New Technology EnhancesOrthopaedic Trauma Center

T here have been tremendous advances in the field oforthopaedic trauma in the last few decades.Thanks to improvements in implant technology

and a vastly increased understanding of the biology ofinjuries, modern orthopaedic traumatologists are savinglives, saving limbs, and preserving function. Theorthopaedic team at NewYork-Presbyterian Hospital/Columbia University Medical Center has taken a leader-ship role in many of these initiatives.

Take the case of a 40-year-old federal agent who sus-tained ipsilateral fractures of the neck and shaft of thefemur during an automobile accident in upstate NewYork. The patient was transferred to NewYork-Presbyterian/Columbia for immediate surgery. Thefemoral neck was reduced, a capsulotomy was performed,and the fracture was stabilized with 3 screws. The shaftfracture was then treated with a retrograde intramed-ullary nail. A year after injury, he has returned to work and to the gym.

“Even in the recent past, we did not have good strategies for this combination offractures,” said Justin Greisberg, MD. “It was not unusual to see a bad result. Thenewer technique of retrograde nailing of the femur fracture, combined with screw fix-ation of the femoral neck, is often very successful. Thirty years ago, this was a life-changing injury. Now, we can get people back to normal. That is what modernorthopaedic trauma care is all about.”

Case Study: NewProsthesis SavesInjured Shoulder

Fall 2007

A 45-year-old female presented inearly 2005 with a significantcomplicated shoulder injury.

Until sustaining the injury to her rightshoulder in a motorcycle accident, she wasa very healthy woman. The injury resulted

in a displaced and comminuted fractureof her proximal humerus and dam-

age to her axillary nerve. Shewas initially treated nonopera-

tively but complicationsarose as the fracture failedto heal. The patient under-went an intramedullarynailing procedure that alsofailed to achieve union. She

then underwent a secondsurgery that included removal

of the nail, placement of a freshfrozen fibula allograft, and a plat-

ing procedure. During the postopera-tive period, the patient was maintained ina body cast, which also failed to achievehealing of the proximal humerus.

When the patient arrived at the Centerfor Shoulder, Elbow and Sports Medicineat NewYork-Presbyterian Hospital/Columbia University Medical Center, shehad significant complaints of pain andwas unable to perform routine functions.Her examination was notable for axillary-nerve injury affecting the anterior head ofher deltoid, inability to raise her armabove her waist, and obvious motion atthe site of fracture of the proximalhumerus. In fact, the plate attached toher humerus was appreciated underneath

see Prosthesis, page 6

X-ray of the knee of an accidentvictim. Orthopaedic traumatologists at NewYork-Presbyterian/Columbiareduced the femoral neck, performed acapsulotomy, and stabilized the fracturewith 3 screws.

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Top left photo courtesy of Christopher Ahmad, MD.

ACL Reconstruction

2 The orthopaedic team repairs arecurrent anterior cruciate ligament

retear in a college basketball player.

Knee Replacement

4 Procedures for total knee arthroplasty now include implants

specially designed for women.

Scoliosis Surgery

5 Columbia orthopaedic surgeons usenew technology and patient selection

criteria to improve outcomes in the treatment of scoliosis in children.

INS

IDE

Total Hip ResurfacingWebcastFor more information, please visitwww.nyp.org/columbiaortho

Questions, comments, suggestions?Contact the EditorMelvin P. Rosenwasser, MDmpr2@columbia.edu

see Trauma, page 7

COLUMBIA ORTHOPAEDICSN E W Y O R K – P R E S B Y T E R I A N

Affiliated with COLUMBIA UNIVERSITY COLLEGE OF PHYSICIANS AND SURGEONS

COLUMBIA ORTHOPAEDICSN E W Y O R K – P R E S B Y T E R I A N

Affiliated with COLUMBIA UNIVERSITY COLLEGE OF PHYSICIANS AND SURGEONS

UPDATE

S

T he following case study describes a21-year-old male varsity college basketball player at Columbia

University who suffered a recurrent anterior cruciate ligament (ACL) retear.The patient presented at the Center forShoulder, Elbow and Sports Medicine atNewYork-Presbyterian Hospital/Columbia University Medical Center,under the care of William N. Levine, MD,who is Head Team Physician for theColumbia University AthleticDepartment. For the past 9 years, Dr. Levine has been responsible for theorthopaedic care of 29 varsity teams.

