NewYork-Presbyterian COLUMBIA ORTHOPAEDICS Fall 2011 WHAT S INSIDE 2 4 5 6 Wrist Fractures Patient Reported Outcomes Guide Treatment Man On Mission Volunteer Work in China Training the Next Generation Mentoring Clinician-Scientists Not Just a Headache Treating Concussions SAVE the Date Bridging Care for People with Cerebral Palsy NewYork-Presbyterian Morgan Stanley Children s Hospital November 5, 2011 For more information and to register, visit www.columbiacpcenter.org Don t miss the Webcast premiere of Current Trends in Arthroscopic Shoulder Surgery and Computer Simulation November 8th at Noon Go to www.orlive.com/ NYPColumbiaortho/shoulder NYOH Residency Graduation June 15, 2012 in New York City Visiting Professor Michael J. Bosse, MD Dr. Benjamin Roye with Wilmer, a 17 year-old CP patient who is transitioning out of pediatric based care and benefitting from the new Columbia CP Center. New Center Bridges Cerebral Palsy Patients to Adult Care BENJAMIN ROYE, MD, MPH; DAVID P. ROYE, JR., MD According to the United Cerebral Palsy Foundation, some 800,000 children and adults in the United States are living with one or more symptoms of cerebral palsy (CP). The U.S. Centers for Disease Control and Prevention estimates that another 10,000 infants born in America each year develop CP. A multitude of medical and support services are available for these patients during childhood. But the transition to adult health care is not as seamless. Medical advances are helping those with CP live longer, more productive lives, with nearly 90 percent of CP patients reaching adulthood. But as these patients move through adolescence and into adulthood, they face new health issues, and adult healthcare systems have not yet been able to provide the services they need. There s a major problem in that these patients age out of the pediatric healthcare system, explained Benjamin Roye, MD, MPH. To meet this need, Dr. Roye an orthopaedic surgeon who specializes in the care of CP patients and his colleagues, have established the Columbia Cerebral Palsy Center (CCPC) at NewYork- Presbyterian Hospital/Columbia University Medical Center, which is dedicated to providing comprehensive health care to CP patients of all ages, from childhood through adulthood. The Center is the first of its kind in the country and will set the standard for transitional, comprehensive CP care. It was developed with a generous donation from the Weinstein family. Dr. Roye and his father the Center s Executive Medical Director, David Roye, Jr., MD initially explored the existence of formal transitional care programs at children s hospitals. We found that there s no model for this kind of program anywhere, said Dr. Benjamin Roye. No one has looked at the concept of transition, until now. For more information visit www.columbiaortho.org
At this point, we don t really know what all of those needs will be, because many adult CP patients have become lost in the healthcare system. This registry will enable us to capture information about what they need and help us determine how we can best meet those needs. Many children with CP undergo multiple surgical procedures from a variety of specialists including orthopaedic surgeons (tendon lengthenings, hip reconstruction and scoliosis surgery), general surgeons (feeding tube placement and control of acid reflux), neurosurgeons (procedures to decrease muscle tone including baclofen pump placement and dorsal rhizotomy) and ophthalmologists. As adults, they may develop arthritis and require joint replacements. But because many adults with CP don t have the specialized health care they need, it s not uncommon for them to end up in emergency rooms when they need medical care. Our goal is to prevent this from happening, said Dr. Roye. To reach that goal, the CCPC has affiliated with nearly 40 Columbiaassociated physicians who have signed Benjamin Roye, MD, MPH on to provide adult care to CP patients. They include internists, cardiologists, gastroenterologists, neurosurgeons, general surgeons, ophthalmologists, gynecologists, dentists, and others effectively, any specialist whom an adult with CP may need to see. Because they are affiliated with Columbia, these doctors have access to the patient s electronic medical record, facilitating continuity of care. Occupational, physical, and speech therapists, psychologists, and social workers are also part of the team. Patients who come into the CCPC are evaluated and their medical needs identified. Then the Center links them with the physicians needed to provide their care. Ideally patients will come in as young children and stay with the Center for years to receive any medical services they may need throughout their lives. A pivotal part of the new Center