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Orthopaedic
Surgery news
Advantages of direct anterior approach
to total hip replacement
The growing preference for less invasive surgeries has renewed interest in the
direct anterior approach (DAA) to hip arthroplasty.
Erik Hansen, MD, of the UCSF Orthopaedic Institute, believes the combination
of technical advances in surgical instrumentation and proper training has
allowed the technique to be performed more reproducibly, thus allowing it to
realize its theoretical benefits:
n
n
As the only intermuscular, internervous approach to the hip, the DAA can
minimize soft-tissue injury and anatomic disruption. This can facilitate
faster return to function while achieving comparable outcomes to other
surgical approaches at the six-month to one-year mark.
Because the patient is in the supine position, the DAA can facilitate anesthesia monitoring, as well as a more accurate assessment of leg length
equality. Furthermore, it allows intraoperative use of fluoroscopic X-rays
to provide real-time feedback to confirm implant position and sizing.
CONTINUED ON PAGE 3
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
s u m m e r /f a l l
2 0 13
V O L U M E 12 N U M B E R 1
CONTENTS
Message from the chair
2
Bringing exemplary orthopaedic
care to the East Bay 4
Investigating innovative ways
to restore the lives of
orthopaedic cancer patients5
Advances enable increase
in outpatient spine procedures 6
Optimizing bone health
across the life span7
CME courses8
Message from the chair
I
In the era of health care reform, it is more important than ever that
clinicians at leading institutions implement evidence-based improvements
in care and prevention that restore patients’ lives and ease the financial
burden on our entire health care system. This issue of Orthopaedic Surgery
News offers examples of how the UCSF Department of Orthopaedic
Surgery is making its contribution.
Thomas Parker Vail, MD
In our cover story, surgeon Erik Hansen, MD, discusses two important
developments in arthroplasty procedures. First he outlines the risks and
advantages of the anterior approach to hip replacement; then he
describes the efforts of a consortium we have joined to reduce the risk of
periprosthetic infection. Other stories describe improvements we are
implementing – some of which we’ve pioneered here – in orthopaedic
oncology, outpatient spine surgeries and preventive and ongoing care for
osteoporosis and other skeletal insufficiencies. Patients benefit in a
number of ways: avoidance of later or more complex health challenges,
faster recovery times and retention of limbs they might have lost in an
earlier era.
A final story chronicles our growing collaboration with Children’s
Hospital & Research Center Oakland, where the combination of two
historically renowned facilities and staffs is improving and extending
care to more children than ever before throughout the Bay Area.
That brings me to an essential point: Such improvements occur most
often through collaboration among caring and dedicated professionals.
As always, we are proud to join all of you in these ongoing efforts. ©
Thomas Parker Vail, MD
Professor and Chair
Department of Orthopaedic Surgery
2
Advantages of direct anterior
approach to total hip replacement
CONTINUED FROM FRONT COVER
Training Matters
“The replacement procedure itself is the same regardless of
surgical approach,” says Hansen, who received special training
in the DAA at one of the few places in the country to offer it:
the Rothman Institute at Thomas
Jefferson University in Philadelphia. “But a growing respect for
the soft-tissue envelope around
the hip and its importance in
a patient’s recovery and outcomes has made the DAA my
approach of choice.”
Erik Hansen, MD
Nevertheless, he cautions that
for those who have been trained
only in the more traditional lateral
and posterior approaches, the
DAA presents unique challenges
and complications.
n
For more traditionally trained surgeons, conceptualizing the
anatomy from a new angle can make proper implant placement a challenge.
n
Lack of familiarity with the more fragile skin associated with
the DAA can compromise incisional integrity and lead to a
higher rate of wound complications.
Above: Drawing the
anterior incision
Left: Final placement
of the stem
n
Lack of experience with the technique can place patients at
a higher risk of lateral femoral cutaneous nerve injury, which
results in anterolateral thigh numbness.
Finally, patient selection is an important consideration, and an
honest discussion between patient and surgeon is important to
determine if this surgical approach makes the most sense for a
given individual.
“But in the hands of a surgeon trained in the technique, the direct anterior approach works quite well for many patients,” says Hansen. ©
Dr. Erik Hansen can be contacted at (415) 353-2808.
FIGHTING PERIPROSTHETIC INFECTION
Given projected increases in joint replacements and
revisions, the prevalence of more resistant bacterial
organisms and a more acutely ill patient population,
experts predict a significant rise in the number of periprosthetic infections.
