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Access to expertise, experience critical
for orthopaedic oncology patients
“Because sarcomas of the bone and soft tissues are relatively rare, it is
especially important that these patients have access to team-based
expertise that can help determine and deliver the best course of treatment,”
says UCSF orthopaedic surgeon Rosanna Wustrack, MD.
Wustrack’s arrival at UCSF Medical Center – after fellowship training in
orthopaedic oncology at Memorial Sloan Kettering Cancer Center in New
York – has helped lead to the expansion of clinics at UCSF Bakar Cancer
Hospital, San Francisco General Hospital (SFGH), the San Francisco VA
Medical Center, both UCSF Benioff Children’s Hospitals and our satellite
clinic in Walnut Creek.
CONTINUED ON PAGE 3
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
s p r i n g /s u m m e r
2 0 15
V O L U M E 14 N U M B E R 1
CONTENTS
Message from the chair
2
Children deserve tailored
orthopaedic services 4
Advances in the evaluation and
treatment of hip conditions5
The advantages of specialized
care for adult spinal deformity 6
Reverse shoulder arthroplasty
offers new options for patients
7
CME courses8
Message from the chair
A
All patients deserve personalized care and access to the best treatments
possible. This applies to patients with difficult-to-treat musculoskeletal
conditions, as well as patients for whom best practices require a team
using the latest knowledge and techniques. In this issue we highlight some
programs that deploy unique expertise for specific patient populations.
Thomas Parker Vail, MD
Orthopaedic oncology, especially pediatric orthopaedic oncology, is an
area where a multidimensional team can change the patient experience.
The arrival of Rosanna Wustrack, MD, our new orthopaedic oncologist,
has created significantly more access to expertise in the treatment of
sarcomas of the bone and soft tissues for Bay Area patients from all walks
of life. Her practice coincides with the opening of UCSF Benioff Children’s
Hospital San Francisco at Mission Bay and the new affiliation with UCSF
Benioff Children’s Hospital Oakland. Both events have made it possible
for more Bay Area kids to see pediatric orthopaedic specialists for an
array of conditions, including cancer and other childhood musculoskeletal
problems. In addition, both of these facilities offer a pediatric sports
medicine program that is now the most comprehensive child athlete
program in Northern California.
Several adult programs also reflect our interdisciplinary approach to care,
including the management of spinal deformity and complex shoulder
pathology. We have pioneered successful new techniques for both
nonoperative and operative care of spinal deformity, and our significant
experience with reverse shoulder arthroplasty allows us to take care of
patients who have struggled after a traditional total shoulder replacement.
All of these stories reflect collaborations with our community of patients,
families and referring physicians. We hope you’ll continue to work with
us to further these invaluable collaborations. ©
Thomas Parker Vail, MD
James L. Young Professor and Chairman
Department of Orthopaedic Surgery
2
Access to expertise, experience critical for
orthopaedic oncology patients
CONTINUED FROM FRONT COVER
In turn, bone cancer patients from all age
groups and all walks of life have more
access to continuous and coordinated
care from leading experts, including
surgeons, radiologists, pathologists,
medical oncologists, radiation oncologists, orthotic and prosthetic specialists
and other professionals. These teams
deliver the latest evidence-based treatments for:
n
Primary bone sarcomas and
benign tumors of the bone
n
Primary soft-tissue sarcomas of
the extremities
n
Metastatic disease of the skeleton
Limb Salvage Surgeries
Quality care for any of these conditions
begins with a precise, team-based
evaluation that draws on advanced tests
and imaging techniques, and discussions
at a regular tumor board. At UCSF, the
sarcoma tumor board is now weekly,
in addition to a quarterly sarcoma conference. Clinical teams then meet with
patients and families to decide on the
best treatment course.
“If surgery is required, we have a number
of proven limb salvage techniques
available,” says Wustrack. “Radiation
therapy, delivered intraoperatively (IORT),
pre- or postoperatively, plastic surgery
reconstruction and, where needed,
neoadjuvant or adjuvant chemotherapy
all can help patients avoid amputation
for soft-tissue sarcomas, while reducing
the rate of local recurrence.”
IORT, specifically, has other advantages,
which include:
n
Reducing or preventing
complications associated with
pre- and postoperative radiation
n
Reducing the field for
postoperative dosing
n
Enabling extreme precision when
tumors are close to vital organs,
nerves or blood vessels
Rosanna Wustrack, MD
“And our collaborations with plastic
surgeons enable us to cover defects
with rotational or free flaps in surgeries
that often require resection of not just
the tumor, but also surrounding muscle
and skin,” says Wustrack.
