Innovations In Orthopaedics

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1 UH Innovations In Orthopaedics Department of Orthopaedics The Harrington-McLaughlin Heart & Vascular Institute Advanced Treatments for Elbow Osteoarthritis page 4 Paying tribute to Evidencebased a physician who pediatric revolutionized spine surgery orthopaedics surgery A new approach for anterior shoulder stabilization UHhospitals.org/ortho Fall 2010

2 Chairman s Message A Proud Legacy Randall E. Marcus, MD, Chairman, Department of Orthopaedics, University Hospitals Case Medical Center, Charles H. Herndon Professor, Case Western Reserve University School of Medicine (left), with the late Henry H. Bohlman, MD, Henry H. Bohlman Chair in Spine Surgery and Director, Spine Center, University Hospitals Case Medical Center, and Professor of Orthopaedic Surgery, Case Western Reserve University School of Medicine Welcome to this issue of UH Innovations in Orthopaedics, which allows us to share the outstanding achievements of the clinicians and scientists in the Department of Orthopaedic Surgery at University Hospitals Case Medical Center/Case Western Reserve University School of Medicine. Our department is consistently ranked as one of the top orthopaedic departments in the United States. This issue features two of our innovative clinical services that contribute to this recognition: n Innovative surgical techniques for osteoarthritis of the elbow: Elbow specialist J. Robert Anderson, MD, is performing arthroscopic débridement arthroplasty of the elbow and hemiarthroplasty of the elbow, providing pain relief and functional improvement without the limitations of total elbow arthroplasty. University Hospitals Case Medical Center is one of a few centers in Cleveland offering both procedures. n A novel technique for anterior shoulder stabilization developed by one of our surgeons: Shoulder specialist Brian Victoroff, MD, developed labroplasty, a procedure for labral reconstruction where the labrum is either irreparable or missing. Labroplasty is most useful in revision of failed anterior stabilization procedures and salvage reconstructions. We also highlight the accomplishments of George H. Thompson, MD, and the Pediatric Orthopaedics Division. Dr. Thompson and his team are developing a model of evidence-based pediatric orthopaedics surgery, particularly in spine surgery. Sadly, we also announce the unexpected death of Henry H. Bohlman, MD, on May 27, Dr. Bohlman was a pioneer in spine surgery, the director of our Spine Center and a mentor to some of the leading spine surgeons nationwide. He was the Henry H. Bohlman Chair in Spine Surgery at University Hospitals Case Medical Center and Professor of Orthopaedic Surgery at Case Western Reserve University School of Medicine. We welcome your comments, questions and suggestions. Feel free to contact us via or phone, or through our professional referral service. Randall E. Marcus, MD Chairman, Department of Orthopaedics University Hospitals Case Medical Center Charles H. Herndon Professor Case Western Reserve University School of Medicine UH Innovations in Orthopaedics Fall 2010, Volume 2, Issue 1 Contributors: Randall E. Marcus, MD; J. Robert Anderson, MD; Nancy Hagan, RN, BSN; George H. Thompson, MD; Brian Victoroff, MD Publication Coordinator: Rich Riley UH Innovations in Orthopaedics is published biannually by University Hospitals for physicians and should be relied upon for medical education purposes only. It does not provide a complete overview of the topics covered and should not replace the independent judgment of a physician about the appropriateness or risks of a procedure for a given patient. Among the nation s leading academic medical centers, University Hospitals Case Medical Center is the primary affiliate of Case Western Reserve University School of Medicine, a nationally recognized leader in medical research and education. The commitment to exceptional patient care begins with revolutionary discovery. Faculty at the Case Western Reserve University School of Medicine, who also are physicians at UH Case Medical Center, are at the forefront of medical research and innovation. The School of Medicine is the largest medical research institution in Ohio and among the nation s top medical schools for research funding from the National Institutes of Health. UHhospitals.org University Hospitals in Cleveland, Ohio. All rights reserved. Produced by McMurry. Contents of this publication may not be reproduced without the express written consent of University Hospitals. 2 Fall 2010 For referrals, call UH4-CARE ( )

