BRIGHAM AND WOMEN´S HOSPITAL
Thomas S. Thornhill, MD
JOHN B. AND BUCKMINSTER BROWN PROFESSOR OF ORTHOPAEDIC SURGERY, HARVARD MEDICAL SCHOOL
CHAIRMAN, DEPARTMENT OF ORTHOPAEDICS, BRIGHAM AND WOMEN´S HOSPITAL, BOSTON MASSACHUSETTS

Introduction

This past academic year at the Brigham and Women’s/ Faulkner Hospitals (BW/F) has been marked with continued growth and expansion clinically as well as in research and education. There has been a change in our department administrative structure and we are pleased that Tom Gakis, Administrative Director, and Peter Cerbone, Director of Finance, have joined our department. Tom is the administrative leader of the department; he brings to the department over 10 years of experience at the Brigham and a strong skill set from his most recent work with the BW/F Center for Clinical Excellence. Peter now directs the financial operations, planning, and analysis for the department. Peter brings 20 years of experience in finance management within healthcare to the department, most recently with Quest Diagnostics. Karen Young has been promoted within the management team. Karen has been with the department for over 8 years, most recently as practice administrator for several of our largest ambulatory centers. In her new role, Karen directs all clinical ambulatory operations and administrative staffs throughout our distributed campus.

Under the leadership of Dr. Gary Gottlieb, president and CEO of BW/F, musculoskeletal disease has been named one of the five major core businesses in the strategic plan of our institution. This will allow us to further build upon the unique relationship between orthopedics and rheumatology, which was started at the Robert Breck Brigham Hospital. The Departments of Orthopedic Surgery and Rheumatology continue to share administrative leadership through the Orthopedic and Arthritis Center. Moreover, part of the BW/F strategic plan is to create a BWH Research Institute to coordinate research efforts across our expanding campus. This initiative has been lead by Dr. Michael Brenner, Chairman, Division of Rheumatology and it will allow us to integrate a robust research initiative in each department as we all compete for precious wet and dry lab space on the BW/F campus as well as to buffer a decreasing federal grant support.

BRIGHAM AND WOMEN’S ORTHOPEDIC AND ARTHRITIS CENTER

The Brigham and Women’s Orthopedic and Arthritis Center, one of the largest centers of its kind in the world, provides comprehensive orthopedic and rheumatologic care for patients with orthopedic conditions, joint diseases and bone disorders such as osteoporosis.

Over the next year, the Orthopedic and Arthritis Center will undertake a collaborative effort with the Institute for Healthcare Improvement (IHI) and the BWF Center for Clinical Excellence. The effort is grant funded by the Rx Foundation. The aim of this project is to optimize the Center’s operational systems and processes and to further develop staff to enhance the operational capabilities of the Center and patient experience.

DEPARTMENT OF ORTHOPEDIC SURGERY PROGRAMS AND SERVICES



Adult Reconst ruction Service/Joint Replacement
The Joint replacement Service at the BW/F remains a sentinel part of our Orthopedic Program. It is based on the rich tradition of the Robert Breck Brigham Hospital and, while the implants have changed, the quality and commitment to excellence in arthroplasty is strong. It is interesting that when I first started at the Robert Breck Brigham Hospital, 80% of our joint arthroplasty patients were rheumatoids and 20% osteoarthritic. Our profile now is strongly weighted to non-rheumatoid conditions and reflects roughly the national demographics. Part of that change is the fact that rheumatoid care is not as centralized as it was many years ago. Moreover, the success of the disease modifying agents (DMARDS) is beginning to foster a demonstrable decrease in the incidence of arthroplasty in rheumatoid patients. Those of you who remember the Robert Breck Brigham will remember the severe rheumatoid who might require 8-10 total joints. Fortunately, we do not see those patients anymore yet our combined musculoskeletal research in inflammatory arthritis remains a focus at this institution.

