It’s a Spa, It’s a 5 Star Hotel: No, It’s The Spine Hospital!
Their goal is to create a never-before-seen hospital experience for spine patients. Dan Riew, M.D., Larry Lenke, M.D., and Ron Lehman, M.D. said goodbye to friends and colleagues at Washington University in St. Louis this summer, and they are now hard at work in New York. Dr. Riew is the new Director of Cervical Spine Surgery at The Spine Hospital at the New York Presbyterian/Allen at Columbia University College of Physicians and Surgeons. Dr. Lenke functions as Surgeon-in-Chief and Director of Spinal Deformity. Dr. Lehman is Director of Lumbar Degenerative Surgery and Director of Spine Research. Dr. Riew tells OTW, “There is a real excitement in the air, with people contacting us from all over the globe to ask about joining us.”
And why the buzz? “Drs. Lenke, Lehman and I have a shared vision of what will give spine patients the best hospital experience possible. Our first goal is, of course, to provide world-class surgical and clinical care. But in addition, we provide concierge level service often reserved for elite hotels. At check-in, patients are given a ‘Spine Hospital’ robe and an amenities bag. One patient told me, ‘I have had many operations, and I never want to have surgery anywhere else but here.’ Another patient from the Middle East told me that she has been in hospitals all over the world and this is the ‘best care she has ever experienced.’”
“In December, Drs. Mark Weidenbaum, Jay Kim and Charla Fischer will be joining us from the main campus. All of our patients will have critical care intensivists and/or hospitalists as part of the clinical team. We round with a PA, hospitalist, nurse, PT, OT, resident and/or fellow and, if necessary, respiratory therapists, dieticians, and social workers. Our nurse-to-patient ratio is either one on one or one on two. And when patients need telemetry or a step-down unit care they can actually remain in their rooms, as the equipment and nursing are all built-in. We have the first spinal robotic surgery apparatus in the greater New York metropolitan area, the latest radiology equipment able to perform low-dose X-rays of the entire spine and skeleton from skull to feet, intraoperative CT and navigation capability, 3D microscopes, and brand new state-of-the-art operating rooms with a surgical viewing area that is unparalleled. Every piece of equipment that is necessary to provide top-notch care, as well as provide for the ease and comfort of the patient is available.”
“As for the operating room (OR), visiting surgeons don’t even have to enter the OR to see the surgery. They can remain in a comfortable conference room and watch an HD television screen showing exactly what I see through the microscope. They can watch three different operations occurring in three different rooms. On my microscope, they can watch on a 3D monitor with 3D glasses to get a great perspective. We’ve already had visiting surgeons from Asia, Middle East and Latin America and have many others signed up over the next three years.”
Further clarifying the emphasis on detailed patient care, Dr. Riew notes, “I had a patient whose wife called me at 6pm on a Friday. She said that the room temperature had been increasing for the last hour and was 75; she wanted it to be 72. I called the floor administrator and someone was there to repair it immediately—on a Friday evening! You would never see anything like this happening at the typical urban medical center. Because we are a small and specialized hospital, we can control everything from the temperature to how everyone interacts with the patient.”
“Over the next year we hope to have the Columbia University neurosurgeons join us, add more nonoperative staff, as well as more patient rooms and ORs. We have three fellows for our inaugural Comprehensive Orthopedic & Neurosurgery Columbia Spine Fellowship for 2016-17 and are excited that we were able to match our top three choices with phenomenal fellows.”
Ace the Exams With an Unusual New Tool
Need an unusually concise, precise, book to prepare for board/recertification exams or the Orthopedic In-Training Examination? Now there is a tool that goes beyond the basics and provides challenging answers to tough clinical situations. Acing the Orthopedic Board Exam: The Ultimate Crunch-Time Resource, a new vignette-based prep book, was edited by Brett R. Levine, M.D., M.S., an Associate Professor of Orthopaedics in the Adult Reconstruction Division at Rush University Medical Center. Dr. Levine tells OTW, “What sets this book apart is that it is based on vignettes, and is written in a colloquial—even funny—style. You can tackle it in a weekend and retain high yield information.”
“There is an extensive list of co-authors, most of whom are recent graduates of residencies or who are senior residents. We attempted to get into the mind of the question writer. We want the reader to be able to pick up key words and phrases that he or she can look for on an exam. You don’t always know the answer, but if you know what the question writer was thinking then you can get yourself to the point where you’ve narrowed it down to a couple of options on a multiple choice question. At that point you can use your knowledge to determine the correct answer.”
