Fellowship-trained physicians in West Virginia University’s Department of Orthopaedics provide an easily accessible one-stop shop for the entire spectrum of pediatric and adult orthopaedic care.
WVU Healthcare’s Department of Orthopaedics utilizes a collaborative approach that elevates the standard of care. The department’s service lines include subspecialties such as adult reconstruction and revision, foot, hand, metabolic bone disease, musculoskeletal oncology, pediatric orthopaedics, research, spine, sports medicine, and trauma.
“Having such a degree of depth allows us to consult within our own department for patients whose conditions lie outside an individual’s skill set,” says Adam Klein, MD, Chief of Adult Reconstruction and Assistant Professor of Orthopaedics at WVU School of Medicine. “Whenever we have questions about a patient, there is an expert in the department we can bring in for consultation.”
Through direct communication within the department, formalized trauma conferences and 24/7 access to electronic health records, physicians can easily collaborate to determine optimal courses of treatment that minimize risks inherent in complex cases.
For example, physicians recently admitted an elderly patient to repair a comminuted acetabular fracture complicated by severe osteoporosis. Surgeons also identified damage to the femoral head, and when establishing the treatment plan, trauma surgeons noted that, in the near future, the injury would likely result in arthritis and severe pain. The team decided on a multiple-step procedure. First, trauma surgeons repaired the damaged acetabulum, and then adult joint reconstruction specialists performed a total hip replacement.
Innovations in Musculoskeletal Oncology
Brock Lindsey, MD
Another case exemplifies the leading-edge capabilities specialists in WVU Healthcare’s Department of Orthopaedics can provide. Only approximately 800 cases of osteosarcoma are diagnosed annually, and half of these occur in children and teenagers, according to the American Cancer Society. This cancer affects people of any age, but it typically strikes teenagers who are rapidly growing.
In an unusual presentation of the rare cancer, a 6-year-old patient presented with osteosarcoma involving the entire femur. Such cases traditionally allow two choices: amputation of the leg at the hip or multiple operations to treat the cancer and replace the femur, according to Brock Lindsey, MD, Director of the Musculoskeletal Research Lab and Assistant Professor of Musculoskeletal Oncology and Adult Reconstruction at WVU School of Medicine.
“We performed one surgery to implant a growing total femur that could potentially last a lifetime,” says Dr. Lindsey, who is also Assistant Professor of Surgical Oncology at WVU School of Medicine. “There’s a drill and screw component that telescopes within the metal total femur. A unique magnet causes the device to extend, allowing for growth. Because it’s essential for soft tissues to adapt, we meticulously extend the femur 4 millimeters at a time so as not to over-lengthen the leg.”
Dr. Lindsey adds that the procedure was “similar to doing a hip and knee replacement, but then also replacing everything in between.” Cobalt chrome or titanium femur replacements result in a functional leg that preserves the ability to walk, as well as the capability to bend and straighten the knee.
A partnership with the Mary Babb Randolph Cancer Center makes possible conjunctive radiation oncologic, chemotherapeutic, and hematologic/oncologic treatments for adults and children. The collaborative effort also enables enrollment in clinical trials for patients likely to benefit from advanced chemotherapy agents.
A Muscle-Conserving Approach
Benjamin Frye, MD
Traditional approaches to total hip replacement require incisions on the side of the thigh and varying degrees of tissue and muscle dissection or manipulation. In addition to increased postoperative pain and heightened reliance on pain medications, routine activities, such as sitting down and lying in bed, can translate to great discomfort due to putting pressure on the surgical site.
Benjamin Frye, MD, Assistant Professor of Orthopaedics at WVU School of Medicine, uses the direct anterior approach for total hip replacements to provide patients a long-lasting, more stable replacement. The approach also expedites recovery and eliminates postoperative restrictions patients must endure following other methods for replacement.
