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 has been marked by continued growth in the research, education, and patient care aspects of the Department of Orthopedic Surgery at the Brigham and Women’s Faulkner Hospital. Our double digit clinical growth is in large part been due to 4 new surgeons in our department. As it is difficult to separate the fiscal year, calendar year and date of publication of this report, I am not certain if any or all of our new surgeons have been introduced in this report. We were fortunate to recruit Dr. Laurence Higgins from Duke University. Dr. Higgins came to Boston as Chief of the Sports Medicine program in our department and the Brigham Chief of the Partners Shoulder Service. He has been very active in redefining the sports medicine program and has also worked closely with Dr. J.P. Warner at the MGH to enhance the clinical research and educational aspects of the shoulder service. They have an active combined fellowship, have frequent national and international visitors and lecturers, and have been academically very productive. As the Partners Shoulder Service and Partners Trauma Service are integrated between the Brigham and the MGH, they will be reported as separate sections of this publication. Dr. Higgins has also worked on a change in both the structure and curriculum of the sports medicine service. Dr. Tom Minas, head of the cartilage repair service, now divides his time between the arthroplasty group and the sports medicine group. The curriculum has also changed, but I will discuss this later in this review.

Dr. Christopher Bono was recruited as BWH Chief, Orthopedic Spine Center in 2006. He did his orthopedic residency at New Jersey Medical School and a spine fellowship with Dr. Steven Garfin in San Diego. 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. Chris has been an outstanding addition to our group both clinically and academically.




Dr. Andreas Gomoll finished the Harvard combined residency, completed a fellowship at Rush in Chicago and has rejoined our group working primarily with Dr. Minas in the cartilage repair center. Andreas brings a fresh vision to our sports medicine program and has been essential in redefining the integration of the watershed area between sports medicine and arthroplasty.


Dr. Brandon Earp took a brief sojourn for the birth of her second child but has returned to active practice in the BWH and HVMA hand program. She has also excelled in her role as a faculty supervisor for our PA program.




Dr. John Abraham joined Dr. John Ready in the musculoskeletal oncology group. This completed the sarcoma program, which includes first-rate general surgeons, oncologists, pathologists and an experienced support staff. The musculoskeletal oncology program in orthopedics has expanded greatly. It has been a challenge to our infrastructure as these cases must be done at the Brigham, are associated with a high patient acuity and they depend on OR and ICU space.

A major administrative change within the department has been the establishment of a Department of Orthopedic Surgery at the Faulkner Hospital. We now do nearly 2000 orthopedic cases there annually and it became clear that our continued growth required “feet on the ground” dealing with orthopedic issues at Faulkner. Working with the board of trustees, we developed a job description, went through a national search and chose Dr. Michael Wilson as the first chair. The program at Faulkner is integrated with the Department of Orthopedic Surgery at the Brigham and Women’s Hospital and it has been a true collaborative effort. We are about to open four new operating rooms at Faulkner and a substantial part of the growth will be in orthopedics. Our major focus will be in foot and ankle, sports medicine and hand/upper extremity.

The department administrative structure is headed by Mr. Tom Gakis, and there have been some changes in other administrative positions. Most of the departures have been due to promotion and we have been very pleased with the new staff. We continue to have a three-campus strategy at the Brigham and Women’s, 850 Boylston Street and the Faulkner Hospital. We, like many of your programs, feel the need to diversify from the main campus and connect with the community.

The resident training program is alive and well at the BWH. The expansion of the residency has required us to expand our PA and fellow program. I will discuss each of these later in this report. Finally, I am happy to report that Jenny D’Isola is still my Executive Assistant. Jenny still wears her many hats and is still the “go to” person in the department. I will try to highlight each of the facets of our mission that includes patient care research and education.

ADULT RECONSTRUCTIVE SERVICE/ JOINT REPLACEMENT

The joint replacement service has changed in response to the changing pattern of joint arthroplasty. We maintain a robust program in each of the aspects of hip and knee replacement. In the hip we have surgeons doing metalon- metal resurfacing, minimally invasive surgery, metal-onhighly- cross-linked poly and we continue to be enthusiasts of improved head-neck ratio, highly cross-linked polyethylene and maintaining a minimal polyethylene thickness. Due to the reported concerns of squeaking in ceramic and ceramic hip, we have been less enthusiastic about adopting this technology to date. While we remained committed to cruciate retention in primary knee replacements, we do both cruciate retaining and cruciate substituting knees. Our revision practice has grown as our referral pattern widens. We run a particularly robust hip revision service under the direction of Dr. Daniel Estok.

