has—for a second time—walked away with the ISSLS (International Society for the Study of the Lumbar Spine) prize for basic science. The honor, formerly known as the Volvo prize, was awarded for his work on a tiny fragment of proteoglycan-link-protein that seems to regulate cartilage metabolism in the spinal disc. Dr. Yoon tells OTW, “This peptide (which we call LPP) is a fragment of link protein. LPP has great potential for the treatment of disc degeneration. Unlike other molecules that have been tested for treatment of disc degeneration (such as BMP-2 and BMP-7), LPP has very little bone forming (osteogenic) properties. We hope that because it’s a smaller molecule that we may be able do things to deliver it in a way that we can’t do with larger proteins. This molecule can be synthesized biochemically as opposed to having to use eukaryotic cells to synthesize it like you have to do with BMP-2 making it potentially easier to synthesize or modify. And because it is a small molecule we may be able to find drug analogs for it. In the future we just may have an oral drug to improve disc health.”

“What we did is to identify the smallest fragment of LPP that’s still active in human disc cells. We also showed that not only does LPP stimulate further production of cartilage proteins but it decreases the production of some important catabolic molecules. LPP reduces the protein levels of a key inflammatory cytokine (IL-1) and the degradative enzyme MMP-1. We are working hard to understand how LPP works and to create variations of LPP that can be even more effective.”

No Need for Certificates of Need!

Chad Mather, M.D., an attending orthopedic surgeon at Duke University, is keeping an eye on other specialties to see what’s happening when certificate of need legislation is reformed. Dr. Mather, a former AAOS [American Academy of Orthopaedic Surgeons] Washington Health Policy Fellow, tells OTW, “In North Carolina they have relaxed certificate of need laws for endoscopy centers so that physicians can more easily provide colonoscopies in the office. Policy makers are hesitant to do this in many situations because they are worried about increased utilization of services that will increase cost. What we have seen in North Carolina is that this is partially correct, about a 40% increase in utilization of colonoscopy. However, overall cost for all colonoscopies in the state decreased by $225 million. The in-office setting is so much more efficient that physicians can perform 40% more of this potentially lifesaving diagnostic test and still save money overall. If policy makers would consider relaxing certificate of need restrictions for orthopedic surgeons, we can provide more convenient access to care and decrease total cost. This issue is so dysfunctional that we’ve ended up with a situation where existing facilities are extorting payments from providers interested in establishing new facilities. I don’t know too many successful industries where they restrict your ability to adapt to a market changing conditions. With episodic payments we have an incentive structure to coordinate care and need to be able to adapt by building new facilities when necessary. While there may be isolated abuse of the system, having more oversight with clinical practice guidelines means that you can find these bad eggs more easily and not throw the baby out with the bath water!”

Richard H. Gelberman, M.D. to Receive Faculty Award

An orthopedic surgeon and sought-after expert in hand and wrist microsurgery will receive a 2013 faculty achievement award from Washington University in St. Louis (WUSTL). Dr. Gelberman, who is the Fred C. Reynolds Professor and head of the Department of Orthopaedic Surgery, will receive the Carl and Gerty Cori Faculty Achievement Award. The award will be presented during a December 7, 2013 event. Dr. Gelberman is also orthopedic surgeon-in-chief at Barnes-Jewish and St. Louis Children’s hospitals, and is a past president of the American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand.

Dr. Gelberman began his time at the WUSTL School of Medicine faculty in 1995 as the first head of orthopedic surgery. At that juncture, the department included 14 full-time faculty, had no NIH-funded (National Institutes of Health) research and was ranked 48 of 50 orthopedic surgery departments included in U.S. News & World Report rankings. Under Dr. Gelberman’s leadership, the department now has 48 faculty members, is ranked in the U.S. News top 10 and, with more than $5 million in annual grant support, has more NIH funding than any other orthopedic surgery department in the United States.

Dr. Gelberman did his residency in orthopedic surgery at the University of Wisconsin and fellowships in hand and microvascular surgery at Duke University Medical Center and in pediatric orthopedic surgery at Boston Children’s Hospital. He is a graduate of the Executive Program at Stanford University’s Graduate School of Business and has an honorary master’s degree from Harvard Medical School.

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