If a plastic surgeon who later studied orthopedics had thought of this idea, the field might be called “Plastortho.” Instead, Dr. L. Scott Levin, Paul B. Magnuson Professor of Orthopaedic Surgery at the University of Pennsylvania, an orthopedist who became a board certified plastic surgeon, had the eureka moment.
Melding Two Fields of Medicine
Dr. Levin, formerly a professor of both orthopedic surgery and plastic surgery at Duke University Medical Center, as well as Chief of the Division of Maxillofacial and Oral Surgery at that institution, explains his background: “When I began my residency in orthopedic surgery at Duke in 1982 we were required to do two years of general and thoracic surgery. This experience greatly broadened my understanding of surgery. I was accepted into the Duke orthopedic residency program by Dr. J. Leonard Goldner, who served as President of the American Society for Surgery of the Hand and was an extraordinary educator.”
“I had always been interested in hand surgery, ” continues Dr. Levin, . “In part this was because after my undergraduate work, I went to Japan and studied reconstructive microsurgery with Yoshikazu Ikuta and Kenya Tsuge. In the late 1980s it was evident that the surgeons who were developing advances in microsurgery and free tissue transfer were plastic surgeons. In 1987 I went to the orthopedic Chair at Duke, Dr. James Urbanick, and told him that I wanted to do a plastic surgery residency. He was somewhat shocked as I had just spent six years doing general, thoracic, and orthopedic surgery. I explained that becoming a board certified plastic surgeon would give me additional skills to become a better hand surgeon.”
A bit of an oracle, Dr. Levin could see that thinking big in orthopedics would increasingly mean thinking small. “In 1988 I began training at the Christine M. Kleinert Institute for Hand and Microsurgery in Louisville, Kentucky. I also spent time as an AO Fellow in Switzerland with Dr. Reinholdt Ganz (1988); I also did a period of study at the acclaimed Center for Reconstructive Microsurgery in Taipei, Taiwan (1991). Following this I was invited to remain on faculty at Duke, and was appointed to both orthopedics and plastic surgery by Dr. David Sabiston.
“I began my practice in 1991 and since that time have performed a variety of reconstructive procedures using the operating microscope to transfer tissue. For example, we often remove muscle from a patient’s back and place it on the tibia to cover open fractures. This and other similar procedures are powerful techniques that solve orthopedic problems. To be able to transfer living bone and tissue is just astounding. Other examples include transplanting a great toe to the hand of someone who had lost a thumb, as well as reconstructing head and neck defects in cancer patients.”
The bottom line: I took my knowledge of orthopedics and plastic surgery and applied the principles and practices of both disciplines to clinical problems simultaneously. The result: orthoplastic surgery.
Training Others in Joint Study
So has his work been met with a red carpet or a grimace? “These efforts were well received at Duke because orthopedic surgeons could readily see that I was providing a need for wound issues that arose during orthoplastic surgery. They relied on me to solve their complications. It went very well because when speaking with them, I was thinking like an orthopedist…as well as a plastic surgeon.”
And the reception in the wider world? “Unfortunately, despite an immense need for microvascular surgery in the world of orthopedics, reconstructive microsurgery is not of much interest to orthopedists. It is not particularly well compensated and takes a long time to learn. It is technically demanding and involves such complexities as replantation and reattaching hands, fingers and arms. In the early 1970s it had an air of ‘sexiness’ that some found alluring. Due to reimbursement and tort reform issues, however, the vast majority of orthopedists now leave such work to plastic surgeons.”
But there are those whose interest runs deep enough to assume this challenge. Dr. Levin: “I have trained many hand and microvascular fellows who want to use orthoplastic techniques for extremity reconstruction. I have seen them go on to perform free flaps and other microvascular procedures.”
And regardless of which “camp” they come from, orthopedics or plastic surgery, they turn to Dr. Levin. “When I served as Chief of plastic surgery at Duke there were no turf battles because my background meant that I was a bridge between the two fields. Here at Penn I have been given the opportunity to create the same integrated hand service that combines orthopedics and plastic surgery. This cutting edge work involves exciting new ideas about soft tissue reconstruction that will help save limbs. Actually, we are in the process of creating a limb salvage and reconstruction center at Penn that will combine foot and ankle, trauma, tumor work, psychiatry, pain management, etc. This program has been created, and will be managed, by the Penn Health System. It was easy to sell the concept to such a collaborative institution.”
The Future of Orthoplastic Surgery
Dr. Levin, who can be found at both orthopedic and plastic surgery meetings around the world, is now bringing his expertise and foresight to the University of Pennsylvania. “One of my undertakings is to replicate the cadaver lab that I established at Duke, something that will allow residents and fellows to learn about new tissue flaps and the anatomy of new free tissue transfers, among other things. These trainees will also be able to take advantage of another new project here at Penn—composite tissue allograft (CTA) transplantation, the next frontier in orthopedics. Along with Dr. Abraham Shaked, Director of the Penn Transplant Center, I am creating the Penn CTA program, an effort that will be up and running in several months.”
Revolutions happen at all levels…such is the case with composite tissue allograft (CTA) transplantation. Dr. Levin:
Applying orthoplastic principles to CTA will reshape the field of orthopedic surgery and change the lives of patients in dramatic ways. For example, let’s say you lost an arm. The only thing I can offer you now is a prosthesis. With CTA you can actually have a new, ‘living’ arm. Or, if someone has a totally destroyed knee the only alternative at present is knee replacement. With CTA you could have a new knee. How? We remove the knee joint out of a donor and put it in your knee. Take elbow and shoulder work, an area where we know that the longevity in joint replacement is fairly short lived. If I can take a living elbow joint and transplant it, that will last the rest of the patient’s life—assuming it is not rejected.
To address this last point, says Dr. Levin, researchers are increasingly looking at the basic science and immunology of implant rejection. “The fact is that orthoplastic CTA may improve the quality of life, but it is not life saving. If you needed a heart transplant you would accept the risk of immunosuppression. But you may not be open to this risk for a CTA elbow replacement because you have to take drugs the rest of your life—drugs that may contribute to cancer, diabetes, etc. Thus, the basic science research underway now is looking at ways to make patients tolerant of transplants. Our first patient will be someone who lost both arms and legs to infection—that person is in line for bilateral hand transplants.”
These and other traumatic injuries often occur in the military arena. Because of this, Dr. Levin was invited to be a visiting scholar at Landstuhl Regional Medical Center in Germany, a staging center for soldiers brought in from Iraq and Afghanistan. “In Iraq and Afghanistan we have seen the most devastating soft tissue trauma ever because of Improvised Explosive Devices and Rocket Propelled Grenades. As a result, soft tissue techniques to save extremities have never been needed more than they are now. We are so fortunate to have advanced microvascular techniques that allow us to reconstruct shattered limbs. Unfortunately, most orthopedic trauma fellowships don’t offer instruction on free flaps or microsurgery.”
Dr. Levin concludes,
Reconstructive microsurgery needs to be present in orthopedic surgery because if not, the optimization of patient care in all subspecialties in orthopedics will be comprised. Knowledge of soft tissue handling and procedures should be part of orthopedic education. You should at least be aware of what is happening in the field and the possible treatment solutions that are available.