To better prevent, diagnose and treat these infections,
UCSF is part of a multicenter initiative along with
several other high-volume arthroplasty centers across
the country. The group is establishing a database of
periprosthetic infections, seeking to answer a number
of key questions.
Diagnosis is challenging as no single test is 100 percent
accurate and many chronic infections are due to
organisms difficult to detect using traditional methods.
Refining established biochemical and hematological
markers could make the tests more accurate.
For prevention, the group is attempting to better characterize risk factors and to target preventive efforts on
not only the patient, but also the organism and implant.
For treatment, they are testing therapies and surgical
techniques that may avert the need to remove the implant and keep patients immobile for extended periods.
The ideal would be to treat the infection in one sitting,
thus minimizing morbidity associated with current
treatment strategies. In addition, they are collaborating
with infectious disease specialists regarding modified
antibiotic regimens to improve the success rate of
infection control.
“The mechanical questions regarding joint replacement
have more or less been answered, so preventing and
treating periprosthetic infection is the next big challenge,”
says surgeon Erik Hansen, MD, of the UCSF Orthopaedic Institute.
Collaborating to bring exemplary orthopaedic
care to the East Bay
S
Since June 2012, the UCSF Department of Orthopaedic
Surgery has collaborated with Children’s Hospital &
Research Center Oakland to provide comprehensive
orthopaedic services to the children of
the East Bay.
Expanding to Meet the Diverse Needs of a
Diverse Population
The collaboration extends to Walnut Creek, where
Children’s Hospital Oakland has an ambulatory clinic and
surgery center, and exemplifies the UCSF department’s
efforts to create specialty collaborations for pediatric
orthopaedics throughout the Bay Area. Today, in addition to its clinics at UCSF Medical Center and Children’s
Hospital Oakland, the Department of Orthopaedic
Surgery has satellite clinics in Greenbrae (Marin County),
Santa Rosa and San Ramon.
“It’s a wonderful opportunity for our
department to play an ever more significant role in the health of children and
their families throughout the Bay Area,”
says UC San Francisco’s Coleen Sabatini,
MD, who also serves as the medical
director of orthopaedics and interim chief And as the collaboration between the two renowned
of orthopaedic surgery at Children’s
institutions matures, Sabatini is optimistic that the partHospital Oakland. “We believe the comnership will lead to centers of excellence for addressing
bination of the two entities strengthens
more unmet pediatric orthopaedic needs in the East Bay.
the work we do and enables us to take
Coleen Sabatini, MD
“We are actively recruiting additional surgeons to further
even better care of more children.”
expand our clinical programs, and hope to deepen our
From Traumatic Injuries to Elective Procedures
focus on prevention programs like playground and sports
injury prevention,” she says.
At Children’s Hospital Oakland, the UCSF orthopaedic
surgeons – assisted by an experienced team of nurses,
orthopaedic techs, physician and medical assistants and
office staff – provide all orthopaedic on-call and clinic
coverage, which includes treatment for acute traumatic
injuries as well as elective surgeries.
Specifically, the range of pediatric services includes:
4
n
Full-spectrum orthopaedic care by Sabatini and
Nirav Pandya, MD
n
Comprehensive pediatric and adolescent
sports medicine
n
Orthopaedic oncology care
n
Congenital hand and complex elbow reconstruction
n
Trauma care that surgeons at Children’s Hospital
Oakland provide, with UCSF orthopaedic
traumatologists from San Francisco General Hospital
available to assist in Oakland with definitive care
for “adolescents who suffer more adult-type injuries,
such as acetabular/pelvic fractures and pilon
fractures,” says Sabatini
n
Treatment for complex conditions and deformities of
the hip, spine, and lower leg and foot
Sabatini is enthusiastic about the opportunity to serve
the patients at Children’s Hospital Oakland. “It’s an honor
to be part of this mission,” she says. ©
Dr. Coleen Sabatini can be contacted at (415) 353-2967
or at Children’s Hospital Oakland at (510) 428-3238.
Investigating innovative ways to restore the lives
of orthopaedic cancer patients
O
Orthopaedic oncologist Rosanna Wustrack,
MD, of UCSF Medical Center believes
the tools and knowledge are emerging to
do more than save the lives of patients
with bone cancer or soft-tissue sarcoma.
