Stay in your own little corner of the world and your life stays little. Venture beyond its confines and new doors open. Dr. Thomas P. Vail, Professor and Chairman of the Department of Orthopaedic Surgery at the University of California, San Francisco, knows that such expansive thinking enlivens his field, his patients, and his life.
While the lay public probably wouldn’t view science as a creative endeavor, Thomas Vail has always seen it that way. “Growing up in Chicago, my life path was heavily influenced by my father and grandfather, both of whom were engineers. I saw my early interest in science and engineering as a creative outlet. It wasn’t exactly the math that got my attention, but that you could create something or learn how to put things together to build something novel. Particularly interesting to me was how that new idea may lead to a useful product or business.”
In line with his propensity for broad thinking, Thomas Vail enrolled in Duke University for his undergraduate studies, in part because of the program’s flexibility. “I liked the school’s curriculum because I could take engineering classes but was given enough latitude to explore other things such as history and English, areas that I thought would help develop my communication skills. Mechanical engineering was a perfect major for me because it offered the most hands-on approach in terms of design and why things work the way they do. It became clear that the aspects of engineering that interested me most were the ones with human applications.”
Indeed, during his undergraduate years Thomas Vail would find vast differences between asking, “What’s wrong with this elbow screw?” and ”What’s wrong with this nuclear power plant system?” Dr. Vail: “In one engineering class we did a failure analysis on a screw used to repair an elbow fracture. The screw broke and we set about trying to determine why, asking, ‘Was there some shortcoming in the design or how it was being applied?’ We looked at where the threads were located relative to the fracture and found that there was insufficient material to withstand the repetitive loading. It was a confirmation to me that you could apply science, design and engineering to predict whether an implant would work.”
Dr. Vail continues: “At that time I did a summer internship with a power company where I worked on nuclear plant design. It was a junior and mundane role, but I got exposed to what it was like to be an engineer on a large project…and knew that it would definitely not be as interesting to me as applying scientific knowledge to the human realm.”
The idea of medical school thus began to travel from the back of Thomas Vail’s mind to the front. “There were no physicians in my family, but I was captivated by biomedical engineering, a new field at the time. I envisioned numerous potential applications of engineering to medicine and wanted to use such knowledge to impact people’s lives. From the time I began medical school at Loyola University of Chicago Stritch School of Medicine in 1981, I was attracted by certain aspects of cardiology, such as fluid mechanics and electrophysiology. But orthopedic surgery got my attention because of the focus on the movement of joints, how people walk, and the interaction between muscles and joints. The idea that you could intervene in the disease process, change its course, and make people walk again was very compelling.”
Despite the obvious rewards of a wide breadth of knowledge, Dr. Vail would soon awaken to the beauty of getting “lost” in one area. “In 1986 I began an orthopedic residency at Duke, selecting my alma mater because I was impressed that the program was producing leaders in surgery. Senior surgeons were telling me that Duke was a place I could go for excellent training—and that it wouldn’t be a problem that I had not yet selected a specialty because of the breadth of opportunity. Between 1985 and 1991 a movement grew that shifted the field from ‘renaissance’ orthopedics to subspecialization. Dr. James Urbaniak, who had just become Chair of Orthopedic Surgery at Duke, was the embodiment of someone who could successfully make that transition. While he was trained in all aspects of orthopedics, he evolved into a world leader in hand and microvascular surgery who embraced subspecialization. He thus encouraged my interest in joint replacement and lower extremity reconstruction, realizing that there was a coming explosion of knowledge in the subspecialties. “Dr. Urbaniak understood the value of becoming proficient in a certain area and was someone who could push the envelope in this regard.”
Dr. Vail continues, Another mentor during this time was Dr. David Sabiston, Chair of the surgery department at Duke, who positively impacted residents from a wide variety of subspecialties. An extremely focused thinker, Dr. Sabiston was a disciplined educator who pushed students to be their best. He was a supreme innovator, and the first surgeon to perform coronary artery bypass surgery. His leadership approach is particularly relevant now that I am Chair. If I’m in a case these days, I do as he did, namely insisting that residents understand not only exactly what happens in the OR but also why it is happening.”