“The direct anterior approach is my preferred way of hip replacement — I perform 90–95 percent of the procedures using this technique,” Dr. Frye says. “I don’t have to cut or separate any muscle from the pelvis or femur, which reduces pain and improves recovery times. Since I don’t disturb the structures in the back of the hip essential for stability, there is a low postoperative dislocation rate as well.”
Some surgeons who use the direct anterior approach employ a specialized operating table that secures patients’ feet in boots. Essentially, the expensive table takes the place of a surgical assistant, who would maneuver the femur into position so the surgeon could broach the bone and place the femoral stem.
Dr. Frye prefers traditional operating tables that offer more surgical control.
“I like the normal operating table, where I can prep and drape both legs into the surgical field,” he says. “As I’m performing the surgery and making trial reductions, I can go to the end of the bed, grab the patient’s feet and place them beside each other to accurately tell what the leg lengths will be — equal lengths are the major concern for the procedure. By not having the patient’s feet attached to the boots, I can ensure a stable hip that doesn’t dislocate by moving the leg. I can also check all ranges of motion, as opposed to dealing with the table’s limits to movement and stability checks.”
Because the average age of total hip and knee replacement patients continues trending downward, the demand for faster return to activities-as-usual is rising. The Department of Orthopaedics has instituted pain management protocols providing preemptive analgesia.
“To give patients the best chance for recovery, we begin pain management preoperatively,” says Matthew J. Dietz, MD, Assistant Professor of Orthopaedics at WVU School of Medicine. “We use spinal anesthetics in addition to pain medication delivered in and around the spine, as well as multimodal injections — which include Epinephrine, Marcaine, Toradol and Clonidine — in and around surgical sites to decrease inflammation and neurogenic inflammatory markers and control pain directly at the source. This enables us to construct pain control regimens not solely based on narcotic medications.”
Having analgesics already acting when patients wake up allows earlier participation in physical therapy and reduced hospitalization. Therapists encourage patients to get out of bed the same day as their surgery, and Dr. Dietz notes that patients typically leave the hospital one to two days after total hip or knee replacement.
An Education Focus
One of the most important components of orthopaedic treatment involves teaching patients about their conditions and postoperative rehabilitation requirements. Empowering patients with information not only helps the recovery process, but it also increases the efficiency with which WVU Healthcare’s Department of Orthopaedics operates.
“As overall healthcare expenditures become increasingly scrutinized, emphasizing efficiency and safety are major considerations,” Dr. Dietz explains. “We’ve constructed a cohesive program in which every provider and staff member plays an important role in informing and educating our patients so they know what to expect following treatment and are more confident when discharged.”
Training Tomorrow’s Surgeons
Adam Klein, MD
Faculty surgeons spearhead the educational charge. The program’s commitment to developing the most prepared orthopaedic surgeons for the future depends upon accessibility and everyday involvement in patient care and resident education.
“Having a residency program means there are multiple layers of physicians visiting patients throughout the day,” Dr. Klein explains. “This keeps everybody informed and helps us identify problems before they happen. We stress the teaching aspect and don’t allow residents to perform unsupervised surgery. Hands-on experience is a critical part of grooming the next generation of orthopaedic surgeons.”
Dr. Lindsey adds that the residency training program pushes established surgeons to remain on the crest of innovation.
“We ask our residents to be on the leading edge, and for us to properly educate them, we have to be there, too,” he says. “They push us as much as we push them.”
Physical therapist Shannan Lawrence (L) and occupational therapist Lisa Ruben (R) assist patient Karen Wainright after her joint replacement surgery.
The advanced procedures and innovative technologies represent WVU Healthcare Department of Orthopaedics physicians’ commitment to the community. Fellowship-trained physicians are on-call 24/7, 365 days a year.
“We treat large volumes of patients, but we’re happy to evaluate and/or treat patients anytime a physician wants a second opinion,” Dr. Klein says. “We’re a resource to be used by physicians whose patients present challenges that can’t be managed or treated at smaller hospitals. We’re motivated to provide the highest standards of care in the nation, and we devote that kind of attention to every patient.”