Orthopaedic oncologists are beginning to
understand how to restore the quality
of these people’s lives and dramatically
reduce the haunting specter of long-term
complications.
Rosanna Wustrack, MD
Wustrack – who trained with Richard
O’Donnell, MD, chief of Orthopaedic
Oncology at UCSF Medical Center – spent
the past year completing a fellowship at
Memorial Sloan-Kettering Cancer Center.
Old Bone
New Bone
In addition to continuing to practice stateof-the-art surgical techniques, she says,
“I’ve been working to identify the long-term
problems with limb salvage surgery and
large endoprostheses, the frequency
with which they occur – and then to think
of new ways to prevent and treat these
problems.”
frequently, both in her fellowship and in
her years at UCSF with O’Donnell – who
may have done more of these procedures
than any practicing surgeon in the world.
Salvaging Joints, Preventing Infection
Wustrack is also working with other
devices and techniques to improve her
patients’ lives, including allograft-prosthesis composites, biologic reconstructions
and joint salvage surgeries.
“With joint salvage, for example, you might
have a tumor in the lower part of the
femur, where you’d take out the entire
bone to complete a big knee replacement,”
she says. “Now we’re trying different
things to save the joint when possible –
and not just the limb.”
Wustrack is also seeking ways to prevent
infection, which for limb salvage surgery
can affect up to 10 percent of patients
over their lifetime. Follow-up, she says,
is critical.
“It is important to follow these patients
yearly and track them for long-term skeleOne long-term concern with most limb
tal effects from their cancer treatments,”
salvage devices is aseptic loosening. Over
she says. “We know, for example, that if
time, tiny particles from the implants
someone gets cancer treatments during
break loose and create a biochemical
adolescence, they have a higher risk of
reaction that causes the bone around the
low bone mineral density as an adult, so
implant to erode.
we need to make sure they get adequate
“This means patients have to undergo a
calcium and vitamin D early, are screened
second or third surgery to revise the device early for osteoporosis and are educated
and, sometimes, require an amputation,”
about fracture prevention.” ©
says Wustrack.
Avoiding Aseptic Loosening
Compressive osseointegration
encourages bone growth and
long-term stability.
She says that the use of compressive
osseointegration – a technique in which a
spring-loaded implant applies hundreds
of pounds of pressure at the boneprosthesis interface to promote osseointegration and stabilization of the implant –
can reduce the risk of aseptic loosening
when compared with more traditional limb
salvage devices. Wustrack used the device
Dr. Rosanna Wustrack can be contacted
at (415) 885-3800.
5
Advances enable increase in
outpatient spine procedures
B
By leveraging surgical and technological
advances and a collaboration with pain
management experts, surgeons from the
UCSF Department of Orthopaedic Surgery
have dramatically increased the number
of minimally invasive spine surgeries they
do in the outpatient setting.
Completed at the UCSF Orthopaedic
Institute at Mission Bay, the outpatient
procedures include:
n
Cervical endoscopic laminotomies
and foraminotomies
n
Lumbar discectomies
n
Minimally invasive lumbar
decompressions
Top: OR nurse Connie Ulep gets
ready to prepare the back of a
patient’s neck for surgery.
Typical surgeries last one or two hours,
with an additional hour of recovery time.
Above: A video camera is placed
on the surgical site, and what it
captures is displayed on the monitor
positioned over the patient.
A Boon for Patients
“Patients love it,” says orthopaedic surgeon
Bobby Tay, MD. “One major advantage
is that there is a more focused, dedicated
team, including nurses and anesthesiologists with deep experience in outpatient
procedures. Anesthetics are more consistently geared towards induction and
wake-up, as well as toward prevention
of nausea.”
Left: Dr. Tay performs surgery
while looking at the monitor for
anatomical orientation. Assisting
him is Michael Dimailig, surgical
technician.
He says that the shifting of single-level
surgeries to the outpatient setting is
made possible by a number of factors:
n
More refined surgical techniques
n
Better equipment
n
Better visualization
n
Advances in pain management
Improving Perioperative
Pain Management
The pain management improvements are
especially important, because the ability
to discharge people is often related to their
level of postoperative pain.
Bobby Tay, MD
6
“We use synergistic local anesthetics intraoperatively, which lengthens the duration
of postoperative analgesia,” says Tay.