3 In Memorium A Tribute to a Spine Surgery Pioneer Henry H. Bohlman, MD: Henry H. Bohlman, MD, pioneered the anterior approach to spine surgery, led one of 20 national spine centers of excellence and mentored fellows who went on to become leading spine surgeons nationwide, before his death at age 72 on May 27, Dr. Bohlman was director of the Spine Center and Henry H. Bohlman Chair in Spine Surgery at University Hospitals Case Medical Center and Professor of Orthopaedic Surgery at Case Western Reserve University School of Medicine. No single surgeon did more to revolutionize spine surgery in the world than Henry Bohlman, says Randall Marcus, MD, Chairman, Department of Orthopaedic Surgery, University Hospitals Case Medical Center, and Charles H. Herndon Professor, Case Western Reserve University School of Medicine. The anterior approach to spine surgery has fundamentally changed the ability of orthopaedic surgeons to treat spinal arthritis and other conditions affecting the spinal cord. Dr. Bohlman s patients included celebrities such as Baltimore Orioles shortstop Cal Ripken and Prince Bandar Bin Sultan of Saudi Arabia. Ripken was able to return to baseball after Dr. Bohlman performed spinal surgery on him. honored with an Endowed chair Under Dr. Bohlman s direction, the Spine Fellowship Program trained more than 110 fellows. His fellows lead the spine centers at most major medical centers nationwide, and four of his fellows are chairs of orthopaedic departments. To honor Dr. Bohlman, fellows formed the Henry Bohlman Wine & Spine Society (Dr. Bohlman was also a wine collector). The society meets annually and helps fund innovative spine care at University Hospitals. In 2008, the society endowed the Henry H. Bohlman MD Chair in Spine Surgery with $2.2 million; Dr. Bohlman s fellows contributed more than half of these funds. Dr. Bohlman was named the first chair. Dr. Bohlman earned his medical degree at the University of Maryland and completed his residency at Johns Hopkins Hospital. He served as a major in the U.S. Air Force, then joined University Hospitals Case Medical Center/Case Western Reserve University School of Medicine in Dr. Bohlman s evidence-based approach to patient care has revolutionized the practice of modern spine surgery. Our department continues to carry on the legacy of spine care excellence that he established, says Dr. Marcus. Henry H. Bohlman, MD, Henry H. Bohlman Chair in Spine Surgery and Director, Spine Center, University Hospitals Case Medical Center, and Professor of Orthopaedic Surgery, Case Western Reserve University School of Medicine A Life of Achievement Dr. Bohlman s many accomplishments included: Publications: n 120+ journal articles n 45 book chapters Presentations: n 300+ lectures Service: n 8 national committees n 6 editorial boards, including: Spine, The Journal of Bone and Joint Surgery and Neurosurgery n President, Cervical Spine Research Society n President, Federation of Spine Associations Awards: n Association of Bone & Joint Surgery: Nicolas Andry Award for Outstanding Achievement in the Field of Orthopaedic Surgery n North American Spine Society: Leon Wiltse Award for contributing greatly to the art and science of spinal disorder management UHhospitals.org/ortho Fall

4 COVER STORY Relieving Osteoarthritis Pain and Improving Elbow Function Two technically advanced procedures enable physical laborers to return to work J. Robert Anderson, MD, Attending Surgeon, Department of Orthopaedic Surgery, University Hospitals Case Medical Center, and Assistant Professor, Orthopaedic Surgery, Case Western Reserve University School of Medicine Although osteoarthritis of the elbow is uncommon, its impact can be severe: disabling pain and loss of motion resulting in serious functional impairment and limitations in the activities of daily living. Osteoarthritis of the elbow occurs most commonly in men in their 40s and 50s who are involved in heavy lifting at work, in the gym or in sports. Heredity also plays a role in the development of this disease. In Ohio, assembly line workers at automobile manufacturers, automotive mechanics and construction workers are especially prone to osteoarthritis of the elbow, according to J. Robert Anderson, MD, Attending Surgeon, Department of Orthopaedic Surgery, University Hospitals Case Medical Center, and