is a clinical research initiative to assess new and established treatments, understand the impact of these treatments on patient outcomes and quality of life, and establish the first CP patient registry in the United States to collect information about patients healthcare needs at all ages. At this point, we don t really know what all of those needs will be, because many adult CP patients have become lost in the healthcare system, said Dr. Roye. This registry will enable us to capture information about what they need and help us determine how we can best meet those needs. Another focus of the Center is the education and training of physicians and caregivers through continuing medical education programs, annual conferences, and workshops (see first page SAVE the date). A goal will be to incorporate CP transitional care into medical school curriculums. Transition is not a single event, but a continuous process, concluded Dr. Roye. Cerebral palsy patients have long received the best possible care from Columbia doctors. This Center will help ensure that as the boys and girls we treat become men and women, they will continue to receive that same excellent level of care. For more information, visit columbiacpcenter.org. Patient Reported Outcomes Impact Distal Radius Fracture Treatment Decisions MELVIN P. ROSENWASSER, MD; ROBERT J. STRAUCH, MD; PETER TANG, MD, MPH Distal radius fractures and fragility fractures in general are increasing with the aging population and attendant osteopenia and osteoporosis. In fact, in a changing paradigm, the presence of a wrist fracture may tell a doctor more about a patient s risk of osteoporosis than a bone density test. The orthopaedic surgeon who sees a patient with a distal radius fracture may be the first to identify and help reduce the risk of subsequent fragility fractures. The optimal treatment for these fractures is changing based on data showing that patients subjective self-reported outcomes which reflect their function and satisfaction one year after injury may be more reliable and predictive than traditional objective measures such as x-rays. Melvin P. Rosenwasser, MD, and his colleagues, Robert J. Strauch MD, and Peter Tang MD, MPH, have been conducting randomized controlled trials to determine the best treatment algorithm for a distal radius fracture using validated outcome instruments. Often the surgeons predetermined beliefs may not be substantiated by the data. As much as we believe restoration of anatomy is prerequisite to the best anatomic result we have found that the surgical exposure and resultant stiffness may detract from the ultimate outcome despite excellent reassembly of fracture fragments Dr. Rosenwasser explained. Certain fracture patterns even after healing with some collapse and deformity have excellent clinical results and it is this refinement in our understanding of surgical indications which is so important in molding surgeons behavior. There is nothing like long-term follow up to help change a surgeon s practice. 2 columbiaortho.org
These studies utilize a validated outcome instrument, the DASH questionnaire (Disabilities of the Arm, Shoulder, and Hand) as well as a pain visual analogue scale to query the patients, regarding comfort and function. It is the analysis of this data which is most accurate in evaluating various treatment protocols, Dr. Rosenwasser maintained. In 2009, he and his fellow investigators compared functional outcomes among patients with unstable distal radius fractures surgically repaired with external fixation (22 patients) (Fig.1A,B), a locked volar plate (12) (Fig. 2A,B), or a locked radial column plate (12) (Fig. 3A,B). All patients completed the DASH questionnaire at 6 weeks, 3 months, 6 months, and one year after surgery. At one year, the patients with a radial column plate had maintained significantly better radial inclination and radial length than patients who had external fixation or a volar plate. However, patient reported function was similar among all three groups, with no significant differences in DASH scores, though the locked volar plate group had better DASH scores in the first 3 months after surgery. (J Bone Joint Surg Am. 2009;91:1568-1577.) This highlighted that proper technique no matter what the surgical approach or implant could result in equivalent and highly satisfactory clinical results. Peter Tang, MD, MPH and his colleagues conducted a prospective study to evaluate the relationship between ligament injuries and patientreported outcomes in patients with distal radius fractures. There is no good data to guide treatment of patients with distal radius fractures who also have wrist ligament injuries, said Dr. Tang. Do we need to repair these ligaments to