In addition, Wustrack and Chief of
Orthopaedic Oncology Richard O’Donnell,
MD, have extensive experience with
compressive osseointegration, a technique that hopes to avoid long-term
complications associated with traditional
cemented endoprostheses. The
Compress endoprosthesis, developed
at UCSF, uses high forces at the prosthesis-bone interface to stimulate bone
growth into a metal endoprosthesis.
Beyond Limb Salvage
When limb salvage is not possible,
patients facing an amputation are
routinely custom-fitted with immediate
postoperative prostheses by expert
UCSF prosthetists.
Teams can treat more complicated
cases at the new UCSF Bakar Cancer
Hospital at Mission Bay. In addition to a
number of ongoing clinical trials, the
new hospital offers the latest diagnostic
A patient receives intraoperative radiation therapy.
technology and state-of-the-art operating
rooms, including tools such as IORT and:
n
High-frequency ultrasound
n
Radio-frequency ablation
n
Minimally invasive treatments for
benign metastatic tumors
“We are thrilled to be able to offer this
level of service to a far greater number
of patients throughout the Bay Area
than ever before,” says Wustrack. ©
Dr. Wustrack can be contacted
at 415-353-3800.
3
Children deserve tailored
orthopaedic services
A
As research on children’s unique health
care needs has expanded – and new
techniques and technologies emerge –
it’s imperative that the health care system
respond, says Mohammad Diab, MD,
chief of Pediatric Orthopaedics at UCSF
Benioff Children’s Hospitals.
He believes three responses are
especially important:
n
Create a tight translational research
loop, with scientists working closely
with clinicians.
n
Enhance the use of coordinated,
team-based medicine among relevant
specialties.
n
Expand access to high-quality care
for all patients.
Nirav Pandya, MD
“All three of those elements are facilitated
by our partnership with UCSF Benioff
Children’s Hospital Oakland and the
opening of our state-of-the-art, independent and dedicated children’s hospital at
Mission Bay,” says Diab.
The partnership and the opening of UCSF
Benioff Children’s Hospital San Francisco
at Mission Bay expand access to patients
in the East and South Bays; the Mission
Bay facility places pediatric orthopaedic
teams in much closer proximity to
UCSF’s translational scientists and the
UCSF Orthopaedic Institute.
Sports Medicine Illustrates
the Advantages
Among the many benefits of these developments is the creation of what is likely
the largest pediatric sports medicine
program in Northern California.
“We have created a one-stop shop for
young athletes in the area – providing
them with everything from surgery to
rehabilitation to human performance
testing,” says UCSF orthopaedic surgeon
and pediatric sports medicine physician
Nirav Pandya, MD.
With dedicated pediatric sports physicians
in San Francisco, Oakland and Walnut
Creek, the growing program builds on a
long history of pioneering surgical and
rehabilitation techniques for children and
teens.
Cardiovascular testing with Human Performance
Center manager Aaron Sparks
4
“Young people are unique physically,
psychologically and developmentally, and
if we treated them the same way we treat
adults, we would have less than optimal
outcomes,” says Pandya. “We only work
with young people – about 14,000
each year – and we believe it’s critically
Mohammad Diab, MD
important to have a program that is solely
dedicated to young athletes.”
Array of Services Tailored to
Young People’s Needs
To illustrate the advantages, Pandya offers
the example of a 10- or 11-year-old athlete
who tears her anterior cruciate ligament,
or ACL.
“The difference begins with a precise
diagnosis, based on advanced imaging
and an experienced understanding of children’s growing and changing anatomy,”
says Pandya.
Surgeons with vast experience in ACL
surgeries would complete the necessary
procedures. “Pediatric experience reduces
the risks of disturbing growth patterns
and developing problems later on, such
as arthritis,” says Pandya.
Then there’s the rehabilitation process,
where it’s important that clinicians listen
and understand patients and their families
before designing a rehabilitation plan.
Such a plan typically includes a return-toplay program rooted in evaluations that
might include motion analysis in a human
performance lab – a more precise and
evidence-based approach to helping children recover properly from their injuries.
“The strength of this program is not just
the expertise, but the commitment to
the use of advanced protocols in every
one of our settings, with every one of our
providers,” says Pandya. “That level of
standardization is unique.” ©
Dr. Diab can be contacted at 415-353-2967.
Dr. Pandya can be contacted at
510-428-3238.
Advances in the evaluation and
treatment of hip conditions
O
Over the last few years, increasing numbers of relatively
young athletes are developing hip conditions that cause
pain and restrict their ability to perform. The conditions
typically affect individuals between 20 and 40 years old,
but can appear in adolescents and older athletes as well.
“The most common of these problems is femoral acetabular impingement,” says orthopaedic surgeon Alan
Zhang, MD. “We think about 15 percent of the general
population has some form of FAI.”