Assistant Professor, Orthopaedic Surgery, Case Western Reserve University School of Medicine. Dr. Anderson is using two innovative surgical techniques to address osteoarthritis of the elbow without the severe limitations imposed after total elbow arthroplasty: Arthroscopic débridement arthroplasty of the elbow and hemiarthroplasty of the elbow. Avoiding the Limitations of Total Elbow Arthroplasty Compared with other joint replacements, total elbow arthroplasty has a relatively high incidence of infection and loosening. The procedure is contraindicated for patients who do physical labor. Due to the materials used and design constraints, the recommendation is to lift no more than 10 pounds with that arm after surgery, and no more than two pounds repetitively. This is rarely compatible with the requirements of most jobs that involve physical labor, says Dr. Anderson. Elbow arthroscopy and hemiarthroplasty of the elbow provide pain relief and functional improvement without these limitations and complications. Both procedures, however, have steep learning curves and are technically demanding. University Hospitals Case Medical Center is one of a few centers in the Cleveland area offering both procedures. Arthroscopic Débridement Arthroplasty Débridement arthroplasty of the elbow results in pain relief and a greater range of motion for most patients. The procedure involves removal of loose bodies in the joint and osteophytes from the olecranon, coronoid and the olecranon fossa, along with capsular release. Patients generally recover more than 50 percent of their lost elbow range of motion. Dr. Anderson performs more than 75 percent of his débridement arthroplasties of the elbow arthroscopically. More advanced cases of osteoarthritis of the elbow sometimes require conversion to an open operation. The main advantages of the arthroscopic procedure are the much smaller incisions and a faster return to activity, he says. With less pain from the arthroscopic technique compared with open surgery, patients can start physical therapy right away. Although some arthroscopic débridement arthroplasties of the elbow can be performed on an outpatient basis, Dr. Anderson prefers to hospitalize patients overnight to immediately begin range-of-motion therapy and provide instructions for home therapy. Compliance with rehabilitation is necessary to maximize the gain. Arthroscopic débridement arthroplasty of the elbow is also associated with better cosmesis compared with open surgery. Advanced Surgical Techniques Elbow arthroscopy, hemiarthroplasty of the elbow and total elbow arthroplasty are three of the many innovative surgical techniques performed at University Hospitals Case Medical Center to restore damaged joints, ligaments and bones. Shoulder and elbow specialists within the Department of Orthopaedic Surgery also have pioneered reverse shoulder arthroplasty and minimally invasive rotator cuff muscle-sparing shoulder arthroplasty. The five specialists in the Shoulder and Elbow Division are: J. Robert Anderson, MD, Reuben Gobezie, MD, Stephen Lacey, MD, John Shaffer, MD, and Brian Victoroff, MD. Conditions and injuries they commonly treat include: n Trauma n Instabilities n Rotator cuff injuries n Osteoarthritis and rheumatoid arthritis n Sports injuries n Arthroscopically treated problems n Shoulder and clavicle fractures For an appointment, please call Fall 2010 For referrals, call UH4-CARE ( )

5 Before and after images of a patient with significant arthritic changes limited to the lateral compartment treated with a capitellar arthroplasty. Hemiarthroplasty allows more aggressive use of the arm, though at the expense of less pain relief, as one side of the joint is still the patient s own tissue. These techniques allow people to buy time and get more years of function. The arthroscopic procedure is generally indicated for earlier cases of osteoarthritis of the elbow. Dr. Anderson, however, sometimes is able to perform arthroscopy in patients with more advanced disease. Prior surgery on the ulnar nerve is a relative contraindication for this procedure. Hemiarthroplasty of the Elbow For patients with severe pain due to osteoarthritis of the elbow, hemiarthroplasty, replacing only one of the two surfaces in the arthritic joint, can provide some pain relief while allowing the patient to return to physical work activities. Hemiarthroplasty allows more aggressive use of the arm, though at the expense of less pain relief, as