The broad range of technique in TJR has given our fellows a very balanced experience. We have been fortunate to have an outstanding group of fellows again this year. Dr. Tom Moyad came to us from the University of Michigan and will be going to San Diego to start his arthroplasty practice. Dr. Troy Schmidt trained at Emory and will be going to the Charlotte area for practice. Dr. Jeffrey Zarin is a graduate of the Harvard Residency Program and will be going to Boston University to establish a joint replacement practice. An integral part of our arthroplasty service has been our international fellowship program, and this year has been no exception. We have just had to bid adieu to three outstanding six-month fellows. Dr. Darren Patterson will be returning to his native Australia, Dr. Shi-Lu Chia has been visiting from Singapore by way of England and Dr. Christian Gauch has just returned to Germany. This has been an outstanding program that has broadened our global scope and we look forward to its continued growth.

Many of you know that Dr. Richard Scott has published a book on Knee Arthroplaty. This has been highly succesful and is a must-read for any TKR surgeon.

CARTILAGE REPAIR CENTER

Dr. Tom Minas established the Cartilage Repair Center several years ago and it has grown from a program that initially was based on the autologous chondrocyte implantation to one that covers the gamut of cartilage repair by both cell based therapy and marrow based techniques. He has developed a robust joint registry, which is a goal mine for our residents, students and fellows. In an era when osteotomy is decreasing in the United States, Dr. Tom Minas is doing over a 100 osteotomies a year. These include tibial, femoral, patellofemoral and combined osteotomies often in association with some other cartilage repair technique. While many of us tried for a long period of time to bridge the gap between sports medicine and arthroplasty, Dr. Minas has come closer to achieving this goal. With redirection of the sports program to encompass cartilage repair and with the combined effort of our sports team including Dr. Larry Higgins, Dr. Scott Martin, Dr. Tom Minas, Dr. Tamara Martin and Dr. Andreas Gomoll, the entire clinical educational and research organization has been revamped.

The website, www.cartilagerepaircenter.org, continues to be a primary site for both patients and surgeons.

FOOT AND ANKLE SERVICE

As Mike Wilson assumed his role as Chairman of the Department of Orthopedics at the Faulkner Hospital, Dr. Chris Chiodo became the Chief of the Foot and Ankle Division. The service located at Faulkner Hospital has been the focus of an outpatient effort that we have done to improve flow, efficiency and patient’s satisfaction. This is a grant given by the Hatch Foundation and run by the Institute for Health Care Improvement (IHI). The year long work has led to a marked improvement in patient’s satisfaction and significant changes that are being implemented throughout our outpatient service. The educational program for the foot and ankle service has also been changed and integrated into the residency core curriculum. Dr. Chiodo spent the past year as President of the Massachusetts Orthopedic Association and both Drs. Wilson and Chiodo have been active in the American Academy and the Massachusetts Medical Society. Dr. James Ioli heads up the podiatry division of the foot and ankle service. The clinical program is located at various campuses and is an integral part of our musculoskeletal care.

HAND AND UPPER EXTREMITY SERVICE

As the hand fellowship goes into its 26th year, the combined program between the Brigham and Women’s Hospital and Children’s Hospital has had another outstanding group of fellows. The program has been further enriched over the past several years with integration with our partners and colleagues at the Massachusetts General Hospital. The three hand fellows this year are Dr. Adam Marachi, Dr. Christina Kuo, and Dr. Eon Shin. The fellowship has again matched in a highly competitive fashion and the clinical program includes the Brigham and Women’s Hospital, the Veteran’s Administration Hospital, Faulkner Hospital, and Harvard Vanguard Medical Associates.

ORTHOPEDIC ONCOLOGY SERVICE

Dr. John Abraham is just completing his first year in practice and has certainly been a boost to the musculoskeletal oncology program. The increased integration between the Dana-Farber Cancer Institute and the Brigham and Women’s Hospital has fostered this growth. The sarcoma service has both national and international leaders in pathology, clinical oncology, and musculoskeletal imaging. The association between the general surgical and orthopedic oncological surgeons has been seamless, integrative, and both clinically and academically rewarding. It is anticipated that this service will be a major growth area in our department.