The Joint Arthroplasty Fellowship run by Dr. Richard Scott and Dr. Tom Minas, has had another strong year. Todd Borus will be going to Portland OR, Drew Noble will relocate to Concord, NC and Shahan Yacoubian will join his brother in Los Angeles, CA. We continue to have an outstanding International Fellowship. Drs. Quang Dao and Darren Chen have been our International Fellows for the past 6 months. They are both from Australia and have done an excellent job. Quang will remain at Children’s Hospital for the next 6 months working with Dr. Min Kocher.

Dr. Dan Estok has been the backbone of the hip revision service. Dr. Tom Minas does about 100 osteotomies a year in addition to his work in cartilage repair. Dr. Wolfgang Fitz has led our computer assisted surgery program and several members of the arthroplasty service have been involved in the minimally invasive hip, knee and shoulder arthroplasty program.

Dr. Richard Scott, Chief of the Implant Service, has recently published a book reviewing is many years of experience with Total Knee Arthroplasty. It has been a great teaching aide for the residents, fellows and attendings.

Cartilage Repair Center
The cartilage repair center continues to care for disabled patients with large chondral defects. Since the first patient undergoing Autologous Chondrocyte Implantation (ACI) in March 1995 at the Brigham and Women’s Hospital June 2006 marks the 400th patient transplant. Patients from all over North America, Europe and as far away as Tibet, have come to the Brigham and Women’s Hospital for their definitive care.

Our web site, www.cartilagerepaircenter.org , is now the number one hit web site in the world for cartilage repair with 40 to 45,000 hits per month. This educational web site has enabled patients to understand more about the available treatment options for those young individuals seeking alternatives to prosthetic arthroplasty.

Their research is focused on noninvasive assessment of cartilage repair procedures to assess the quality of tissue with proteoglycan content indirectly by Degemeric MRI anaylsis. This is being performed clinically and is being validated by a basic science animal research model. Dr. Carl Winalski of the Department of radiology, is heading up this effort. We look forward and welcome Dr. Andreas Gomoll to join our team this August 2006. He is presently completing a sports fellowship at Rush Medical Center in Chicago. He will be complementing our group with his expertise in cartilage repair and sports medicine surgery.

Foot and Ankle Service
The Foot and Ankle Service provides foot and ankle care to patients age 15 and older. Surgeons with a specialty in foot and ankle surgery, along with podiatrists, physical therapists, and radiologists provide comprehensive care for a wide variety of foot and ankle disorders and treatment for all acute and chronic problems including fractures, foot deformities, tendon disorders and sports injuries. We are pleased to announce that Dr. Chris Chiodo has been elected President of the Massachusetts Orthopedic Association, the State’s Orthopedic specialty society. Founded in 1981, the Massachusetts Orthopedic Association has over 400 members. In addition to ongoing physician and patient educational initiatives, it also monitors and promotes both state and national legislation affecting orthopedists and orthopedic patients. As President, Dr. Chiodo will also work closely with the American Academy of Orthopedic Surgeons and the Massachusetts Medical Society, and as well participate in the National Orthopedic Leadership Conference in Washington, D.C.

Hand and Upper Extremity Service

The service continues to be very active. We have expanded with the addition of Dr. Brandon Earp, who just had a new child, and is taking a very active role in patient care at BWH, VAH and now HVMA. She has also participated in the residency selection process.

Dr. Phil Blazar continues to run the conferences for our service has been increasingly active in ASSH and AAOS.

Dr. Mark Koris continues to have an extremely busy practice and continues to handle many of the complex shoulder and elbow problems, including primary and revision shoulder and elbow replacements.

We, once again, had a very successful match and look forward to continuing the educational accomplishments and goals of a very successful, highly competitive fellowship.

Dr. Barry Simmons continues to be active clinically and administratively. He had the honor of being the 17th annual Richard J. Smith lecturer at the MGH.