The CaseDuring his high school basketball

career, this patient suffered a left kneeACL tear. In 2000, he underwent autolo-gous hamstring ACL reconstruction. Thissurgical approach was consistent with bestpractices for a patient of this type.

According to Dr. Levine, “once an ACLhas been torn, the best repair for an eliteathlete is with an ACL reconstruction.” Inthe autologous hamstring ACL reconstruc-tion, 2 tendons are taken from thepatient’s hamstring and used as a substi-tute for the torn ACL. The substitute liga-ment is mechanically attached to boneusing a screw, a pin, or both. The goal isto provide adequate fixation strength dur-ing rehabilitation, while the graft biologi-cally integrates with the native bone.

After a 6-month rehabilitation, thispatient returned to basketball and excelledas a high school player. He was recruitedto play Division I basketball at ColumbiaUniversity. During a game midwaythrough his freshman season, the patientplanted his left foot and twisted his previ-ously injured left knee, which buckled andgave way.

Physical findings. Physical examina-tion and MRI confirmed ACL graft rup-ture. The orthopaedic team faced the taskof a revision ACL reconstruction, a more

complex and difficult surgery than the initial procedure.

Intervention. In planning theprocedure, Dr. Levine anticipatedmultiple problems. First, revisionprocedures are always associated withdecreased positive outcomes; statistically,they never have the success rate of pri-mary reconstructions. Second, the previ-ous surgery may complicate the revision,by the compromising of bone with previ-

ous hardware and grafting, by the cre-ation of bone tunnels, and by the attach-ment requirements and biomechanical

effects of specifichardware used to fixthe initial graft.

Finally, Dr. Levine noted, “the abilityto return to the desired level of play aftersurgery was of great concern to thepatient, as would be expected for an eliteathlete playing Division I basketball.”

Outcome. The patient underwent anallograft revision ACL reconstruction,with a cross-pin technique on the femoralside. New tunnels were created to avoidinterfering with tunnels from the firstprocedure. Screws made from biodegrad-able polymer and a bioceramic attachedthe graft to femoral and tibial bone.

After extensive rehabilitation, the ath-lete returned to his desired level of play.He is currently a contributing memberof the Columbia University team.

DiscussionThere have been many advances in

ACL reconstruction over the pastdecade. Today, surgeons may selectautologous grafts from patellar, ham-string, or quadriceps tendon, or may optfor an allograft taken from a cadaver.

“We have a better understanding ofACL anatomy, leading to a change inthe surgical orientation of reconstruc-tions and, above all, to the developmentof new hardware technologies,” notedDr. Levine.

According to Dr. Levine, ChristopherAhmad, MD, and colleagues, for example,

Case Study: Orthopaedic TeamRevises a Failed ACL Reconstruction

COLUMBIA ORTHOPAEDICSN E W Y O R K – P R E S B Y T E R I A N

Table. Performance of Femoral Fixation Devices

Source: Ahmad CS, et al. Am J Sports Med. 2004;32:635-640.

Total Graft Slippage* Fixation Failure Load†

Interference screw (N=9) 5.44 ± 3.25 mm 539 ± 114 N

EndoButton (N=8) 1.75 ± 0.97 mm 864 ± 164 N

Rigidfix cross-pin (N=8) 6.02 ± 2.12 mm 737 ± 140 N

Bio-Transfix cross-pin (N=8) 1.14 ± 0.53 mm 746 ± 119 N

* P<0.001 † P=0.0008

“We have a better

understanding of

ACL anatomy,

leading to a change

in the surgical

orientation of

reconstructions and

to the development

of new hardware

technologies.”

