100% Sensitive Test for Fracture Risk…Better Football Helmets: Refining Designs for the Littlest Players…New Competition for Level One Trauma Centers Emerging…New Awards Announced…and more.
Trauma in Flux?
Dr. Robert Probe, president of the Orthopaedic Trauma Association (OTA) tells OTW, “It seems that the market is shifting such that whereas most of the volume in trauma traditionally went to level one inner city hospitals, more and more community hospitals are trying to step into that business. The concern is that we don’t have an integrated, thoughtful system to support this trend. Only a few places in the country—like Shock Trauma in Maryland—have a state level plan for the diversion of major trauma. Then there is Chicago, where every hospital is pining to be a level one trauma center…so there is a dilution effect…and that is not an efficient way to spend resources.”
“What does this mean for patient care? On the surface the fact that care would be closer to home is appealing; one of the maxims of trauma care is that patients have access to a major level one trauma center within an hour of the injury location. The downside is that if there are too many trauma centers that means that no one surgeon is doing enough trauma to maintain a high level of care. This is especially true given that trauma injuries are going down. The OTA can’t and doesn’t want to get into the business of restricting the number of trainees…our role is to help maintain the quality of fellowships. There are some responsible programs that are ahead of the game and are voluntarily reducing the number of trainees—but not many.”
Football Helmets: Refining Design for the Littlest Players
Adam Bartsch, Ph.D. P.E. is the director of the Head, Neck & Spine Research Laboratory at Cleveland Clinic Center for Spine Health. Along with Edward Benzel, M.D., chairman of the department of neurosurgery at Cleveland Clinic, Dr. Bartsch is working on ways to reduce head, neck and spine injuries in young athletes with current interest in youth football. They are embarking on a three year project, which is funded by a grant from the Orthopaedic Research and Education Fund (OREF).
Dr. Bartsch tells OTW, “Dr. Benzel and I are spearheading an effort to understand the link between the orthopedic and neurosurgical aspects of head, neck and spine injuries. The fact is that children are wearing football helmets that are designed for adults. We can’t treat kids as ‘little adults, ’ and we hope to learn how we could alter the design of these helmets for kids. In our preliminary work we found that a seven-year-old child who weighs 50lbs was wearing a helmet that weighed 4 pounds. We have also seen kids place their facemask on their sternum during practice because the helmet is too heavy to continuously lift and look straight ahead. It is obvious that youth helmets are ‘little adult’ helmets shrunken slightly to fit onto the child’s head and not designed to the child’s unique orthopedic or neurological development. We just don’t know exactly what influence on head, neck and spine injury risk the heavy helmet has on little kids with big heads and skinny necks.”
“We now have a clinical and engineering team working together and are measuring neck strength, range-of-motion and anthropometry in child players. At this point we have collected preliminary data and are in the process of going through the IRB [institutional review board] to conduct the next study phase under the OREF grant. Additionally, we are scanning helmets in our CT machine and doing crash test experiments. We’ll be segmenting out the padding shell from the facemask so we can do experiments in the lab, either ‘virtual experiments’ done on the computer or in physical experiments by smashing helmets and crash test dummy heads. Our hope is that through this vigorous scientific investigation we may eventually make recommendations on youth helmet designs, including mass, center of gravity, moment of inertia and impact protection, as a function of player age. We hope at the conclusion of this work that child football players will no longer be wearing ‘little adult’ helmets.”
Revolutionary New Way to Assess Fracture Risk
Ara Nazarian, Dr.Sc., instructor in orthopaedic surgery at Harvard Medical School and Beth Israel Deaconess Medical Center is the recipient of a Prospective Clinical Research grant from the Orthopaedic Research and Education Foundation. He tells OTW, “We set out to address the issue of establishing a scientifically accurate and rigorous way to assess fracture risk in patients with skeletal metastasis. Our study, ‘CT-based Prediction of Metastatic Fractures’ offers a new approach, as current clinical guidelines based on radiographic data have proven to be inaccurate. We have employed basic engineering principles, essentially treating bone as a simple beam, to measure changes in bone density and geometry resultant from skeletal metastasis or any other local or systemic musculoskeletal pathologies. The idea is to calculate changes in axial, bending and torsional rigidities of bone to figure out whether the rigidity of bone has been reduced sufficiently enough to warrant prophylactic treatment, is it enough to simply maintain observation and non-invasive therapy.”
“Our technique, called CT-based Rigidity Analysis (CTRA), can be used to upload a patient’s CT data and run a 20 minute analysis on a regular laptop to inform us of the degree of reduction in any bone’s rigidity when compared to the contralateral bone or the same bone form a healthy patient of the same age, sex and physical condition. To that end, the treating physician can inform the patient of the specific percentage of reduction in the bone’s load bearing capacity compared to its healthy state, and whether this reduction falls below the threshold that warrants surgical stabilization. We think that this approach provides treating physicians with a scientific approach to help them make sound clinical decision. For instance, the specificity of current clinical guidelines to assess appendicular fracture risk is less than 35%, meaning that the strict application of these criteria will result in unnecessary surgeries in two-thirds of cases. There are also conflicting reports on sensitivity and specificity of these criteria in different anatomical sites and among different specialties, which emphasizes the need for a more objective and precise clinical tool to assess fracture risk in metastatic lesions. Our latest study of patients with appendicular metastasis has revealed that CTRA is 100% sensitive, 90% specific and 91% accurate to predict fracture risk in this population. This is in contrast to the currently used method, which is only 71% sensitive, 50% specific and 52% accurate.”
Daniel Osei, M.D. and Aaron Chamberlain, M.D. Join Washington University
There are two new assistant professors in the department of orthopedics at Washington University in St. Louis. Dr. Daniel Osei performs surgery of the hand, wrist and elbow, as well as microsurgical reconstruction of the upper and lower extremity, including free tissue transfer. He received his medical degree from the University of Pennsylvania and did a surgical internship at the New York Presbyterian-Weill Cornell Medical Center. He then did a residency at the Hospital for Special Surgery, followed by a fellowship in orthopedic reconstructive microsurgery as a visiting fellow at Chang Gung Memorial Hospital in Linkou, Taiwan. He then completed fellowship training in orthopedic hand and upper extremity surgery at the Lindenhofspital in Bern, Switzerland, as well as Washington University in St. Louis. Aaron Chamberlain, M.D. is a shoulder and elbow surgeon, and received his medical degree at the University of California San Francisco School of Medicine. He completed his residency in Orthopaedic Surgery and Sports Medicine at the University of Washington Affiliated Hospitals, and his fellowship in shoulder and elbow surgery at Washington University School of Medicine, Department of Orthopaedic Surgery.