SPINE SURGERY SERVICE

Dr. Chris Bono is finishing his first year as Chief of the Orthopedic Spine Service. The two major areas of growth have been the appointment of Dr. Arthur Day as Chief of Neurosurgery at the Brigham and Women’s Hospital. Dr. Day is a nationally and internationally recognized neurosurgeon and we are working together to integrate the orthopedic and neurosurgical spine programs. We have also started a center funded by the Osher Foundation. This is the Osher Center for Complementary Therapy which is run by Dr. David Eisenberg. Dr. Eisenberg has published extensively on the use of complementary therapy in the treatment of back and spinal disorders. With the epidemiological strength of the Osher Center, it is possible to critically assess the value of a variety of complementary therapies in the treatment of back and spine disorders. The various components of the spine program have integrated into the Brigham Spine Center which has the ability to provide a seamless transition from nonoperative to operative spine treatment. Moreover, we have increased our exposure through physical medicine and rehabilitation in both the diagnostic and therapeutic aspects of the treatment of back and spine problem. This program is run by Dr. Zacharia Isaac and Dr. Jennifer Baima.

SPORTS MEDICINE PROGRAM

As mentioned earlier, the recruitment of Dr. Andreas Gomoll and the addition of the cartilage repair service to the sports medicine program has changed the face of this division. Moreover, the development of four new operating rooms at the Faulkner will provide a modern effective and efficient center for our sports medicine effort. In addition to this program, the Fish Center for Women’s Health located at our 850 campus has a sports medicine program geared towards female high school and college athletes. It is run by Dr. Tammy Martin and Jennifer Baima.

Our most recent resident evaluation of the sports medicine program, experience of the PGY-5 residents, has been outstanding and is positive reflection of the changes made by the service.

With the large database of the cartilage repair center and the shoulder service, there is a great deal of opportunity to produce excellent prospective studies determining the outcome of our sports medicine procedure.

ORTHOPEDIC RESEARCH

The orthopedic research department is one of the core facilities of the Brigham Research Institute. This group has played an active role in the development of the website and is planning a retreat for the fall of 2007. I have asked each of the investigators to provide a report of their current activities. While the list is not complete, I will highlight several of the individual reports.

As part of a BRI informational report, Professor Julie Glowacki summarized the Orthopedic Program as follows:

The Orthopedic Research Laboratories bring together orthopedic surgeons and researchers to develop tomorrow’s treatment options for patients with orthopedic problems. The approach is to translate new findings from basic and clinical investigations into a platform for skeletal health and orthopedic care. Emphasis is on chronic and acute orthopedic and joint diseases such as osteoarthritis, rheumatoid arthritis, problem fractures, sports injuries, bone cancers and metastases, spine diseases, osteoporosis, and skeletal aging.

Clinical investigations on disease risk factors and optimizing outcomes continue to provide evidence-based rationales for care improvement. New knowledge on mechanisms of disease translates into innovative approaches to prevention and treatment.

Collaborations on cutting-edge diagnostic imaging techniques focus on early detection of musculoskeletal disease and monitoring of interventions.

Research on Tissue Engineering of cartilage, bone, intervertebral discs, knee menisci, and joints holds promise for innovative treatments for a variety of bone and joint problems. Advances are being made with cell-based, cell-free, and gene therapies.

Advanced polymer compositions can provide scaffolds for implantation of genetically modified cells and tissue replacements, release drugs targeted to specific sites, and securely anchor orthopedic implants. Research with innovative biomimetic materials is designed to tap into and augment the patient’s regenerative potential.

Nanotechnology research highlights new bone cements that are stronger and more enduring for use to anchor orthopaedic implants, stabilize spinal fractures, and reconstruct skeletal defects left after trauma or tumor resections.

New optical technologies are being developed and applied for early detection of arthritis, for testing new therapeutics, and for nerve and vessel repair.

  • Investigative Groups
  • Cartilage Repair Center
  • Center for Molecular Orthopedics
  • Optical Coherence Tomography Laboratory
  • Orthopedic Nanotechnology Group
  • Skeletal Biology Research Laboratory

The major addition to our research effort has been the addition of Dr. Jeffrey Katz and Dr. Elena Losina to our department. Jeff and Elena are nationally recognized for their work on outcomes analysis and they bring their group and are collaborating with our clinical staff in multiple projects. We started a unit called PRIDE which gives department sponsored seed grants for pilot studies which will lead to larger funding opportunities in multiple areas. Moreover, Jeff and Elena have been very successful in obtaining grants in this difficult funding environment. Since the last publication of this journal, the Department of Orthopedic Surgery at BWH has launched a bold clinical research initiative, the Orthopaedic and Arthritis Center for Outcomes Research (OrACORe). The Center builds on a long-standing, productive research program in orthopaedic and musculoskeletal disorders. Elizabeth Wright, PhD, Director of Data Management in the Center rounds out the Center faculty. Each of these three investigators is a faculty member in the Department of Orthopaedic Surgery; Dr. Katz is also appointed in Medicine, in the Division of Rheumatology, Immunology and Allergy.