“While it was challenging to achieve a good, representative mix of vignettes, we were able to do so. There are several multidisciplinary vignettes. For example, we took a lot of joint replacement vignettes and turned them into not just questions on osteoarthritis and simple joint arthroplasty, but things like ‘Patients have had questions about recalls. How do you explain the science behind these problems?’ There are vignettes about the basic science of metals (which the modern day patients tend to ask frequently). In general for testing purposes it is hard to tell what next will be added to the boards; however, you are safe with new technology, if it has been out for two years and has had enough publications, then it is fair game to be on the exam.”
This new book is focused on giving students an edge on the really tough questions, says Dr. Levine. “We didn’t want it to be a simple review of the basics. This book goes way beyond that, and can even help you make a good impression while on clerkship rounds. Let’s say you are on the pediatric orthopedic service. You can arrive at the hospital early, grab a cup of coffee, and quickly zip through the high yield questions and pick up 15-20 new facts. Then you go do rounds and you stand out as someone who is ahead of the game.”
Lateralized Reverse Shoulder Implants: NOT Disastrous
He gives credit where credit is due. But as accomplished researchers do, Mark A. Frankle, M.D. knew that improvements were possible. Dr. Frankle is an orthopedic surgeon with Florida Orthopaedic Institute in Tampa and director of the Biomechanical Shoulder and Elbow Research Lab at the University of South Florida College of Engineering. He tells OTW, “As reverse shoulder replacement grows in popularity, improving our understanding on how to improve outcomes and reduce complications will be of increasing importance. The surgery was originally popularized by the French surgeon Paul Grammont, whose device was critical in providing evidence of efficacy of a reverse shoulder replacement. However, associated with the improvements in outcomes were scapular notching, loss of rational strength and alteration of the deltoid contour. Based on my examination of his device, I lateralized the center of rotation, something that was criticized by most shoulder surgeons. They thought it was headed for disaster.”
“My colleague, Mark Mighell M.D., is fluent in French, so he read all of the original papers on Grammont’s device. This then led to the first lateralized reverse shoulder replacement in the United States; it became the Reverse Shoulder Prosthesis (owned by DJO Surgical). The purpose of our most recent study was to evaluate all of the reverse shoulder prostheses that I did from 2000 to 2012. We examined how many reverse patients had to undergo reoperation for component issues. (If another surgeon did the reoperation then we didn’t have data on that.) Of the 1, 418 reverse shoulder surgeries that I did in 12 years, 85 required reoperation. We wanted to know why.”
“During that 12 year period there were design changes…we wondered if those impacted the reason for reoperation. The reasons for reoperation fell into seven categories:
- loosening or breakage of the glenoid base plate attachment
- dissociation of the base plate where the glenosphere attaches
- dissociation of the humeral component (during this time there was a cup attached to the stem)
- dislocation of the glenohumeral joint
- loosening of the humeral component
- fractures around the implant that required an exchange of implant
- infection that required component exchange or removal.”
“From January 2000-2004 the way the baseplate attaches to the bone involved a central screw and a peripheral screw that were nonlocking (3.5mm in diameter). This was the biggest reason for reoperation; of 242, 31 had to undergo reoperation because of that design. In 2004 the peripheral screw was changed to a locking screw (now 5mm). From 2004-2014 only 4 out of 1, 176 patients were revised for that reason, a significant reduction.”
“Overall, there were three design changes made in 12 years. One alteration was a change in the peripheral screws on the base plate. That resulted in a decrease in reoperations, something that correlated with the biomechanical studies at the time.”
“There is ample evidence—not just from my data and biomechanical data—but from other surgeons showing that you can lateralize and not have high likelihood of failure. In Grammont’s design the ball was a hemisphere, so there was only so much distance you can push the socket from the shoulder blade. When the ball was made into an elliptical shape (such that it is farther away from the scapula) the likelihood of the socket on the humerus hitting the shoulder blade was far less. With the Grammont design notching was a real problem. The radiographic evidence showed that there was abrasion of the polyethylene that generates a lot of wear, something that led to concerns about durability. That prompted me to push the socket away from the shoulder blade and thus make a lateralized sphere.”
“Other manufacturers are incorporating lateralization into their reverse designs. Just two weeks ago I attended an instructional course on lateralization in reverse shoulder replacement; the consensus amongst the audience was that lateralization is an important principle.”