A traveling fellowship would then give Dr. Vail an in-depth appetizer of adult reconstructive surgery approaches around the world. “My fellowship, sponsored by Duke, allowed me to travel to a number of centers around the U.S. and the world doing hip and knee surgery and learning a variety of techniques and philosophies. One interesting project I worked on involved looking at how to use other living tissues like the iliotibial band to replace a damaged or absent meniscus. This meshed well with my concept/hope of eventually seeing the field of joint replacement (metal and polyethylene) merge with tissue engineering. This work, replacing joints with living tissue rather than bio inert materials, remains the Holy Grail of orthopedics.”
Dr. Vail, who organized the fellowship, was guided by two notable orthopedists of the day, Colonel John Feagin, M.D. and Dr. Donald McCollum. Dr. Vail: “Dr. Feagin, who had been a fellow with Sir John Charnley, emphasized that I should select centers that would help me learn in-depth knee and hip anatomy. Dr. McCollum taught me the fundamentals of hip and knee arthroplasty, having been one of the first surgeons to perform hip replacement in the United States. One of the biggest ‘takeaways’ from the fellowship was the relationship between anatomy and joint mechanics. I learned, for example, that if the deficient anatomy can be replaced, then the structures that remain can resume functioning.”
“This concept continues to evolve with minimally invasive surgery (MIS), ” adds Dr. Vail. “On the surface, the appeal of MIS is that you’re making a smaller incision. But it turns out that the length of the incision is not as important as sparing tissue and determining what is critical as far as recovery and function…and trying to protect those structures during surgery. Sometimes the importance of the interplay, the anatomy and the goal of replacing part or all of a joint gets obscured by marketing efforts. The focus on tissue preserving surgery will continue, however, because it does have a solid basis in science and anatomy.”
Dr. Vail’s longstanding research interest in cartilage repair could be summed up with, “Go forth, multiply, and integrate.” “In one of my early studies I examined the relationship between the meniscus and the cartilage surface and how sparing more of the meniscus helps protect cartilage. Repairing the meniscus if it’s not functioning normally doesn’t necessarily protect cartilage. The implication is that there is a more sophisticated understanding of cartilage tissue required to have success in doing these repairs. We now understand that just because you put a stitch in the meniscus or other soft tissue doesn’t mean the tissue will function normally.”
On the integration front, Dr. Vail notes, “I am also looking at how to load bone in a more normal way after replacing the hip. I see a lot of younger people in my practice with degenerative conditions of the hip, such as early arthritis. The question regarding these patients is, ‘Can we make them more functional, i.e., do a replacement that would mesh more with the remaining anatomy?’ In past studies I have examined a new material for a hip stem, a carbon fiber composite that I worked on with an orthopedic company. We looked at different stiffnesses of carbon fiber composite hip stems, and measured how bone around the hips was loaded. We found that by changing either the stiffness or the cross sectional area of the stem it was possible to load the bone in a more physiologic way.”
“More recently we have asked, ‘Is there a way to more conservatively replace or resurface the hip?’ So now I am looking at how the bone in the neck of the femur is loaded in hip resurfacing in contrast to where you remove the ball of the hip. This role of hip resurfacing is being tested through experience in the clinical realm. The question remains, ‘What should the role of hip resurfacing be, and who is the most appropriate patient?’”
If given free rein and resources, Dr. Vail would design a fellowship that “reaches across the aisle.” “We are now at a crossroads, ” says Dr. Vail. “Technology has reached the point where we can do groundbreaking work in replacing parts of joints with living tissue. Ideally, fellows would be taught how to approach the hip or knee using the most conservative techniques, and set the stage so that the surface we are treating could be prepared and replaced with living tissues. This would require a focus not just on traditional joint replacement, but on tissue engineering, and perhaps computer navigation with the robotic sculpting of the joint to prepare the surface for living tissue. To our detriment, we are siloed now, teaching fellows how to use metal and plastic, but not instructing them on the biological end of things.”
Lest Dr. Vail work too hard, there is someone to keep him balanced. “My wonderful family begins with my wife Lisa, who I met in medical school. An internist who focuses on health, fitness and preventative medicine, she has always brought balance to our family life. We have a freshman in college and a junior in high school, both exceedingly talented and wonderful. We enjoy simply relaxing and spending quiet time together. Family life just keeps getting better.”
Dr. Thomas Vail…reconstructing joints and engineering an intriguing life.