Among the many projects led by the Center’s investigators, Dr. Losina is Principal Investigator of a five year NIH funded study to develop an osteoarthritis policy model. The model uses computer simulation techniques to examine the costs and outcomes of a range of preventive and therapeutic interventions for osteoarthritis, the most frequent source of disability in the elderly. Dr. Katz is Principal Investigator of another five year NIH funded study to examine the risk factors for long term failure of total hip replacement in the national Medicare population.

In collaboration with Dr. Thornhill and Thomas Gakis, the Center has developed a research initiative designed to foster research conducted by Department faculty. The Program in Research Incubation and Development (PRIDE) was rolled out in the Spring of 2007 and already several PRIDE-supported projects are underway, led by Department faculty and conducted in collaboration with the OrACORe investigators and research staff.

NANOTECHNOLOGY/POLYMER SCIENCE

Dr Anuj Bellare reports: This year, our research has led to the development of three new ultra-high molecular weight polyethylene (UHMWPE) processing technologies that focus on providing oxidation and wear resistant UHMWPE while preserving mechanical properties that are known to decrease in the first generation radiation crosslinked UHMWPE. High mechanical properties, such as fracture toughness, fatigue strength and ultimate tensile strength are all especially important for application in total knee replacement prostheses. One of the technologies is based on the incorporation of Vitamin E antioxidant into UHMWPE, which provides oxidation resistance by scavenging trapped free radicals and thereby obviates the need to thermally treat irradiated UHMWPE, which is known to decrease its mechanical properties. Each of the new technologies have potential for application in both knee as well as hip components.

Ongoing research also includes a study to increase the mechanical properties of a new nanocomposite bone cement. Previous research had focused on using radiopacifier nanoparticles to increase fatigue life of bone cement. A new approach is to fabricate nanoparticles of antibiotics to increase the mechanical properties of bone cement, and also to enable larger quantities of antibiotics to elute into peri-prosthetic tissue and at a higher rate. We are currently exploring the use of biocompatible surfactants to prepare nanoparticles of gentamicin and tobramycin. In addition, we are also investigating a new solvent-antisolvent approach involving water as a solvent and supercritical carbondioxide antisolvent to precipitate microand nano-sized powders of antibiotics with controlled particle size. Optimum particle size of antibiotics will be eventually incorporated into bone cement and evaluated for delivery into peri-prosthetic tissue to treat infections.

SKELETAL BIOLOGY RESEARCH LAB (SBRL)

A report from the SBRL: Current basic work focuses on effects of aging on human marrow-derived progenitors of osteoblasts, chondroblasts, adipocytes, and osteoclasts. Intrinsic and extrinsic effects of aging are being revealed with emphasis on hormonal and other approaches to prevention or “rejuvenation”. These programs are supported by two NIH grants.

Translational projects include impact of vitamin D-deficiency on orthopedic and other disorders. This team has consistently found extreme vitamin D deficiency in 80% of patients with fragility fractures. In addition, vitamin D-deficiency is found in 40% of patients who are admitted for hip arthroplasty for osteoarthritis. Stimulation of osteoblastogenesis by active metabolites of vitamin D is impaired in marrow-derived cells from elders. Progress is being made in enhancing responsiveness in order to maximize bone formation.

Clinical projects include a multidisciplinary team approach for innovative fracture care pathways. Because of the high prevalence of vitamin D deficiency in fracture patients, management of vitamin D status is a key element that can begin upon Other clinical projects concerns the natural history of osteoporosis in patients with osteoarthritis. Having reported that 25% of a cohort of women with advanced osteoarthritis also had osteoporosis diagnosed by bone density measurement, the team identified simple radiographic parameters and clinical risk factors, namely leanness and advanced age, that should prompt a referral of specific osteoarthritic patients for osteoporosis evaluation.

A new collaboration with Dr. Higgins concerns the underlying pathophysiology of rotator cuff arthropathy.