The result is an extension of the postoperative analgesic effect from what was
previously three hours to almost an entire
day. This is not just a matter of comfort,
as studies have shown improved pain
management can also improve wound
healing. In the future, these types of
advances could even enable same-day
procedures for more complicated surgeries like fusions or disc replacements.
The contribution of this type of interdisciplinary thinking has been crucial. “Having
all these great minds together is a distinct
advantage,” says Tay. “It’s one of the
added benefits of being at UCSF.” ©
Dr. Bobby Tay can be contacted at
(415) 353-2840.
Optimizing bone health across the life span
M
Most physicians know well the devastating effects of a
fracture on older adults.
“In patients who have had a hip fracture, more than half
never get back to their prior level of function, 20 percent
are permanently placed in nursing homes and about
25 percent die within a year of their injury,” says Aenor
Sawyer, MD, of the UCSF Department of Orthopaedic
Surgery. After an initial hip fracture, surviving patients are
up to five times more likely to have another fracture.
It’s less commonly understood that many skeletal health
problems are preventable if physicians are more attentive
to maintaining patients’ bone health across their life spans.
This is the thinking behind
the new Skeletal Health
Clinic at the UCSF Orthopaedic Institute at Mission
Bay. There a multidisciplinary team (clinicians
from orthopaedics, endocrinology, nephrology,
rheumatology, physical
therapy, nutrition, radiology
and pharmacology) provides one-stop shopping
for preventing, diagnosing,
Aenor Sawyer, MD
treating and educating
patients about skeletal health concerns.
The clinic deploys some of the most sophisticated boneimaging techniques in the world – including dual-energy
X-ray absorptiometry (DXA) – as well as premier lab and
bone biopsy capabilities and innovative devices for safe
postsurgical mobilization. It also includes a telemedicine
component, where experts conduct multidisciplinary
Web-based conferences for complex cases.
Comprehensive Evaluation Facilitates
Precision Medicine
“Low bone mass and skeletal insufficiency that can lead
to osteoporosis is grossly underdiagnosed and undertreated,” says Sawyer.
Typically, the first opportunity to address these concerns
comes when any patient, including a child, presents with
a fracture. Sawyer and her team will assess the full array of
risk factors, from genetics, medications and underlying disease states to diet and activity patterns. As needed, bone
density, laboratory and genetic diagnostics are conducted.
CONTINUED ON PAGE 8
Aenor Sawyer, MD, explains the concept of skeletal health across
the life span.
REFER FOR A BONE HEALTH
ASSESSMENT IN THE
FOLLOWING SITUATIONS:
Children who:
n
Have had multiple fractures (>2)
n
Fracture from low-level injuries or activities
n
Have systemic chronic illness
Adults who:
n
Are 50+ years of age and have had a
recent fracture
n
Have had three or more nondigital fractures
n
Have a family history of osteoporosis or
multiple fractures
n
Have lost 2 inches from their tallest
recalled height
n
Are postmenopausal
n
Have chronic inflammatory diseases or cancer
n
Use corticosteroids
n
Report falling
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Third Annual UCSF Techniques in
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November 8-9, 2013
Henderson, Nev.
Optimizing bone health across the life span
CONTINUED FROM PAGE 7
If they find a problem, treatment typically
begins with lifestyle modifications, such
as nutritional changes, safe activity interventions and fall-risk assessments that
reduce the risk to fragile bones.
“Then we determine whether pharmacologic interventions are needed and which
type,” says Sawyer. “This is precision
medicine because skeletal insufficiency is
multifactorial and treatment approaches
need to be individualized.”
This is because 90 percent of bone mass
acquisition occurs by a person’s early
adulthood. Sawyer says there are many
things that can be done to optimize this
process so people can “bank some bone”
for later in life.
“Bones are incredibly dynamic,” she explains.
“They grow and remodel according to the
stresses placed upon them. One thing we
try to do is teach people how to load their
bones in a way that best meets their needs
– and [how to] maintain adequate nutrition
Childhood a Window of Opportunity
to optimize this process. We treat every
Sawyer stresses that paying attention to
patient visit, every fracture, as an opporthe entire life span is essential, citing an
tunity to teach the patient that it is never
increase in fractures across all age ranges. too early or too late to improve their bone
That’s why, she adds, “We consider
health and prevent the next fracture.” ©
childhood a key window of opportunity.”
Dr. Aenor Sawyer can be contacted at
(415) 514-1519.