Perhaps, most exciting, was the 25th anniversary of our fellowship. We have educated over 50 fellows and approximately 80% returned for the event. Organized by the hand surgery staff both at BWH and CHMC, lead by Peter Waters, Co-Director of the fellowship, a superb scientific day was held with many interesting and innovative presentations. On the evening of the arrival there was a welcoming dinner at Peter Waters’ home. However, the highlight of the event might have been dinner prepared by Laura Simmons at the Simmons house. Over 75 people indulged in her culinary delights, especially the desserts; it was a fantastic evening.

Orthopedic Oncology Service
The Orthopedic Oncology Service, part of Dana-Farber/Brigham and Women’s Cancer Center, specializes in the treatment of patients with bone and soft tissue cancers as well as patients with musculoskeletal complications related to the disease. Patients are diagnosed and treated by a multidisciplinary team that cares for them through each phase of their treatment. We are excited that Dr. John Abraham will be joining the Orthopedic Oncology Service upon completion of his Musculoskeletal Oncology Fellowship here in Boston. John was an outstanding resident and the recipient of the William H. Thomas Award which is given annually to the Senior Resident who best exemplifies excellence in orthopedics, devotion to patient care, collegiality and teamwork. Both Dr. Ready and Abraham will be working with the expanded Dana Farber/BWF Sarcoma Service.

Spine Surgery Service
Dr. Christopher Bono has been recruited and will join our faculty as Chief of the Spine Service at Brigham & Women’s Hospital. Dr. Bono is currently at Boston University School of Medicine. He did his orthopedic residency at New Jersey Medical School and a spine fellowship with Dr. Steven Garvin in San Diego. In the 4 years since completing his fellowship, he has been extremely productive and has contributed 49 articles to the peer review literature as well as over 50 reviews, book chapters, etc. He will be joining Drs. Greg Brick and Mitch Harris who continue to be active on the Spine service. We have received a large foundation grant that will greatly boost our Spine Center integrating with Physiatry, Rheumatology, Neurosciences and Rehabilitation. Dr. Zac Isaac continues to run a very busy spinal physiatry program.

The Spine Center offers comprehensive services to evaluate and manage treatment for patients with back, neck and spine problems. Working collaboratively with physical therapists, pain specialists, surgeons, radiologists and other providers at Brigham and Women’s Hospital, the physicians of The Spine Center evaluate a wide range of problems. Patients who are coping with sprains and strains of the lower back, work-associated low back pain, sciatica, scoliosis, whiplash and other conditions can make an appointment at The Spine Center for evaluation and any necessary treatment. Orthopedic and neurosurgery services are readily available for innovative surgical solutions to difficult spine problems.

Sports Medicine Program
In December 2005 we were fortunate enough to recruit Dr. Laurence Higgins, MD, as Chief of BWH Sports Medicine & Shoulder Service in the Department of Orthopedic Surgery and co-chief of the Harvard Shoulder Service with Dr. JP Warner. Dr. Higgins joins BWH from Duke University where he was an Assistant Professor of Surgery of Orthopedics and the Orthopedic Team Physician for Duke University and North Carolina Central University. He completed his residency at the Hospital for Special Surgery in New York City and was a fellow in Sports Medicine and Shoulder Surgery at the Center for Sports Medicine, University of Pittsburgh Medical Center. His clinical interests include rotator cuff injuries, shoulder instability, shoulder replacement and knee instability, especially ACL, PCL and complex ligamentous injuries. Also, he is trained in cartilage and meniscal repair. In addition to surgical accomplishments and interests, Dr. Higgins is active in both clinical research and the education of residents and fellows. He has published nearly 50 peer-reviewed papers, and is very active in the national orthopedic community where he is a member of the American Shoulder and Elbows Surgeons, The American Orthopedic Association, The Eastern Orthopedic Association, and the International Cartilage Repair Society.

The Sports Medicine Program is located primarily at our 850 Boylston Street campus. Moreover, the Sports Medicine Program will be a major player in the development of the Women’s Musculoskeletal Unit and will include Dr. Scott Martin and Dr. Tamara Martin. Dr. Tamara Martin has also done an outstanding job in taking over as Chief of Orthopedics at the West Roxbury VA program. We are in the midst of making substantial changes with new recruitment at the Boston VA Center and currently have residents from both the Harvard and BU orthopedic programs.