For a collaboration with Dr. Siegel at Mc Lean Hospital, Dr. Glowacki identified the pivotal role of muscle-derived Interleukin-6 in exercise-induced hyponatremia in stricken Marathoners, including two recent fatalities.

Ongoing work on skeletal tissue engineering involves cellfree and cell-based approaches to regenerate articular cartilage, bone, menisci, and whole joints. With Drs. Mizuno and others, there are 4 platform technologies that support efforts for innovative approaches to skeletal repair and reconstruction. First, a 3-dimensional osteoinductive device changes normal human skin fibroblasts or marrow-derived “stem” cells into chondrocytes or osteoblasts and enables analysis of molecular mechanisms of post-natal chondrogenesis and osteogenesis. Second, porous 3D collagen sponges support in vitro histogenesis by many cell types, including marrow, meniscus, chondrocytes, and osteoblasts. Third, a medium perfusion system optimizes histogenesis of many tissues in 3D culture. Fourth, a novel pressure apparatus further enhances histogenesis of cartilage and bone. With these tools, it was shown that culture conditions, including specific growth factors, nutriceuticals, oxygen concentration, and mechanical pressure can be optimized for generating each tissue type and for studying fundamental mechanisms of histogenesis.

In the past year, Professor Glowacki’s local activities included chairing the Harvard Orthopedic Surgery Research Committee, being Co-chair of the BWH Musculoskeletal Research Center, and serving as a BWH Professional Standards Officer for Research Staff. She has continued her service on the NIH review panel for Musculoskeletal Tissue Engineering, advises NASA and the FDA, and chairs the Ethics Advisory Committee of the American Society for Bone and Mineral Research.

CENTER FOR MOLECULAR ORTHOPAEDICS

Dr Chris Evans reports: An additional RO1 was funded by NIAMS to support research into the use of novel biological approaches to healing the ACL. This is a collaborative project with Martha Murray, Children’s Hospital. Ryan Porter, PhD, received a F32 award from NIH. This provides him with salary and some discretionary money to support his post-doctoral research into novel, biological approaches to cartilage repair. These awards are very difficult to get. Total funding now includes 3 RO1 grants, an STTR grant, Foundation money and some industry support – direct costs in excess of $1 million and indirect costs of several hundred thousand dollars per annum.

Continued stream of research papers in journals such as JBJS, Gene Therapy, Molecular Therapy, JOR, Arthritis and Rheumatism, Arthritis Research and Therapy etc.

Continued focus on developing a Phase I clinical trial in the gene therapy of osteoarthritis and pre-clinical development of novel approaches to the repair and regeneration of bone, cartilage and other tissues of orthopaedic interest. Because these are translational projects, we value and seek serious clinical collaborators. Research into bone healing has been greatly expedited during the past year by an increasingly close relationship with members of the trauma service, particularly Mark Vrahas and Mitch Harris. This has led to much better conceptual bridging of the transition from laboratory research to possible clinical application and increased funding. These two busy clinicians are much appreciated for their willingness to set aside time for serious research discussions.

We are hoping to start a new line of research into the immunotherapy of orthopaedic tumors. A new post-doctoral fellow, James Wells, PhD, has joined the lab. to spearhead this effort. He has got off to a good start, winning a 2007 BRI Research Excellence Award from BWH.

TISSUE ENGINEERING LAB

Dr Myron Spector reports the following: We are continuing our research and development of collagen devices for musculoskeletal and neural tissue engineering. We have demonstrated that the collagen devices can serve as delivery vehicles for plasmid DNA for non-viral gene transfection. We also recently demonstrated the presence of a cartilage-lubricating protein (lubricin/superficial zone protein) in osteoarthritic cartilage, indicating that chondrocytes in OA tissue have the capability to produce cartilage surfaces that have normal lubricating qualities.

AWARDS/HONORS

Dr. Spector was inducted into the American Institute for Medical and Biological Engineering as a Fellow. Dr. Spector was named one the three editors-in-chief of a new journal Biomedical Materials: Materials for Tissue Engineering and Regenerative Medicine, published by the prestigious Institute of Physics of the United Kingdom.

SUMMARY

I have tried to give you a brief update on the various activities within the Department. We were pleased to have moved from 17th to 11th in the recent US News and World Reports ranking of Orthopedic Departments. In so much as we have no Pediatric Orthopedics which factors into the rankings, this is a good sign of our growth and diversity of program. The only certainty is that I have omitted individual contributions and perhaps even whole programs, and for this I apologize. I look forward to seeing you in the coming year. Go Red Sox!





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