In FAI, the bony anatomy of the hip joint is shaped
abnormally, either from birth or because extra bone
forms during maturation, perhaps due to overuse.
The abnormal growth impinges on the hip, hindering
movement or causing pain, typically in the groin or anterior region. The condition is often accompanied by a
torn labrum from the chronic rubbing.
Diagnosis and Treatment, Including
Arthroscopic Surgery
Because early diagnosis and treatment of FAI can avert
some of the pain and discomfort – as well as some of the
perceived risks, such as early arthritis – community physicians who encounter athletes with hip or groin pain and
whose X-rays reveal an abnormally shaped femoral head
should refer these patients to a specialty center like UCSF.
“We’ll combine a thorough physical exam with X-rays and
advanced imaging to get a precise diagnosis,” says Zhang.
Conservative treatment – physical therapy, and cortisone
injections in the hip joint – comes first, but if it is not
effective, surgery becomes an option.
Alan Zhang, MD
“For many patients, we can offer arthroscopic procedures
in which we can reattach the labral tear – we don’t always
have to remove it – and shave and recontour the hip,”
says Zhang. “We’ll do the arthroscopic procedure most
commonly for FAI and labral injuries, but also for loose
bodies in the hip.”
Using Quantitative MRI to Monitor
Cartilage Deterioration
Quantitative magnetic resonance imaging (qMRI) is
another advanced technique available only at a few
specialty centers.
“A qMRI lets us pick up damaged cartilage very early on,
before substantial degeneration,” says Zhang. “While
the use of a qMRI is not routine, at UCSF orthopaedic
surgeons collaborate with our musculoskeletal radiology
team to do qMRIs as part of a set of NIH-funded grants
aimed at using this technology to help prevent arthritis.”
Patients who undergo surgery at UCSF and elect to
enroll in the studies may receive qMRIs as part of
pre- and postsurgical monitoring, while those who don’t
have surgery may have periodic qMRIs so experts can
determine if and when surgery or lifestyle modifications
become necessary. ©
Dr. Zhang can be contacted at 415-885-3832.
Left: A quantitative MRI of a hip
allows surgeons to analyze
cartilage on the femoral head that
correlates with early cartilage
injury. Right: An image of a
repaired labrum, postsurgery.
5
The advantages of specialized care
for adult spinal deformity
I
It is quite common for adults over age 60
to have some malalignment or deformity of
the spine. The impact on these individuals’
lives – a growing and health-conscious
group – is often measurable in pain, functional status, appearance and mental health.
Yet because these spinal deformities
encompass a broad spectrum of pathologies, there is significant variability in
treatment – locally, regionally and nationally. Reducing that variation demands
an evidence-based, multidisciplinary
approach, as well as a commitment to
working collaboratively and learning from
one another, says the clinical team at the
UCSF Spine Center.
The center – a collaboration among
orthopaedic surgeons, neurosurgeons,
physiatrists and pain management
specialists – pioneers new techniques for
both nonoperative and operative care,
while rigorously tracking patient outcomes.
The spine team for the UCSF Department of Orthopaedic Surgery, from left to right: Shane Burch, MD,
Sigurd Berven, MD, Sibel Demir-Deviren, MD, Vedat Deviren, MD, Bobby Tay, MD
should be screened with 3-foot X-rays
that capture the entire spine on one
X-ray.
n
An Integrated Approach
Adult spinal deformity typically develops
between ages 50 and 80 due to progression of pediatric deformity with age, disk
degeneration leading to new deformity,
spinal arthritis or an original surgery that
led to malalignment of the spine.
Using a team-based approach – from
original diagnosis through nonoperative
management and, if required, preoperative
evaluation, surgery, postoperative care
and rehabilitation – is the best way to
ensure each patient gets the right approach
for his or her specific case.
Key steps in the process include:
n
6
Specialized Imaging: Any patient who
on clinical examination has evidence of
spinal imbalance – or who has had
multiple surgeries but never improved –
n
n
n
Multidisciplinary Evaluation: Evaluation should include consideration of
spinal alignment, pain patterns, neural
involvement and patient condition.
Appropriate use of nonoperative and
operative care depends on clinical
presentation, patient preference and
information on clinical outcomes.
Multidisciplinary Screening: Determining fitness for surgery should include
input from medicine, psychology, anesthesia, surgery and pain management.
Short- and Long-Term Planning:
Clinical teams should create an operative plan and postoperative treatment
plan, including long-term rehabilitation.
Expert Surgical Care: Because a
common complication after surgery is
subsequent degeneration above or
below the segments treated, UCSF
surgeons have developed techniques
that minimize the need for further
revision surgery and have led to
changes in how surgeons treat these
complications around the country.