Partners Harvard Shoulder Service
The Partners Harvard Shoulder Service, under the direction of Dr. J.P. Warner at MGH and Dr. Laurence Higgins at the BW/F, has had another outstanding clinical, academic and surgical year. The International Fellowship program is extremely popular and this service annually surpasses its goals both clinically and academically.

There are several new research initiatives that are underway. A prospective database has been created to collect preoperative, intra-operative and pos-operative data on surgical cases generated through both physician and patient entry. Additionally, hospital records, including but not limited to radiology images and reports as well as anesthesia data will be seamlessly incorporated into the database. This will facilitate rigorous analysis of surgical outcomes and provide a mechanism to enter this data into the registry.

The second initiative is to collect 3-D fluoroscopic analysis on patients who have undergone total shoulder arthroplasty. With this technique, contact and force analysis can be ascertained for a variety of shoulder prosthesis, in an effort to optimize surgical reconstruction of the shoulder.

Finally, radiostereometric analysis (RSA) of total shoulder replacements will commence. By placing small radioopaque beads into the glenoid component, wear patterns of total shoulder arthroplasty can be made within a fraction of a millimeter. This will provide invaluable data on how componets function in vivo and provide opportunities to prolong the lifespan of shoulder arthroplasty.

CENTER FOR ARTHRITIS AND JOINT DISEASES PROGRAMS AND SERVICES Arthritis Center
BWH’s Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy this spring launched a new Center for Outcomes Research in Musculoskeletal Disorders (CORe). The new center builds on a long-standing, productive research program in MSK disorders led by Jeffrey N. Katz, MD, MSc, who was named director of the Center.

The new center will encompass clinical research across the spectrum of orthopedic and musculoskeletal problems using a wide range of disciplines including clinical trials, epidemiology, policy analysis, translational research, cost effectiveness analysis, computer simulation modeling and others.

Through the center, BWH will lend its voice to national discussion and debate on policy relative to the recognition and clinical management of musculoskeletal disorders. Specifically, CORe research will pay attention to osteoarthritis, spinal and regional MSK disorders, total joint replacement and other surgical interventions, rehabilitation and technology assessment.

In addition, the center will focus research to understand better the nature of racial, ethnic, gender and socioeconomic disparities in the outcomes of musculoskeletal conditions.

“Through our research at CORe, we aim to improve osteoarthritis management and prevention and identify appropriate utilization of surgeries, such as joint replacements,” Jeff said. “And we expect to improve quality and safety while optimizing access for vulnerable populations.”

In addition to Jeff Katz, Elena Losina, PhD, will join MSK-CORE this summer as Co-director and Director of Methodology. Losina is an associate professor of biostatistics and medicine at Boston University’s School of Public Health. Also, Elizabeth Wright, PhD, was named director of Data Management. Several more BWH faculty in Orthopedic Surgery, Rheumatology, Pharmacoepidemiology, Musculoskeletal Radiology, Rehabilitation and Physical Therapy and Orthopedics Research will collaborate with CORe investigators.

Orthopedics Research
The Department of Orthopedics at BW/F has an active research program in several areas. Moreover we are increasingly collaboration with our rheumatology colleagues, who have a robust musculoskeletal program ranging from clinical trials in inflammatory arthritis to basic mechanisms of inflammation and control of immune mechanism. While the list is not complete, it will give you a sense of our areas of interest. They are listed by investigator and much of this is in their own words.

