We are proud to announce that our very own Dr. Nicholas Abidi is one of the 120 surgeons worldwide performing ACL/PCL preserving knee replacements.
Dr. Abidi: “Dr. Todd Albert at HSS was my partner and mentor in Philadelphia before he moved to NYC to chair at HSS. I agree with his philosophy for service line management: distributive leadership as opposed to micromanagement. Train people and let them do their jobs.”
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“Healed” Athletes Crashing and Burning! ACL/PCL Preserving Knee Set to Surge in Joint Replacement World and More! Elizabeth Hofheinz, M.P.H., M.Ed. • Tue, December 2nd, 2014
Athletes Who Frighten the Best Surgeons
When David Altchek takes a phone call from a despondent coach these days, it just may be because a “healed” player crashed and burned. Dr. Altchek is an attending orthopedic surgeon and is the Medical Director for the New York Mets. He tells OTW, “It is really eerie that high level players who have had a full year of recovery after ACL reconstruction of the knee or ulnar collateral ligament (UCL) reconstruction of the elbow are getting reinjured so often. It’s unsettling to think that we have done a solid procedure and that the patient has rehabbed well, and then everything falls apart. Postop, these patients pass all the required milestones easily; then, within several months of intense competition, they reinjure their knee or elbow.”
Dr. Altchek, clinical professor of Orthopedic Surgery at Weil Cornell Medical College, says, “We are now recruiting patients who have ‘failed’—for the knee it is high school, college, and professional athletes. For the elbow it’s college level or professional pitchers. We want to see what kind of similarities there are in these patients. We hypothesize that it’s something to do with healing, i.e., that the new ligament never really matures to ultimate strength so it can’t bear the loads involved. To what extent it is the biology we don’t know. In the ACL a clear pattern emerged immediately. If we did a hamstring graft on aggressive pivoting athletes in soccer and lacrosse (particularly females) there was less pain at the time of surgery when compared to patients with patellar tendon grafts. In the former group there was a higher incidence of this immediate re-tearing. A Scandinavian study of 45,000 ACLs confirmed that finding.”
“So we’re taking data from the past five years (failed surgeries versus those who did well) and comparing it to controls. The two study groups will include athletes from the same sport who had the same graft, same surgeon, and same physical characteristics. We will be getting a prospective MRI of the knee and elbow at three month intervals to examine variability in graft healing and maturity. It’s a scientific approach to determining if we are not waiting long enough to put these athletes back in the game. I will say, however, that I do believe we are waiting long enough because it is eerie how they just explode after a full year of recovery.”
“One hypothesis is that a subset of these patients injures an associated ligament known as the ‘anterolateral ligament’ (which is poorly defined). Repairing this ligament causes major trauma to the patient and does not result in a big difference in stability of recovery…so we never fix it. But, it may be that some patients need this repaired; their bodies may need the support of this ‘sister’ ligament.
Quieter, ACL/PCL Preserving, More Natural Knee!
A team of joint preservation superstars have dusted off a concept that was waiting in the wings…and given it wings. Adolph V. Lombardi, Jr., M.D., F.A.C.S. is president of Joint Implant Surgeons, Inc. in New Albany, Ohio. Dr. Lombardi tells OTW, “Along with my colleagues—Keith Berend, Craig Della Valle, Jeff DeClaire, Chris Peters, Professor Thomas Andriacchi, and Jorge Galante—I have developed a new design of a knee that preserves the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). With roughly 120 surgeons across the globe implanting them, the preliminary comments from patients are that the knee feels more normal than a standard knee. For the surgeon, it feels more stable during the procedure.”
“While the concept of an ACL/PCL preserving knee is not new, it didn’t gain traction because the instrumentation was archaic. The design involved putting in the femur and tibia and doing distraction in flexion and extension…it was cumbersome. The new instrumentation that we have developed is very streamlined; the most challenging part is cutting the tibia and preserving the central island of bone. We have also developed a new way of doing the procedure. The femoral and patella preparation is straightforward; on the tibial side we’ve been through a couple of iterations in making the jig, how to do the cutting, how to set the rotation of the island and how to set the depth of resection. All of these are critical…and we can finally say that this process is user friendly.”