one side of the joint is still the patient s own tissue. These techniques allow people to buy time and get more years of function, says Dr. Anderson, who is one of a handful of surgeons in Cleveland who perform hemiarthroplasty of the elbow. In almost all cases, the hemiarthroplasty involves replacement of the humeral side of the patient s elbow. Through a posterior incision and an olecranon osteotomy, the elbow joint surfaces are accessed. Using cutting jigs, the end of the distal humerus is prepared for the implant, which is designed to reproduce the shape of the normal articular surface. The stem of the metallic implant is secured into the medullary canal with bone cement. The implants require a smaller bony resection than a traditional total elbow replacement, facilitating later revision to total elbow arthroplasty. Patients who undergo hemiarthroplasty can return to physical work, although certain types of very heavy activities, such as demolition work, are prohibited. In general, patients function for about 10 years with a humeral implant before progressive arthritis on the biological side of the arm becomes severe enough to warrant total elbow arthroplasty. By that point, patients are at or closer to retirement age, and the hemiarthroplasty can be revised to total elbow arthroplasty. Dr. Anderson also performs total elbow arthroplasty in older patients with severe osteoarthritis of the elbow and in individuals with rheumatoid arthritis. To Learn More For more information about débridement arthroplasty and hemiarthroplasty of the elbow, please call UHhospitals.org/ortho Fall

6 physician highlight Pediatric Orthopaedist George H. Thompson Building the evidence for more advanced pediatric orthopaedic surgery George H. Thompson, MD, Director of Pediatric Orthopaedics, University Hospitals Rainbow Babies & Children s Hospital and Professor of Orthopaedic Surgery and Pediatrics, Case Western Reserve University School of Medicine Under the leadership of George H. Thompson, MD, pediatric orthopaedists at Case Western Reserve University School of Medicine are developing a model of evidence-based pediatric orthopaedics surgery, particularly in spine surgery. This work is based on extensive experience with growing rods and videoassisted thorascopic surgery (VATS) to correct severe spinal deformities, the administration of Amicar (epsilon aminocaproic acid) to decrease perioperative blood loss, and continuous intravenous morphine infusion for improved postoperative pain management. We are continually presenting evidence-based surgery, publishing our work for the world to see, says Dr. Thompson, Director of Pediatric Orthopaedics at University Hospitals Rainbow Babies & Children s Hospital since 1987 and Professor of Orthopaedic Surgery and Pediatrics, Case Western Reserve University School of Medicine. Looking Toward Tomorrow Dr. Thompson and his team publish about 12 to 15 research articles every year, most commonly in The Journal of Bone and Joint Surgery, Journal of Pediatric Orthopaedics, Clinical Orthopaedics and Related Research, and Spine. Dr. Thompson himself has published more than 100 peer-reviewed articles, 80 textbook chapters and four textbooks. He has made more than 600 presentations. Most of Dr. Thompson s practice focuses on correcting spine deformities, including scoliosis and kyphosis, using advanced surgical techniques such as growing rods and VATS. Dr. Thompson and his colleagues are among the most experienced surgeons nationwide in performing growing rod procedures. They are also among a few surgeons in Ohio who perform VATS for anterior spinal procedures. I tell parents that what I do for your child isn t for today; it s for tomorrow. Many times the goal is to redirect the child s growth to allow Mother Nature to take over and make the child as normal as possible as an adult, says Dr. Thompson, whose other major interests are trauma, hip abnormalities and foot deformities. Leading in Research and Practice Among Dr. Thompson s many research awards are the Arthur H. Huene Memorial Award for Excellence and Promise in Pediatric Orthopaedics Research (2008) and a Pediatric Minimally Invasive Surgery Grant from the Cleveland Foundation (2009). He is using funds from both awards to further his team s research through infrastructure improvements (investments in computer systems and databases) and study funding. The funds also support the Growing Spine Study Group, an international study