improve long-term outcomes? He compared DASH scores among 30 patients who were arthroscopically evaluated for injuries to the scapholunate (SL) ligament, the triangular fibrocartilage complex (TFCC), and the carpal and distal radius articular surface. Patients completed the DASH questionnaire at 2, 6, 12, 24, and 52 weeks post-surgery, and were also assessed for range of motion, grip strength, and pain. More than 70 percent of the patients had ligament injuries,most of which did not create carpal instability. SL and TFCC injuries were the most common. After one year, Dr. Tang found that DASH scores did not differ significantly between patients with ligament injuries and those without them. He concluded that these injuries did not affect patients outcomes and that the surgeon should carefully assess for the potential for latent instability to guide decision-making for ligament stabilization concomitant with fracture fixation. An ongoing distal radius fracture registry will permit many other such studies to enlighten surgeons as to the best treatment plans for various fracture patterns and presentations with the emphasis on patient outcome and satisfaction being paramount. The Department of Orthopedic Surgery at the NewYork-Presbyterian Hospital/ Columbia University Medical Center is home to the Trauma Training Center (TTC), which is the epicenter of these clinical trials and is directed by Dr. Rosenwasser. This facility includes a clinical outcomes training facility to instruct residents and fellows about the importance and application of patientreported data. Dr. Rosenwasser noted that in the future, reimbursements may be tied to patient-reported outcomes. Patients want to know what they ll be able to do after surgery, but until recently the literature has been relatively silent about this. It is important for patient decisionmaking, said Dr. Rosenwasser. This is where clinical research in our field is headed. Best Clinical Practice algorithms will come from studies of patientreported outcomes. 1A 1B 2A 2B 3A 3B 1. AP and lateral x-rays of distal radius fracture treated with external fixation and K-wires (Fig. 1A, B). 2. AP and lateral x-rays after treatment with volar locked plating (Fig. 2A, B). 3. AP and lateral -xrays after treatment with radial column plating (Fig. 3A, B). 3
Man on Mission: David Roye in China DAVID P. ROYE, JR., MD The literal definition of the word orphan is a child whose mother and father have died. But in China, it s not unusual for children with illness or deformity to be placed in orphanages by their parents. It s the aim of David P. Roye, Jr., MD, to help those children, using his surgical skills and leadership experience. Dr. Roye travels as many as six times a year to China to provide medical services to children in need through the Children of China Pediatrics Foundation, a group he has worked with for a dozen years. He is now its Chief Medical Officer, and leads teams of surgeons, operating and recovery room nurses, anesthesiologists, pediatricians, respiratory and physical therapists, orthotists, translators, and administrators on an annual two-week mission. In May 2011, a medical and surgical team most of whom donate their personal vacation time treated orphans at Chengdu Women s and Children s Hospital in the capital of the Sichuan Province. They assessed 60 children and performed 37 surgeries: 15 orthopedic operations (including leg lengthening and bilateral thumb repairs), 8 urological procedures (including hypospadias repair and bladder augmentation), and 14 plastic surgeries (primarily cleft lip and cleft palate repairs). While many of the children and their caregivers came from Chengdu, others journeyed from the neighboring provinces of Hunan, Guangxi, and Guizhou. Can you imagine an American hospital allowing a group of foreign nurses, doctors, and others to usurp a few operating rooms for a week or so and perform surgery? said Dr. Roye. Not only did the senior administration of the hospital allow us to do this; they helped and guided us every step of the way as we unpacked and organized the mission. Dr. Roye, who is also Executive Medical Director of Columbia s Cerebral Palsy Center, performs osteotomies of the femur to place the hips back in joint in Chinese children with cerebral palsy. He is also a specialist in the correction of congenital hand disorders and in post-trauma reconstruction. Working hand-in-hand with colleagues from other specialties, we straighten out crooked bones and return children to an acceptable level of function, he said. He also travels regularly on his own to Beijing Children s Hospital, where he spends a week performing procedures in his particular area of expertise: spine surgery, including correction