The team also rigorously assesses the
long-term effect of various interventions on
their patients’ overall health status: pain,
function, mental health, self-image and
overall quality of life. It believes the longterm impact of spinal interventions on
health status is the essential measurement,
the most important driver in an evidencebased approach to care. ©
The UCSF Spine Center can be contacted
at 866-817-7463 (866-81-SPINE).
WHEN TO REFER
Refer patients to the UCSF Spine
Center who have:
n
Disorders of the spine
accompanied by significant pain
and functional impairment
n
Spinal deformity or instability
n
Nerve compression resulting
in pain, weakness or reduced
sensation
n
Tumors affecting the spinal column
n
Persistence of pain or functional
limitations after previous
nonoperative or operative care
Reverse shoulder arthroplasty offers new
options for patients
A
After a senior triathlete broke his shoulder,
the patient had a partial, ball-side shoulder
replacement performed in his community.
Unfortunately, the patient developed
an infection that required removal of his
shoulder replacement. This caused him to
develop severe arthritis in his shoulder –
debilitating pain and discomfort.
Benjamin Ma, MD
When he came to UCSF for an evaluation
and revision surgery, experts determined
he was a good candidate for reverse
shoulder replacement. After the successful
surgery, the patient eventually returned
to participating – quite successfully – in
competitive triathlons.
imaging to determine the severity of the
arthritis or rotator cuff tear and guide surgical treatment. Once the surgical team
determines that a patient is an appropriate
candidate, experience with the procedure
and thorough follow-up care offer the best
chance for success.
“We have a robust database to track our
patient outcomes over time,” says Ma.
A study of patients two years out has shown
outcomes for the reverse shoulder replacement at UCSF to be very similar to outcomes for total shoulder replacement, with
low complication rates and high patient
satisfaction scores. This is good news, since
the sports medicine surgeons at UCSF do
more than 100 shoulder replacements
annually, with 90-day readmission rates at
about half the national average.
“Reverse shoulder replacement allows us to
take care of patients who don’t do well
with a traditional total shoulder replacement,
typically those with large rotator cuff tears
or those with failed shoulder replacements,”
“For a particular group of patients who had
says orthopaedic surgeon Benjamin Ma,
no real options in the past, this procedure
MD, chief of Sports Medicine at the UCSF
can really change their lives,” says Ma. ©
Orthopaedic Institute. “For many of these
Dr. Ma can be contacted at 415-353-9400.
patients, total shoulder replacements can
actually worsen their pain and limit their
range of motion.”
Drawing on Experience, Expertise
Above: X-ray shows a shoulder
fracture that did not heal. Below:
Reverse shoulder replacement
restores function.
UCSF is one of the few centers in Northern
California with significant experience in
reverse shoulder arthroplasty. Whereas a
total shoulder replacement attempts to
replicate the normal anatomy of the shoulder with a prosthetic device, in a reverse
shoulder procedure, surgeons switch the
positioning of the socket and metal ball,
fixing the ball to the socket and the plastic
cup to the upper end of the humerus. This
arrangement allows the deltoid muscle to do
the work of damaged rotator cuff tendons.
As with many surgical procedures, patient
selection is important. Candidates for the
reverse procedure tend to be older, though
younger people with severe trauma might
also qualify. The UCSF team uses advanced
WHEN TO REFER
Refer patients to the UCSF Orthopaedic
Institute for evaluation if they have:
n
A completely torn rotator cuff that
cannot be repaired
n
Rotator cuff tear arthropathy
n
A previous shoulder replacement
that was unsuccessful
n
Severe shoulder pain and difficulty
lifting their arm away
n
Bone-on-bone arthritis of the shoulder
n
Shoulder pain despite having tried
other treatments, such as rest,
medications, cortisone injections and
physical therapy
7
UCSF Medical Center
505 Parnassus Ave., San Francisco, CA 94143-0940
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Mark R. Laret, Chief Executive Officer,
UCSF Medical Center
Orthopaedic Surgery News is published annually
for referring physicians by the Marketing Department
of UCSF Medical Center. It is written by Andrew
Schwartz and designed by Robin Awes Everett.
Photos: James Cavallini/Science Source, cover;
Elisabeth Fall, p. 4; Marco Sanchez /UCSF Documents
& Media, p. 5.
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Volume 14, Number 1, Spring/Summer 2015.
© 2015 The Regents of the University of California
CME Courses
For more information, visit www.cme.ucsf.edu
10th Annual UCSF Spine Symposium
May 29-30, 2015
San Francisco, Calif.
5th Annual UCSF Techniques in
Complex Spine Surgery Program
November 6-7, 2015
Las Vegas, Nev.
Case Reviews in Trauma
April 27, 2016
San Francisco, Calif.
11th Annual International San Francisco
Orthopaedic Trauma Course
April 28-30, 2016
San Francisco, Calif.