group focused on early onset scoliosis to which the Pediatric Orthopaedic Division is a major contributor. Dr. Thompson is co-editor of the Journal of Pediatric Orthopaedics and Scoliosis Research Society representative to the Board of Specialty Societies of the American Academy of Orthopaedic Surgeons. He is also Past President of the Scoliosis Research Society, the Pediatric Orthopaedic Society of North America and the Ohio Orthopaedic Society. Specialized Pediatric Orthopaedic Care The pediatric orthopaedists at University Hospitals Rainbow Babies & Children s Hospital specialize in spine and complex deformities, and treat congenital and acquired musculoskeletal problems in children. We re one of the largest pediatric orthopaedic programs in the country. All of our physicians are subspecialists, says George H. Thompson, MD, one of six pediatric orthopaedic surgeons, along with Daniel Cooperman, MD, Allison Gilmore, MD, Jochen Son-Hing, MD, Ray Liu, MD, and Patrick Getty, MD. The division also includes two nonoperative sports medicine specialists: Suzanne Briskin, MD, and Amanda Weiss Kelly, MD. There are also two pediatric orthopaedic nurse practitioners: Connie Poe-Kochert, RN, CNP, and Suzanne Fortuna, RN, MSN, CNP; and a clinical nurse: Michelle Moran, RN. For more information, please call Fall 2010 For referrals, call UH4-CARE ( )

7 Case study A Novel Technique for Anterior Shoulder Stabilization A UH Case Medical Center surgeon develops a procedure for labral reconstruction An 18-year-old high school hockey player experienced anterior dislocation of his right shoulder while playing hockey. He underwent arthroscopic anterior stabilization; less than a year after the procedure, the patient presented to University Hospitals Case Medical Center with recurrent anterior shoulder dislocation. Evaluation Brian Victoroff, MD, Sports Medicine and Shoulder Specialist, Department of Orthopaedic Surgery, University Hospitals Case Medical Center, and Associate Professor, Orthopaedic Surgery, Case Western Reserve University School of Medicine, ordered an MRI. The scan showed destruction of the patient s glenoid labrum. Arthroscopic stabilizations generally work very well, but when they fail, the sutures tend to cut through and shred the labrum, says Dr. Victoroff. Treatment With the labrum missing, anatomical repair was impossible. Neither arthroscopic revision nor standard open Bankart repair techniques were options. Dr. Victoroff performed labroplasty, a procedure he developed, on the patient. This is a novel technique for labral reconstruction for those cases where the labrum is either irreparable or missing, he explains. Since developing the procedure in 1992, Dr. Victoroff has performed about 40 labroplasties. The initial stages of labroplasty are similar to open Bankart repair. Instead of repairing the labrum, however, Dr. Victoroff reconstructs it by labroplasty. Using the medial capsule, Dr. Victoroff re-creates the labrum and restores medial capsulolabral integrity. The sutures and their knots remain intracapsular. Dr. Victoroff completes the procedure by repairing the anatomy of the lateral capsule and subscapularis, followed by routine closure. Although labroplasty is most useful in revision of failed anterior stabilization procedures and salvage reconstructions, Dr. Victoroff notes that it is also an option for primary anterior dislocation of the shoulder when the capsulolabral anatomy is disrupted to the extent that Bankart repair would be ineffective or impossible. Postoperative Management and Return to Sport The patient regained full shoulder function and returned to hockey four months after Dr. Victoroff performed the labroplasty. His rehabilitation mirrored that of repair of an initial shoulder dislocation. As captain of his high school hockey team in his senior year, the patient led his teammates in winning the Ohio state championship. For more information, please call Brian Victoroff, MD, Sports Medicine and Shoulder Specialist, Department of Orthopaedic Surgery, University Hospitals Case Medical Center, and Associate Professor, Orthopaedic Surgery, Case Western Reserve University School of Medicine Labroplasty Offers Excellent Results Brian Victoroff, MD, reported the following results of 14 labroplasties performed between 1992 and 2003 compared with 10 Bankart-type labral repairs, in Techniques in Shoulder and Elbow Surgery ( The Labroplasty Procedure for Anterior Shoulder Stabilization, 7(4): , December 2006). The article concluded that labroplasty offers excellent short-term results in a select patient population with shoulder instability due to a deficient or irreparable labrum. Labroplasty patients (mean follow-up at 4 years) Bankart patients (mean follow-up at 3 years) Modified Rowe scores Mean: 86 Range: American Shoulder and Elbow Society scores Mean: 90 Range: Mean: 89 Range: Mean: 93 Range: Loss of external rotation in adduction 7 degrees 6 degrees Loss of external rotation at 90 degrees of abduction 6 degrees 8 degrees UHhospitals.org/ortho Fall