of scoliosis and kyphosis, noting there is a great deal of congenital kyphosis in China. These kids aren t treated early enough, so they end up developing significant curves, Dr. Roye noted. He encourages the use of growing rods in young patients. We ve treated about 300 children whose lungs were probably saved because their spines weren t fused at age 2, he added. During his visits, Dr. Roye not only cares for patients; he also teaches seminars focusing on topics related to healthcare management and policy, including multidrug- This kind of work gives me a chance to really feel needed. I feel like I m really making a difference. David P. Roye, Jr., MD Dr. David Roye with orphans and orphanage staff members. 4 columbiaortho.org
resistant organisms, the impact of healthcare reform, and other topics. Such instruction is sorely needed in China, which is in desperate need of better hospital management and medical education. He also helps facilitate meetings between government officials (such as those from the Chinese Ministry of Health), hospital administrators, and academic leaders with the shared goal of improving medical care. In a country where medical education is broken and specialty training doesn t exist, according to Dr. Roye, the expertise brought by him and his colleagues is highly valued. Knowing this, Dr. Roye invites Chinese fellows to come to Columbia each year to hone skills they can bring back to China. Between 30 and 40 fellows have gone through the program already, many of whom Dr. Roye continues to correspond. Three new fellows from China are scheduled to arrive at Columbia by the end of 2011. The program has also brought hospital administrators to Columbia to expand their knowledge base. In 2006, Dr. Roye founded the International Healthcare Leadership (IHL) at the Columbia University Mailman School of Public Health. The IHL is an independent nonprofit organization developed to train Chinese healthcare professionals about how to incorporate healthcare public policy into healthcare reform and hospital management. Dr. Roye has assembled the resources for a five-week non-certificate program at the Mailman School to teach Chinese healthcare professionals the elements of modern health policy and management, health economics, biostatistics and epidemiology, and environmental health. If he can secure funding, he hopes to make it an annual program. This kind of work gives me a chance to really feel needed, concluded Dr. Roye. I feel like I m really making a difference. Guiding the Way for Orthopaedic Researchers FRANCIS Y. LEE, MD, PHD The challenge of securing federal biomedical research funding is well known in the scientific community. But that challenge is even greater for the nation s 30,000-plus orthopaedic surgeons, of whom less than 0.1% are successful in garnering grant funding from the National Institutes of Health (NIH). Francis Y. Lee, MD, PhD, is an active clinician-scientist. His recent election to the Columbia University Senate is a confirmation of his dedication to academia. Dr. Lee has been awarded two NIH R01 grants, as well as one grant from the U.S. Department of Defense (DOD) one of only a handful of orthopaedic surgeons to do so. He eagerly guides young faculty who are starting their research careers to help them secure funding for new projects. Dr. Lee leads translational research efforts related to musculoskeletal diseases, including cancer, through Columbia s Center for Orthopaedic Research. His current projects focus on Participants of the First Columbia Orthopaedics Research Day 2011. On the left is Dr. Francis Lee and center is Dr. Louis Bigliani. inflammatory bone loss in implant loosening, ERK signaling, and readyto-use tissue constructs for military bone and cartilage injuries. In a recent paper published in the Journal of Bone and Joint Surgery in April 2011, Dr. Lee and his colleagues showed, in a mouse model, that adding the investigational drug PD98059 (a MAPK/ERK pathway inhibitor) to doxorubicin overcame the resistance that osteosarcoma cells develop to doxorubicin and prolonged survival. (J Bone Joint Surg Am. 2011;93:723-32.) They concluded that inhibiting ERK1/2 signaling resulted in osteosarcoma cell death by upregulating pro-apoptotic genes and inhibiting Bcl-2-mediated resistance to doxorubicin. 5