—William N. Levine, MD

2 www.nyp.org/columbiaorthowww.nyp.org/columbiaortho

recently publisheda study showing that

girls are 8 times more likelythan boys to sustain injuries of the ACLwhile playing sports, in part because ofmuscle imbalances present only in girls(Am J Sports Med 2006;34:370-374). Thestudy found that, following menarche,girls increase the muscle strength in theirquadriceps more than the muscle strengthin their hamstrings, leaving the ACLmore vulnerable to tears.

Important research on various mech-anical hardware devices has also been con-ducted by NewYork-Presbyterian/Columbia’s Center for Shoulder, Elbowand Sports Medicine. For example, in2004, clinicians from the Center—led byDrs. Ahmad and Levine and their team—published results of biomechanicalresearch comparing several types of hard-ware for ACL reconstruction (Am J SportsMed 2004;32:635-640) (Table).

The hardware studied was developedto improve fixation of soft tissue grafts.Results showed that 2 devices may bepreferred options for fixation becausethey reduce graft slippage: the Bio-Transfix cross-pin (Arthrex, Inc.; Naples,Fla), which allows the graft to bewrapped 180 degrees and held under ten-sion around the pin, and the EndoButton(Smith & Nephew, Inc.; Andover, Mass),which seats the graft firmly against thefemoral cortex. “These studies have beencrucial in paving the way for the use ofthese new implant devices,” said Dr.Levine. “They have provided a greaterlevel of confidence in dealing with fail-ures of soft tissue grafts, like the one suf-fered by the basketball player I treated.”

Moreover, the studies have establishedthe Center for Shoulder, Elbow and SportsMedicine at NewYork-Presbyterian/Columbia as a site of the best possible carefor all patients—whether elite athletes orweekend warriors. All of the Center’sphysicians conduct basic science and clini-

cal research, educate residents and fellows,and practice clinically, with some alsoserving as team physicians.

“Our physicians,” said Dr. Levine,“have dedicated their careers to improving ACL reconstruction and othersports medicine procedures. This is arenowned sports medicine center thatleads the field.”

Christopher Ahmad, MD, is AssistantAttending Orthopaedic Surgeon, andAssociate Director, Center for Shoulder,Elbow and Sports Medicine at NewYork-Presbyterian Hospital/Columbia UniversityMedical Center, Director of the Center forPediatric and Adolescent Sports Medicine atMorgan Stanley Children’s Hospital of

NewYork-Presbyterian/Columbia, and isAssociate Professor of Orthopaedic Surgery atColumbia University College of Physiciansand Surgeons. E-mail: csa4@columbia.edu.

William N. Levine, MD, is Director, SportsMedicine and Associate Director, Center ofShoulder, Elbow and Sports Medicine atNewYork-Presbyterian Hospital/ColumbiaUniversity Medical Center, and is Head TeamPhysician for the Columbia UniversityAthletic Department, and is Vice Chairmanand Professor of Clinical Orthopaedic Surgeryat Columbia University College of Physiciansand Surgeons. E-mail: wnl1@columbia.edu.

Top center photo courtesy of William N. Levine, MD.

NewYork-Presbyterian Columbia Orthopaedicsis a semi-annual newsletter published by NewYork-Presbyterian Hospital. The articles in this newsletter represent thework of the Columbia University faculty at NewYork-Presbyterian Hospital/Columbia University Medical Center, who areat the forefront of research and practice in the diagnosis, treatment, and rehabilitation of musculoskeletal conditions inadults and children.

