Riew, Lenke and Lehman Leaving Wash U // Academic Institutions Re-Operate More Often? Limb Loss Study Says “Yes”// and More!

Unprecedented Spine Surgeon Exodus From Wash U

Larry Lenke, M.D., Dan Riew, M.D., and Ron Lehman, M.D. will be heading to New York City this summer, where they will embark on a new adventure: They will be establishing the first Spine Hospital in North America at the New York Presbyterian Allen Spine Hospital at Columbia University College of Physicians and Surgeons. Dr. Riew tells OTW, “Being in New York will make it much more convenient for our national and international patients to see us. Columbia, under the leadership of William Levine, M.D., the Frank E. Stinchfield Professor and recently appointed Chairman of Orthopedic Surgery, had the vision and was willing to make a solid commitment to developing the top spine program in the United States—and they were willing to dedicate unprecedented resources and funding to build the program. I don’t know of any previous case where one institution hired three full professors in orthopedics at once to develop such a program. The vision and commitment of resources that are being brought to bear are a testament to the leadership of Bill Levine, as well as Steve Corwin, M.D., the CEO of New York Presbyterian Hospital.”

Drs. Lenke, Riew and Lehman all expressed sadness at leaving good friends and colleagues behind at Washington University-St. Louis, but said that they were attracted by the opportunity to create something unique and transformative for spinal surgery at a nationally recognized institution like Columbia.

Asked how they will differentiate themselves from other New York hospitals, Dr. Riew stated, “First of all, we have Larry. If you think, ‘deformity’ the top surgeon in the world right now is Larry Lenke. Second, Ron is a very accomplished surgeon with extraordinary research and over $5 million in grants from the Department of Defense. He does everything in spine and does it superbly. Third, we have the first and only hospital in North America that will be focused on Spine Surgery. We will be working with Drs. Mark Weidenbaum, Jay Kim and Charla Fischer in Orthopedic Surgery, Drs. Paul McCormick and Pete Angevine, as well as others in Neurosurgery and Dr. Joel Stein and his team in Physiatry. Fourth, unlike many programs where all surgeons do everything, we will have surgeons that focus on specific areas. For example, Larry only does thoracolumbar deformities and I only do cervical spine. Finally, we will train fellows from the U.S. and abroad to teach what we know to the next generation of surgeons.”

According to Dr. Lenke, “In phase two, we plan to bring on additional top-notch spine providers, both non-operative specialists and surgeons. We want leaders in the field with outstanding clinical and interpersonal skills, a commitment to research and teaching, and who share our vision of providing the highest quality spine care for our patients.”

Academic Institutions Re-Operate More Often? Limb Loss Study Says “Yes”

Age, weight, comorbid conditions…all are impossible or at least challenging to change preoperatively. Saam Morshed, M.D., M.P.H. is a principal investigator on one of the METRC (Major Extremity Trauma Research Consortium) studies being funded by the Department of Defense. Dr. Morshed, an attending orthopedic trauma surgeon and director of the Clinical Research Center at the UCSF/San Francisco General Hospital Orthopaedic Trauma Institute, tells OTW, “The first two papers in this series were epidemiological studies where we used the National Trauma Database to examine the incidence of lower and upper extremity amputations; included in that database are admissions to over 900 trauma centers. We wanted to undertake a new epidemiological study because the literature is pretty dated and thus does not reflect what is happening in the clinical realm.”

“Regarding lower extremity limb loss, we were looking for modifiable risk factors. The major finding was that ‘time to operation’ predicts length of hospitalization after the first operation; it also predicts complications. ‘Time to operation’ is in the hands of treating team, so as a field we need to investigate earlier care of these patients. This research should serve as a stimulus for new investigations on earlier patient care in these situations; as of yet, no one has looked at this.”

“As for upper extremity limb loss, our major finding was not that ‘time to operation’ was important, but that it was the type of institution that mattered. It’s counterintuitive, actually…we found that academic and teaching institutions tended to reoperate on patients more frequently than nonacademic centers. Does this reflect a real difference in the way patients are cared for in deciding to revise a surgery…or is it that there is such a disproportionate burden of severely injured patients showing up at teaching versus nonteaching hospitals? I think it is probably the latter, but this merits further study.”

“Our third paper was a systematic review of the literature on the lack of outcomes assessment in traumatic limb loss research. We are in real need of better measurements of prosthetic fit and alignment. Unfortunately, many times orthopedic surgeons have a short relationship with amputees and disengage from the rehabilitation process unless another operative complications result. My advice to my colleagues is to stay in the loop and work with prosthetists and rehabilitation specialists in a collaborative way. And we all need to understand the signs of poor prosthetic fit and alignment, and how this affects patients over time. We orthopedic surgeons tend to ‘check out’ way too early in the care process. If our goal is really to get the patient back to their prior selves, then we are falling short.”

“Lastly, we looked at developing better outcome measurements, i.e., more accurate ways to assess health related quality of life of those who lose limbs after trauma. So rather than looking at infection and reoperation we are asking, ‘Are they returning to daily activities? Are they depressed? These are questions that both clinicians and researchers need to measure in determining outcomes of their patients.”

“This research dusts off ‘the old’ and opens the door to several new lines of research that could benefit those who lose limbs to trauma.”

$1.04 Million to Use HA to Rescue Cells, Prevent Injury

Liping Tang, Ph.D., a bioengineering professor and interim chair of the bioengineering department at the University of Texas at Arlington, is making progress with the $1.04 million grant he has received from the U.S. Army. Dr. Tang tells OTW, “We are using biomolecules to recruit patients’ stem cells to the injured cartilage to promote its healing process. At this time we are making hyaluronic acid (HA) particles to deliver biomolecules that will trigger a stem cell response. HA is a biological hydrogel, so in order for us to determine the right size and the right density for this task, we are trying numerous sizes and densities and testing their ability to release different bioactive molecules.”

“We are also developing a new targeting mechanism. Most early stage cartilage damage usually involves trauma caused by cell injury and activation; we want to see if we can develop nanoparticles which can recognize injured cells and to deliver a specific drug to the area—and not to other places –healthy tissues. The goal is to determine which molecule is more accurate in targeting an inflammatory cell. In addition, we want to target the injured cartilage cell; we will also target the activated immune cells.”

“We need to have the HA particles travel from the injection site into the joint (the injury site). That will reduce the potential for side effects. And if we carry out the therapy at early stage of the disease then we can likely prevent long term injury. At present the majority of osteoarthritis injuries are caused by propagation of cell injury, so we want to see if we can rescue the cell before the injury spreads.”

“Six to nine months from now we hope to have identified the targeting marker, filed a patent, and have identify the optimal physical and chemical property of HA particles. We hope that in less than five years, injured soldiers and civilians alike will one day benefit from these cartilage regeneration efforts.”