Dr. Myron Spector, Director – My efforts continue in the research and development of collagen devices for tissue engineering of musculoskeletal and nerve tissues. I am currently implanting chondrocyte-seeded type II collagen scaffolds in cartilage defects in a goat model. Previously, we have shown the advantage of an off-the-shelf collagen tube as a substitute for nerve autograft in treating peripheral nerve injuries. A clinical trial is being planned with colleagues at the San Raffaele Hospital in Milan, Italy. I have received a grant from the Veterans Admnistration as a PI 6/2006-5/2009; $480,000 total direct costs “Brain Tissue Engineering: A Collagen-GAG Implant for Tissue Loss” Investigates collagen scaffolds with stem cells and genes for treating defects in the brain.

Sonya Shortkroff, PhD has accepted a position at Histogenics, a biotech firm developing techniques for tissue engineering of cartilage. Dr. Shortkroff has been in the department of Orthopedic Surgery at BWH since 1980 and as Dr. Sledge’s Research Associate ran the Radiation Synovectomy project.

She received her PhD in 2000 and was promoted to Instructor in 2001. Her research interests have included cartilage- synovial tissue interactions, the effects of radiation on synovitis, and the effects of biomaterials on synovial tissue and cartilage.

Her recent investigations as member of the Nanotechnology Group have included the biocompatibility of nano-structured biomaterials and particulates and development of nano-structured scaffolds for cartilage tissue engineering. In the past two years, she has been collaborating with Karen Yates, PhD on Dr. Yates’ studies investigating the impact of glycosaminoglycans on Wnt signal transduction in aging and in patients with osteoarthritis. In addition, she has worked with Dr. Mark Brezinski to evaluate the potential of optical coherence tomography as a micro-imaging technique to assess injury and regeneration of various joint tissues. She has also continued her long-standing collaboration with Dept of Radiology as a co-investigator on a project that evaluated novel MRI contrast agents for detection of early changes in osteoarthritic cartilage.

Over the years she has served on the thesis committee of three PhD candidates at MIT and has supervised several graduate students from Harvard Dental School. She also has served on the BWH Research Career Development Committee since its inception and has been the Safety Officer for the BWH Orthopedic Research Lab.

Chris Evans, Ph.D. - Center for Molecular Orthopaedics: The funding position has improved considerably with the awarding of an additional RO1; moreover we have just received word that our latest RO1 application has received a very competitive priority score. Including everything, the Center for Molecular Orthopaedics now brings in well over $1 million per year, direct costs, in external funding. Most of this pays the full BWH indirect.

As a result of increased funding we have been able to accommodate several new recruits. Ryan Porter, PhD and Fangjun Liu, MD, Post-doctoral Fellows, and Francois Kwang, MD, a Post-Graduate Student, are working with me. Vida Bil de Arce a Post-Graduate Student, Jinsoo Joo a Technician, and Chris Southgate, PhD, a Research Fellow, are working with Keith Crawford. This brings the total personnel to thirteen. Oliver Betz, PhD was recently promoted to the faculty rank of Instructor and has just submitted his first R21 application.

As a sign of our increasing productivity, the publication rate continues to climb and during the past twelve months we have placed articles in The Proceedings of the National Academy of Science, The Journal of Bone and Joint Surgery, Molecular Therapy, Arthritis Research and Therapy and Gene Therapy, among others.

The focus of the research continues to be gene therapy, proteomics, genomics and related technologies applied to the study and treatment of arthritis, bone healing, cartilage repair, ligament healing and others. With an emphasis on translational research, we are anxious to collaborate with interested clinical faculty in advancing this agenda and are pleased to note the involvement of Drs. Thomas Thornhill, Jeff Katz and Philipp Lang in studies of osteoarthritis, Drs. Mark Vrahas and Mitch Harris in studies of bone healing, Dr. Martha Murray (Children’s Hospital) in studies of ligament healing and Dr. Mark Gebhardt (Beth-Israel Deaconess) in studies of Ewing’s Sarcoma. These types of collaborations between individuals from different disciplines and institutions are essential.