To help other investigators initiate similar translational research projects, Dr. Lee shared his experience with the federal grant application process in a two-day nuts-and-bolts workshop that he chaired this past May in Florida. Eleven faculty members advised 15 participants about topics such as the grant review processes for the NIH, DOD, and the Department of Veterans Affairs (VA); designing translational and clinical research studies; presenting preliminary data; handling budgets and statistics; addressing reviewers feedback; and planning for continued funding. The program was co-sponsored by the American Academy of Orthopaedic Surgeons (AAOS), Orthopaedic Research Society (ORS), and the Orthopaedic Research and Education Foundation (OREF). Among the faculty were James Panagis MD, NIAMS, Robert Tracy Ballock, MD, Cleveland Clinic, Kenneth Mann, PhD, SUNY Upstate, Mathias Bostrom, MD, Hospital for Special Surgery, Mary Gold Ring, PhD, Hospital for Special Surgery, Tamara Alliston, PhD, UCSF, and Jonathan Forsberg, MD, National Naval Medical Center. They were joined by clinician-scientists, biologists, and statistics experts from other institutions. Chairing the workshop is one of many commitments Dr. Lee has made to furthering orthopaedics research. He leads TRIO: the Translational Research in Orthopaedics Program at Columbia University, which provides one year of research experience to an orthopaedics resident. He runs the Clinician Scholar Program at Columbia for junior faculty. This past May, Dr. Lee hosted Columbia Orthopaedics first research day, which showcased the efforts of student research fellows and visiting scholars. And he is chairing the AAOS/OREF/ORS Clinician Scholar Development Program, to be held in Chicago in October 2011. He is also a member of the ORS Mentoring Committee and the AAOS Research and Development Committee, and is a grant reviewer for the NIH. High-quality orthopaedic research is imperative for our field, but investigators need the research money to get started, said Dr. Lee. I hope these efforts spur young investigators to pursue orthopaedic research that will ultimately improve the lives of the patients we serve. Not Just a Headache: NewYork-Presbyterian/Columbia Center Recognizes Significance of Concussions CHRISTOPHER AHMAD, MD Some 10 percent of student athletes will sustain a concussion during a sports season. Those who do are at risk of future concussions a risk that is heightened further if an athlete returns to play before he 1 2 1. Columbia football player during a play. 2. MRI of patient from a concussion work-up. or she has fully recovered. With each successive concussion, the threshold for another concussion drops and the risk of complications escalates. At NewYork-Presbyterian Hospital/Columbia University Medical Center, a team of specialists in the Columbia Concussion Clinic assesses athletes before concussions, performing baseline neurocognitive tests, and after, to assess the degree of injury and counsel the athlete about the appropriate time to return to sports. Today there is intense focus on concussions in athletes at all levels, from high school through college and professional sports, said Christopher Ahmad, MD. It s a mild injury to the brain that has to be taken seriously. While many people think that a concussion is defined by a loss 6 columbiaortho.org
of consciousness, it is actually any alteration in mental state resulting from trauma to the head. Symptoms may include headaches, dizziness, distractibility, forgetfulness, anxiety, and depression. Post-concussion sequelae may present as impairment in performance and cognitive function and even emotional disturbances. The best treatment for a concussion is simply brain rest. Depending on the severity of the injury and the patient s age, that may take days or weeks. Younger patients take longer to heal than those who are older. It s not unusual for players to tell their coaches they want to go back into the same game after such an injury, but it s exactly that decision that can get them into even more trouble. Athletes who sustain a second concussion before the first one has healed are at risk for Second Impact Syndrome, which can be fatal or cause symptoms similar to severe traumatic brain injury. It is therefore imperative that concussion patients are diagnosed early and appropriately and allow themselves to heal fully before returning to sports. The state of New Jersey took this so seriously that they passed the strictest law in the nation, requiring student athletes suspected of sustaining a concussion to be immediately removed from play and requiring them to be evaluated and cleared by a concussion specialist before returning. The diagnosis of concussions has not been an exact science, however, and has been based largely on tests such as the clinician asking the patient to repeat five words he or she just stated. At the Columbia Concussion Clinic, the team evaluates concussion patients using computer-based neurocognitive testing software called ImPact. The patient sits at a computer in a quiet room and answers questions and performs tasks assessing emotional state, concentration