“One of the things about orthopedic oncology is that every patient is different. If you do total joint replacements you take care of the same problem, with only a little different flavor. If you do sports medicine you take care of the same problems, with slightly different flavors, in each person. But in oncology you work with people from the very young to the very old and everyone in between. The youngest patient I have taken care of was a couple of months old. The oldest was in his high 90’s.” — Dr. Joel Mayerson, Associate Professor of Orthopaedics; Director, Division of Musculoskeletal Oncology; Ohio State University Medical Center.
Creativity and orthopedic surgery are usually incompatible concepts—except in oncology where the ability to think creatively in five dimensions (3D spatially + biomechanically + biologically) has forged a restless class of surgeons who scramble onto the surgical high wire and perform remarkable feats of anatomical reconstruction. Formulary? Text books? These guys don’t need no stinkin’ formulary.
Mayerson, whose surgical legerdemain OTW has featured a couple of times, is the orthopedic oncologist who reinforced his patient’s pelvis with bones from his amputated leg. Where do these restless orthopedic surgeons come from?
In Mayerson’s case, the industrial rust belt town of Lima, Ohio, a pharmacist father and stay-at-home mom. His first distinction in life came from becoming one of the 2% of Boy Scouts to attain the rank of Eagle. “In scouting I got to do outdoor activities that I never would have done otherwise, ” he said. “My parents were not outdoor type people. With scouting I got to do camping and activities that they would not have gotten me involved in.”
On his lengthy list of professional and academic awards, Mayerson’s Eagle Scout rating tops the list. He credits scouting with teaching him how to be a leader and a member of a team. “Being part of a team is another part of being a good surgeon, ” he says. “Learning how to be the captain of a team was developed in me during those early years in scouting.”
From a young age Mayerson wanted to be a doctor. “I enjoyed science and I wanted to help people. Medicine was a good way to mesh the two together. My parents tell me that I wanted to be a doctor from the time I was in elementary school.” An offensive tackle on his high school football team (“I was a big guy, ” he says), as well as a runner and a wrestler, he wanted to become a sports medicine doctor and take care of athletic teams.
Mayerson graduated from the University of Toledo in 1990, summa cum laude in biology, and received his M.D. degree from John’s Hopkins in 1994. His course was set when, as a fourth year medical student on an elective rotation , he was, totally by accident, assigned to work with Dr. Frank Frassica , chair of the orthopedic oncology service. “From that day, ” Mayerson says, “I fell in love with orthopedic oncology.”
Mayerson continued.
Everyone who has a tumor, has it in a different location in the body. Some people have it in their bones, some people have it in their muscles, sometime the tumor starts in that area, and sometimes it starts in another place and spreads to their bones and muscles. Every patient is different, every problem is different.
“When I graduated from my fellowship I had done over 500 oncology cases and several hundred as a resident. I thought I was really well trained and there was not a whole lot more that I was going to see.
“I was pretty naïve. I have been in practice now for 11 years and I still see new stuff every day. That is one of the reasons I love my job—it is different all of the time. I would have a hard job doing the same thing over and over again. With this career I do not have to.”
Mayerson finds that anatomy is pretty much all the same. “The important part of oncology is not only anatomy. You have to work at the six cardinal directions, figuring out where you can get around the tumor, make sure you can remove it with appropriate margins, top and bottom, left side and right side, front and back. And we have to look at the imaging, know where the pitfalls are and how we are going to get around them.”
Rotationplasty/Dr. Joe Mayerson
The reconstructive side, he says, should be decided by the patient’s expectations and what they want to do in their life. “You have to get to know the patient, ” he says. “People have different reconstructive needs and varying levels of desires in life. Somebody who is 80 years old has different needs to ambulate and get around in life than if they were 15.
A recent patient was a ten-year-old fourth grader who, when he broke his femur, doctors discovered that he had a softball size malignant tumor just above his knee. The standard of care in the United States would have been to fill the void with a cadaver bone and a metal knee.
In talking with his patient, Mayerson discovered that what his young patient wanted most to do in life was play baseball. “That was his goal and all that he wanted. He wanted to be a major league baseball player.” The most important consideration was the boy’s activity level now and into the future. Mayerson knew that with a cadaver bone or a metal bone in his leg the boy would not be able to play sports. The cadaver bone is fragile and the metal and plastic parts wear out—usually between 10 and 15 years. “Like the transmission on your car, ” Mayerson notes, “they have a certain number of miles in them and then they wear out and you have to do a revision and fix it. Every time you fix it, it gets harder. After a while you run out of opportunities to redo it.”
Taking into consideration the patient’s young age and his fervent desire to play baseball, Mayerson performed a rare procedure, called rotationplasty, in which the leg is amputated, turned around, and the foot is attached to where the knee joint used to be.
The foot’s heel is in front with the toes pointed back so that the ankle joint functions as a knee joint. The surgery was a success and the boy is playing baseball.
In another rare surgery Mayerson implanted a device called the Repiphysis, by Wright Medical Technology, in the arm of a five-year-old girl with cancer. Mayerson removed most of the cancerous upper arm bone to treat the cancer and filled the gap with donated living bone and the high-tech implant that could be lengthened as the girl grew. Since the implant had not yet been approved by the FDA, he had to get a “compassionate use” approval before he could proceed with the surgery. The implant consisted of a hollow titanium tube inside a plastic tube housing a compressed steel spring. When warmed by heat, generated by an electromagnetic field, the device lengthens. “Because of this device, Elizabeth was able to keep her arm, which will help her lead a normal healthy life, ” said Mayerson.
In the first surgery of its kind performed in the United States ( or, perhaps anywhere) Mayerson and his team removed the left leg, hip and part of the pelvis of a cancer patient and used the healthy bone, blood vessels and muscles from the amputated leg to rebuildthe hip and pelvis so it would be strong enough to support a prosthetic leg.
The surgery was performed by the entire sarcoma surgery team that Mayerson had put together and heads. Working together in the operating theater was a surgical oncologist to make sure that the bowel and blood vessels were moved out of the way; there was a neurosurgeon to do the spine part of the surgery; there was a plastic surgeon who was able to dissect out small blood vessels so they could save the parts that were not being amputated and could be used in the reconstruction and an anesthetist who could deal with major blood loss.
“As a team, we all sat down for seven to eight hours in advance and went through each step of the surgery, ” said Mayerson. “ The first day the patient had surgery for twelve hours—with two shifts of doctors. The second surgery lasted for 25 hours with three or four shifts of people.” Mayerson estimates that, altogether, counting nurses, technicians and staff in the blood bank, from 400 to 500 people were involved in this surgery.
Mayerson says, “One of the things we have worked very hard to do is develop a multi-disciplinary team. There are very few centers in the country that have an entire team that is able to do these things. Our goal is to continue to build the program and let people who have terrible problems know that there are various ways to take tumors out. Other places may not have the team and so they tell their patients that their tumors are not removable and that they cannot help them. We want these people to know that this institution is a place that may be able to help them.”
Does Mayerson and his team celebrate their successes? “Absolutely, ” he said. “We are always a little bit anxious when the surgery is done because there are a whole host of complications that can occur. Our celebration may not be that day. But when Mr. P ( the pelvis reconstruction patient) left the hospital in three weeks, off pain medication, we celebrated. It was one of the most amazing things I have ever seen.”
Indeed, chronicling the surgical artfulness of not only Dr. Mayerson, but also his team and other orthopedic oncologists are some of the most amazing stories we cover in OTW.