NewYork-Presbyterian Columbia Orthopaedics Editorial Board

Melvin P. Rosenwasser, MDEditor-in-ChiefDirector, Hand and Orthopaedic Trauma Services

NewYork-Presbyterian/ColumbiaRobert E. Carroll Professor of Orthopaedic Surgery

Columbia University College of Physicians and Surgeonsmpr2@columbia.edu

Louis U. Bigliani, MDChief, Orthopaedic Surgery Service and Director,

Center for Shoulder, Elbow and Sports MedicineNewYork-Presbyterian/Columbia

Frank E. Stinchfield Professor and ChairmanDepartment of Orthopaedic SurgeryColumbia University College of Physicians and Surgeonslub1@columbia.edu

Francis Y. Lee, MDChief, Tumor and Bone Disease Service

NewYork-Presbyterian/ColumbiaAssociate Professor of Orthopaedic SurgeryDirector, Center for Orthopaedic Research

Columbia University College of Physicians and Surgeonsfl127@columbia.edu

William N. Levine, MDDirector, Sports MedicineAssociate Director, Center for Shoulder,

Elbow and Sports MedicineNewYork-Presbyterian/Columbia

Vice Chairman and Professor of Clinical Orthopaedic SurgeryColumbia University College of Physicians and Surgeonswnl1@columbia.edu

William B. Macaulay, MDDirector, Center for Hip and Knee Replacement

NewYork-Presbyterian/ColumbiaAssociate Professor of Orthopaedic Surgery

Columbia University College of Physicians and Surgeonswm143@columbia.edu

Christopher B. Michelsen, MDChief, Orthopaedic Spine Service

NewYork-Presbyterian/ColumbiaChief, Orthopaedic Surgery

The Allen Pavilion of NewYork-Presbyterian HospitalProfessor of Clinical Orthopaedic Surgery

Columbia University College of Physicians and Surgeonscbmmd@yahoo.com

David P. Roye, MDChief, Pediatric Orthopaedic Surgery

Morgan Stanley Children’s Hospital of NewYork-Presbyterian/Columbia

St. Giles Professor of Pediatric Orthopaedic SurgeryColumbia University College of Physicians and Surgeonsdpr2@columbia.edu

3

4 www.nyp.org/columbiaorthowww.nyp.org/columbiaortho

P rocedures for total knee arthroplasty(TKA) at NewYork-PresbyterianHospital/Columbia University

Medical Center now include implants spe-cially designed for women. Early resultssuggest enhanced patient satisfaction andpossibly earlier than usual postoperativerecovery of range of motion, which is asign of long-term success.

“I believe that there are merits to it,”said Jeffrey Geller, MD, who has, to date,performed several dozen proceduresinvolving the gender-specific implant.“It’s almost exclusively the knee that I’vebeen [performing implants on in] womensince it came out several months ago.”

In terms of patient demographics, theadvent of a distaff knee should not comeas a surprise. Of the approximately400,000 implants performed annually,nearly two thirds are for women. For bothmen and women, the number of totalknee replacements is rising, reflecting theaging yet active population of post-WorldWar II baby boomers. The recent intro-duction of less-invasive procedures, likepartial knee replacement and gender-spe-cific knee replacement, have made replace-ment procedures a more amenable optionfor many patients. The risk of arthritisand related diseases in older adults shouldmake the operation even more common inyears to come.

“We’re seeing arthritis earlier in peopleand we’re becoming more aggressive intreating it,” said Dr. Geller.

Several anatomic differences distinguishthe female knee and surrounding struc-tures. The shape of the female femur,which is somewhat different from themale femur, is generally narrower alongthe medial to lateral plane but wider fromfront to back. Working with conventionalimplants, surgeons often need to manuallycompensate for this difference to improvethe replacement fit in women patients.

“Because we usually measure the femurfrom the front to the back when we’re siz-ing an implant, if the femur is narrower

side to side, you may get some overhangon the implant,” said Dr. Geller. A ten-dency to use a device slightly larger thannecessary can have undesirable clinicalimplications, including pain to the collat-eral ligaments and an “overstuffed” kneethat feels tighter to the patient. “In thepast, during surgery I have had to slightlyalter the desired position of the implantand use a smaller than normal size for afemale knee.” This can work, he added,“but you worry that you can affect thepatient’s range of motion, the position of

the implant, and whether or not you riskperiprosthetic fractures as a result ofnotching the femur.” The new implantobviates these dangers.