skills, reaction time, and memory over a 15-to-20-minute period. NewYork-Presbyterian Columbia Orthopaedics is a semi-annual newsletter published by NewYork-Presbyterian Hospital. The articles in this newsletter represent the work of the Columbia University College of Physicians and Surgeons faculty at NewYork-Presbyterian Hospital/Columbia University Medical Center, who are at the forefront of research and practice in the diagnosis, treatment, and rehabilitation of musculoskeletal conditions in adults and children. NewYork-Presbyterian Columbia Orthopaedics Editorial Board Columbia University College of Physicians and Surgeons Peter Tang, MD, MPH Editor-in-Chief Assistant Professor of Clinical Assistant Attending Orthopaedic Surgeon E-mail: pt2214@columbia.edu Louis U. Bigliani, MD Chief, Service Director, Center for Shoulder, Elbow and Sports Medicine President, Medical Board Frank E. Stinchfield Professor and Chairman Department of E-mail: lub1@columbia.edu Francis Y. Lee, MD, PhD Chief of Musculoskeletal Oncology Associate Professor with Tenure Vice Chair for Research Department of E-mail: fl127@columbia.edu William N. Levine, MD Director, Sports Medicine Associate Director, Center for Shoulder, Elbow and Sports Medicine Vice Chairman of Education and Professor of Clinical E-mail: wnl1@columbia.edu The team at the Columbia Concussion Clinic includes a neuropsychologist, neurologists, sports medicine specialists, a physiatrist, and a physical therapist who collaborate to assess and care for patients. They ensure that a patient s neurocognitive test scores have returned to normal before William B. Macaulay, MD Director, Center for Hip and Knee Replacement Anne Youle Stein Professor of Clinical E-mail: wm143@columbia.edu Christopher B. Michelsen, MD Chief, Orthopaedic Spine Service Chief, The Allen Hospital Professor of Clinical E-mail: cbmmd@yahoo.com Melvin P. Rosenwasser, MD Director of the Hand and Orthopedic Trauma Services Robert E. Carroll Professor of Clinical E-mail: mpr2@columbia.edu David P. Roye, Jr., MD Chief, Pediatric St. Giles Professor of Clinical Pediatric E-mail: dpr2@columbia.edu Our goal is to identify players at risk to reduce the incidence of concussion-related consequences down the road. Christopher Ahmad, MD giving him or her clearance to return to sports. Other services include consultation with the student s academic institution regarding resumption of coursework; academic accommodations, if appropriate; and referral for physical therapy and rehabilitation. 7
The Columbia Concussion Clinic provides proactive care to junior varsity and varsity athletes at Columbia University and City College and some local high schools. Players receive baseline preseason neurocognitive testing and are referred to the clinic for evaluation if a concussion is suspected during the season. As the official hospital of the major league New York Yankees professional baseball team, NewYork-Presbyterian/ Columbia also monitors and treats concussions in those athletes. We counsel patients and families about the risk of concussion and post-concussion sequelae, and advise them about which sports they can play and which ones they may want to avoid, explained Dr. Ahmad. Our goal is to identify players at risk to reduce the incidence of concussion-related consequences down the road. For more information or to refer a patient, visit columbiaconcussionclinic.com. Contributing Faculty The following is a list of the medical professionals quoted in this issue of the NewYork-Presbyterian Columbia Orthopaedics Newsletter. For more information on their work, please contact them at the e-mail addresses listed. NewYork-Presbyterian Hospital Columbia University College of Physicians and Surgeons Christopher Ahmad, MD Chief, Adolescent and Pediatric Sports Medicine Associate Professor of Clinical Head Team Physician, New York Yankees E-mail: csa4@columbia.edu Francis Y. Lee, MD, PhD Chief of Musculoskeletal Oncology Associate Professor with Tenure Vice Chair for Research Department of E-mail: fl127@columbia.edu Melvin P. Rosenwasser, MD Director of the Hand and Orthopedic Trauma Services Robert E. Carroll Professor of Clinical E-mail: mpr2@columbia.edu Benjamin Roye, MD, MPH Assistant Professor of Clinical Assistant Attending Orthopaedic Surgeon E-mail: bdr5@columbia.edu David P. Roye, Jr., MD Chief, Pediatric St. Giles Professor of Clinical Pediatric E-mail: dpr2@columbia.edu Peter Tang, MD, MPH Editor-in-Chief Assistant Professor of Clinical Assistant Attending Orthopaedic Surgeon E-mail: pt2214@columbia.edu NewYork-Presbyterian COLUMBIA ORTHOPAEDICS NewYork-Presbyterian Hospital 622 West 168th Street New York, NY 10032 NONPROFIT ORG. U.S. Postage PAID Permit No. 1043 New York, NY