Open Shoulder Surgery…Not the Ugly Duckling After All?
When it comes to instability, this decision of which kind of surgery is better is not solved after all. Jeffrey Abrams, M.D. is president of the American Shoulder and Elbow Surgeons. He tells OTW, “We are trying to concentrate on which patients are in jeopardy of having a recurrence after surgery. Age, activity level and bone changes play a role in the decision. For example, take a 20-year-old who wants to play sports, but has a history of shoulder dislocation. The arthroscope has virtually taken over surgery for this type of patients. The problem is that because it doesn’t create much scar tissue and is a chance that the shoulder will pop out again. We are now beginning to question whether we should go back to open surgery for certain patients at risk for recurrence. ”
“The ideal patient for the arthroscopic is someone with no significant bone changes and the overhead athlete. Many people who dislocate their shoulders damage the edges of the ball and cup, and as a result there is less glenoid to support the ball. There is a controversy surrounding how much bone loss is important. Open surgery plays a big role when we are talking about a moderate reduction in the width of the cup or the surface of the ball. Fortunately, there is research underway on whether adding bone in the shoulder is advantageous. If there is a bone deficiency then the question is, ‘At what point does placing more bone improve the situation?’”
“At the present time we’re a bit all over the place with this. Some surgeons are trying to do this surgery through the scope, but most are doing an open procedure. If there is a high school football player who injures his shoulder as the result of a dislocation, then arthroscopy is still the most popular choice. But in situations where there has been a significant amount of bone change or tissue laxity is excessive, then open repair has higher success rates.”
Meniscal Injury and Future OA
How is a meniscal injury related to the development of osteoarthritis (OA)? Many have speculated. A team of researchers recently set out to find out more. James J. Irrgang, PT Ph.D., ATC FAPTA is Professor and Director of Clinical Research in the Department of Orthopaedic Surgery at the University of Pittsburgh School of Medicine. Dr. Irrgang told OTW, “It is well known that meniscectomy can lead to knee OA, however we wanted to know the role that injury to the meniscus may lead to the future development of knee OA, regardless of whether meniscectomy was performed. In undertaking our case control study, we used data from the Knee Osteoarthritis Initiative, a prospective observational study of individuals at risk for the development of knee OA.”
“Interestingly, we found that a meniscus tear alone, was not associated with the development of knee OA. However, when a meniscus tear was combined with increased MRI signal within the meniscus, there was a trend for this to predict the development of knee OA. More importantly, characteristics of the meniscus lesion including extrusion, complex tears and tears involving a greater radial involvement of the meniscus were associated with the future development of OA. Extrusion of the meniscus and greater radial involvement of the meniscus leads to greater loss of function of the meniscus, which likely predisposes the cartilage to increased contact and wear, ultimately leading to OA. This information may be useful to surgeons and other physicians in advising patients on the appropriate course of management for individuals with a meniscus tear.”
Orthopedic Research: Could it Get More Challenging?
Doing orthopedic research? Have your crossed your ‘t’ s with the state? Dotted your ‘I’ s with the feds? Concerned about the avalanche of regulations surrounding orthopedic research, Dr. James Slover and his colleagues decided to assess the situation via a literature review. James Slover, M.D., M.S. is assistant professor in the Department of Orthopaedic Surgery at the NYU Hospital for Joint Diseases. Dr. Slover’s article, “Basic Principles for Conducting Human Research in Orthopaedic Medicine, ” recently appeared in the Journal of the American Academy of Orthopaedic Surgeons. He tells OTW, “Most orthopedic surgeons are too busy learning clinical skills that they have not had a chance to get training in regulatory requirements and scientific research methods. Finding one’s way through the maze of state and federal laws, as well as ethical issues, can be daunting. But doing so is essential to protecting patient information; and not doing so can mean stiff penalties for physicians.”
“Because things are only getting more challenging as far as regulations, we surgeons must take the time to learn these things. Proper data management, including the requirements of the Health Insurance Portability and Accountability Act (HIPAA), is critical. I see numerous HIPAA issues when I read journal articles. We need to ask, ‘Is the data secure?’ and ‘What are the regulations protecting patient data?’ It’s a particular challenge for those surgeons who don’t spend much of their time doing research. And modern technology is so vulnerable to problems; we must be careful that patient data is secured via passwords, firewalls, and the like.”
“People need to understand that they must protect any information that could be traced back to the patient. You should have a secure system in place, and you should absolutely have a thorough regulatory binder in place. That way you can know the expectations of the Institutional Review Board and can track them. These are the kind of things that surgeons can learn through continuing education courses that are offered at different venues throughout the year.”
HSS Celebrates 150 Years
This year, the country’s oldest orthopedic hospital is celebrating. Hospital for Special Surgery (HSS) in New York has recently turned 150. With this milestone comes the publication of a book on the history of this world-renown institution, “Anatomy of a Hospital” by David B. Levine, M.D. Dr. Levine, emeritus attending orthopedic surgeon at Hospital for Special Surgery and professor emeritus of clinical orthopedic surgery at Weill Cornell Medical College, spent eight years writing the book. Dr. Levine was a spine surgeon at HSS for 28 years; he also served as director of the scoliosis service and was later director of orthopedic surgery.
Dr. Levine, HSS’ self-appointed archivist since 2003, tells OTW, “The roots of this hospital go back to 1863 when it was opened as the Hospital for the Relief of the Ruptured and Crippled. The Civil War was underway, and poverty, unemployment, and general misery were rampant. James Knight, a general practitioner, was so concerned about the lack of medical care for the downtrodden—the children in particular—that he assembled a group of prominent citizens to fund and establish this facility. The facility opened six weeks before the draft riots in New York City, and anyone peering out the windows could see burning buildings and general chaos.”
Dr. Levine, who also serves as historian of the Association of Bone and Joint Surgeons, says his fascination with HSS’ history goes back to when he first came on staff there in 1961. “I find it so gratifying that ours is such a place of ‘firsts.’ In the late 1800s Virgil Gibney, M.D., an orthopedic surgeon, started the first orthopedic training program in the country. It was he who coined the term ‘resident.’”
“Interestingly, The Hospital for the Relief of the Ruptured and Crippled was the first hospital in New York City to create a public school within a hospital. There were numerous children with crippling diseases who stayed on as inpatients for years. To accommodate their needs, Manhattan PS 401 was established in the hospital.”
“Orthopedic research at HSS was born in 1955 when the first director of research was Philip D. Wilson, M.D., who had stepped down from the surgeon-in-chief position. In 1966, Dr. Robert Lee Patterson, Jr. appointed Dr. Harlan Amstutz the first director of the Biomechanics Department. It was in this setting that early total knee implants were designed and popularized in the 1970s by Peter Walker, Ph.D., John Insall, M.D., Albert Burstein, Ph.D. and Chitranjan Ranawat, M.D.”
Asked why orthopedic surgeons need to know this history, Dr. Levine says, “Surgeons must be aware of what was tried and used in the past…what failed and what worked. If, for example, doctors had really known and understood what happened when Dr. William Coley was treating cancer patients with his vaccine then our field could have benefitted from his work earlier on. We must build on the past to construct the future.”