“We have made a point to release this product slowly so as to ensure that surgeons grasp each aspect of the process…and so that we can catch any issues early on. The big difference is that this knee gives the patient added proprioception and enhanced stability. The knee does well on the Lachman’s Test and the Anterior/Posterior Drawer Test; patients report that there is less noise than a standard knee and that it has a better range of motion and good stability.”
“We are requiring that surgeons do cadaver training because we want to ensure that they are totally comfortable with the technique. We learned that we must be meticulous about the cementing technique because when you do a standard knee you can displace the tibia all the way forward and you have to pressurize the cement. When you keep the ACL you can only displace it partially forward.”
“Looking ahead to the next six months or so, with the purchase of Biomet by Zimmer I predict that we will see an explosion of this technology because they will probably try to adopt it to their Persona line as well. I see this technology as a new element in the continuum of constraint in total knee arthroplasty (TKA). You start with a patient who has one or two compartment disease and do a partial replacement…and depending on the enthusiasm for partial knee arthroplasty, this could represent 15-20% of someone’s practice. The next element we’d like to look at are knee replacements for those patients who are active and have intact ACLs, but who have more disease in the lateral compartment. In these cases you can’t do a uni so this new knee would be a good fit. The utilization of the knee will depend on the surgeon’s ‘appetite’ for doing partial knee replacement.”
Todd Albert Shaking Things Up at HSS
Five months in we decided to see how Todd Albert, M.D. is managing the 107 surgeons at Hospital for Special Surgery (HSS). Brought on board in June 2014 as Surgeon-in-Chief and Medical Director, Dr. Albert is doing some restructuring and empowering those around him. He tells OTW, “This hospital is flat out amazing, with incredible staff who provide a phenomenal patient experience. That being said, there are always ways to improve any situation. My major initiative has been to strengthen the service chiefs (arthroplasty, spine, sports, etc.) using what I call ‘distributive leadership.’ I told them, ‘You are the CEOs of your corporation. Take charge.’ We have 107 surgeons and a total of 4,000 employees; you either leave people to their own devices or you have accountability structures that are like branches of a tree. If the service chiefs all do their jobs and are empowered then we can all start pulling in the same direction.”
“The two most challenging services to restructure have been spine and sports medicine. Spine was an issue because there were essentially two services—spine and scoliosis—but they were not really working collaboratively. I made it into one service under the leadership of Frank Camissa, with leaders of research, education and fellowship. It’s been important to let the deformity surgeons know that they are included and that we honor the history and accomplishments of their service. There is an increasing need for deformity work and HSS is well known for its exceptional care of these patients.”
“The sports medicine service has been challenging because it is one of the most famous services here with a large number of surgeons…26. It contains a significant nonoperative component, which, along with the surgeons, is kept busy taking care of nearly every professional sports team in the New York [area]. We had two co-chiefs on this service for many years, but it was complicated. I named Bryan Kelly as the sole chief of this service. Thus far he is doing a great job with the distributive leadership, and has created subdivisions within sports for shoulder, knee, elbow, and general sports medicine, etc…and each subdivision has its own divisional leadership.”
“We will be hiring a new Chief Scientific Officer in the next six months and he or she will be an internationally acclaimed basic scientist who possesses the sensitivity to conduct and oversee translational and clinical research. We perform 30,000 surgeries annually, meaning that we touch so many patients and thus are well positioned to define best practices in orthopedic surgery. My aspiration is that HSS will be THE center for national trials. We already have the bandwidth, but to reach this goal we need a platform at the service level. To this end, I will push for accountability in clinical research and the development of functional registries for each service. We want to provide the tools and give authority to the surgeons to collect baseline data that can be used to run the registries and therefore run large trials. This may require an additional Clinical Research Chief who may be identified and brought on board in concert with or shortly after the new CSO.”