Julie Glowacki, Ph.D. – Skeletal Biology: This team is interested in mechanisms of skeletal aging, vitamin D and skeletal health, comparison of BMP and Demineralized Bone’s effects on target cells, and engineering of cartilage, bone, and joints. Julie Glowacki was invited to speak at the 2006 meeting of the American Academy of Orthopedic Surgeons on “Vitamin D-Deficiency and Bone Health” in its symposium on “Bone Health for the General Orthopedic

Surgeon: Essentials for Your Practice”. Research by this team is supported by competitive grants and in the last year resulted in numerous peer-reviewed publications in two major areas, one concerning aspects of cartilage and bone tissue engineering in defined media and oxygen concentrations, and the second area concerning vitamin D and skeletal health. Julie Glowacki started a 4-year term as reviewer on the NIH study section on Musculoskeletal Tissue Engineering. She has been busy locally as Co-Chair of the BWH Biomedical Research Institute’s Musculoskeletal Research Center, as member of the research working group for the BWH Center for Women’s Health, and as representative of Orthopedic Surgery on the

Biomedical Research Institute’s Research Oversight Committee. Julie was presented with the Hohl Award by the American Society for Bone and Mineral Research for her efforts as co-founder of, and first 4-year Chair of the Society’s Ethics Advisory Committee.

Shuichi Mizuno, Ph.D., devotes his time to cellular mechanophysiology and tissue engineering for joint tissue. He published a solo paper on intracellular calcium increased due to pure hydrostatic pressure and others including chondrogenesis promoted with low oxygen pressure. Using biophysical stimuli such as pressure and stress, his unique bioreactor born in our department, is now used in clinical study for producing neocartilage. It is funny looking apparatus (may require a hard hat to look at) but allows the patients’ chondrocytes for 4 hours’ marathon and 20 hours’ couch potato a day for infinite number of days. Eventually it became a useful platform technology for not only orthopedic research but also cellular mechanophysiology (his favorite terminology). Bringing those new idea and machines, Shuichi has teamed up with our colleagues, Dr. Mitch Harris on intervertebral disc regeneration and with Dr.

Larry Higgins on meniscal repair as well as interacted on skeletal system biology with Dr. Glowacki. He was also is taking a responsibility to run BWH’s laser confocal microscopy core at LMRC building. Dr. Mizuno was recently promoted to Assistant Professor, Harvard Medical School.

The Clinical Fellowship Programs at BWH continue to be very strong. This August we welcome the following Clinical Fellows to BWH:

Arthroplasty Service:
Jeffrey Zarin M.D. – Harvard Orthopedic Combined Residency Program
Thomas Moyad, M.D. – University of Michigan
Troy Schmidt, M.D. – Emory University.

Foot & Ankle Service:
Rommel Francisco, D.O., - New York College of Osteopathic Medicine.

Hand/Upper Extremity Service:
Eon Shin, M.D. – Yale University School of Medicine
Christine Kuo, M.D. – University of Chicago Pritzker School of Medicine
Adam Mirachi M.D. - Temple University School of Medicine

Partners Shoulder Service:
Nathan Endreas, M.D. - University of Vermont

Sports Service:
Christopher Vinton, M.D. – U Mass Medical Center

Trauma Service:
Kevin Riche, M.D. – Louisiana State University


And finally …alumni news: I had a long chat with Clem Sledge about a month ago. Clem sounds great and is spending much of his time on the coast of Maine. Bob Poss continues to do an excellent job at the JBJS. Reports are that Fred Ewald is back and forth between Colorado and Massachusetts and is apparently fitter than ever. Bill Thomas finally sold the house in Brookline that he bought as a resident, which we were using as a boarding house for many of our visiting scientist and clinical fellows. Bill and Dickie have bought a place nearby and still maintain properties in Naples Florida and Martha’s Vineyard. The Bill Thomas Award that we set up in 1996 continues to be one of the sentinel awards at the Resident’s Graduation. It is given in Bill’s name to the Senior Resident who best exemplifies excellence in orthopedics, devotion to patient care, collegiality and teamwork.

I am grateful of the support that we received from many of the alumni at the reception in Chicago. We look forward to seeing in next year in San Diego.





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