8 University Hospitals of Cleveland Marketing & Communications MSC Euclid Avenue Cleveland, OH PRSRT STD U.S. POSTAGE PAID UNIVERSITY HOSPITALS Printed on recycled paper! When to Refer/Grand Rounds Call Our Foot and Ankle Experts From damage to the articular surfaces of the foot and ankle to developmental deformities such as hallux valgus with symptomatic bunions to ligament and tendon injuries, physicians can expect optimal care for patients referred to the foot and ankle experts at the Department of Orthopaedic Surgery at University Hospitals Case Medical Center. We have a very active foot and ankle service with two fellowship-trained foot and ankle surgeons: Shana Miskovsky, MD, and myself, says Randall Marcus, MD, Chairman, Department of Orthopaedic Surgery, University Hospitals Case Medical Center, and Charles H. Herndon Professor, Case Western Reserve University School of Medicine. Through minimally invasive treatment of early arthritis, the foot and ankle specialists can eliminate the need for later reconstructive surgery. They perform many other foot and ankle procedures, including ligament reconstructions, tendon transfers, cartilage resurfacing or replacement, ankle arthroplasty and ankle fusion (either arthroscopic or open). Your Feedback is Important As a medical professional, your input is invaluable in helping Image Courtesy of Apple us shape future issues of UH Innovations in Orthopaedics. We want to know what s important to you. Do you want to read about cuttingedge research, learn about the latest technology, or hear firsthand case studies of how others in your specialty are improving and saving lives? Tell us what you want to read about and your name will be entered to win one of two Apple ipads! Simply visit UHhospitals.org/innovations. Grand Rounds n Sept. 22: Metastatic Bone Disease and Pathologic Fractures Patrick J. Getty, MD, Director of Musculoskeletal Oncology and Assistant Professor of Orthopaedics, Case Western Reserve University School of Medicine n Sept. 29: Tales from the Crypt Daniel R. Cooperman, MD, Professor of Orthopaedics, Division of Pediatric Orthopaedics, Case Western Reserve University School of Medicine n Oct. 6: Evaluation of the Multiply Injured Patient John Como, MD, Associate Professor of Surgery, Division of Traumatology, Case Western Reserve University School of Medicine n Oct. 13: The Allen Fellows Lecture: Understanding Medical Statistics Richard Leeber, PhD, Professor of Orthopaedics, University of California, San Diego n Oct. 20: Biology and Physiology of Arthritis Roland Moskowitz, MD, Professor of Medicine, Division of Rheumatology, Case Western Reserve University School of Medicine n Oct. 27: Metastatic Disease of the Spine: Evaluation and Management Christopher Furey, MD, Assistant Professor of Orthopaedics, Division of Spine Surgery, Case Western Reserve University School of Medicine n Nov. 3: The Carter/Makley Lecture in Orthopaedic Oncology John Healey, MD, Chief of Orthopaedics, Sloan Kettering Medical Center, and Professor of Orthopaedic Surgery, Cornell University Medical Center, New York, NY n Nov. 10: Upper Extremity Injuries in Children Jochen Son-Hing, MD, Assistant Professor of Orthopaedics, Division of Pediatric Orthopaedics, Case Western Reserve University School of Medicine For further information about these events, held at the Wolstein Research Building Auditorium, including directions, please contact Ellen Greenberger, Education Coordinator, Department of Orthopaedics, at or Ellen.Greenberger@UHhospitals.org. Nancy Hagan, RN, BSN Orthopaedic Triage Service Clinical Nurse Manager Nancy Hagan, RN, BSN, answers physicians questions, triages patients and ensures that appointments are made within 48 hours when necessary. Call to access orthopaedic specialists and refer patients to University Hospitals Case Medical Center s Department of Orthopaedic Surgery.