Quantitative analysis of the morpholog-ical features of the human knee helped todevelop the basic fit of the gender-specificprosthesis. Generally, in the evolution oforthopaedic procedures, reconstructionsthat more closely match the natural anato-my seem to do better, according to Dr.Geller. However, procedures are not as arule gender-designed, making the knee anexception. Shoulders for female patientsmay use smaller sizes, for example, butthey have never been marketed ordesigned specifically with women inmind.

Another design characteristic to makethe gender-specific knee more suited tofemale anatomy is the quadriceps or “Q”angle. In women with wider hips, the Q

angle is larger than in men, and the newprosthesis reflects that difference. Alsoimportant is the high-flex design of theposterior part of the knee, which has beenshown to result in increased ultimaterange of motion.

Early results for the new knee areencouraging. Studies to test distinctiveimprovement can only be expected in thelong-term, but meanwhile, anecdotalreports tend to be favorable. One of Dr.Geller’s patients, a 78-year-old female,underwent the procedure for the rightknee and described a fairly typical recov-ery with physical therapy, home use of icecompresses, and follow-up exercises thatshe still performs.

“I was able to drive with confidencewithin 5 weeks and now I’m able to getaround quite well,” said the patient. Sheestimated that range of motion was nor-

mal at “about 98%.” While continuingprescribed stretching exercises, sheacknowledges tightness across the knee.She was pleased by the elimination ofboth pain and deformity due to arthritis.“My leg is perfectly straight. I look at itwith great pleasure.”

Patients receiving TKA are often stillin the workforce and many may be expect-ed to outlive their first implant andrequire revision surgery. “Patients whoundergo this operation today tend to beyounger and more active and they expectmore out of an implant,” said Dr. Geller.

Jeffrey Geller, MD, is Director, MinimallyInvasive Joint Replacement Surgery atNewYork-Presbyterian Hospital/ColumbiaUniversity Medical Center, and is AssistantProfessor of Orthopaedic Surgery at ColumbiaUniversity College of Physicians and Surgeons.E-mail: jg2520@columbia.edu.

Better Fit, Early Recovery: KneeImplants Designed for Women

COLUMBIA ORTHOPAEDICSN E W Y O R K – P R E S B Y T E R I A N

A design characteristic that makes the gender-specific

knee more suited to female anatomy is the “Q”

angle. In women with wider hips, the Q angle is

larger than in men, and the new prosthesis reflects

that difference.

R ussell Hibbs, MD, an orthopaedicsurgeon who was a professor atColumbia University College of

Physicians and Surgeons in the earlyyears of the 20th century, pioneered sur-gical treatments for scoliosis, performingthe first operation in 1914, just 3 yearsafter his first-ever spinal fusion in apatient with Pott’s disease (tuberculosisof the spine).

Dr. Hibbs’ procedure, highly controver-sial at the time, involved stripping theperiosteum from the posterior arches,splitting the spinous processes so thatthey might overlap the interspinousspaces, and inserting fragments of bone

into the interlaminar spaces. When in1924 he reported on a series of 59patients, Dr. Hibbs had obtained gener-ally good results in children aged 3 1/2to 9 years. Still, for decades, recoveryfrom spinal fusion was long and arduous.After surgery, young patients were fittedwith a traction jacket that they wore for6 weeks while remaining immobile inbed. They then wore a removable jacketfor the next 6 to 12 months.

Today, Columbia surgeons at MorganStanley Children’s Hospital of NewYork-Presbyterian are still pioneering surgicalapproaches to scoliosis, leading the way inthe use of “third-generation” instrumenta-tion that facilitates recovery and improvesoutcomes for both adolescents andyounger children.

According to Michael G. Vitale, MD,when surgery is performed with the new

technology, a lengthy postoperative periodof restricted movement is no longerrequired. Most surgery for scoliosis entailsa 4-day hospital stay; return to school ispossible within 2 weeks, and participationin active sports after several months.

“That is much different than in thepast,” said Dr. Vitale, who is the Chief ofthe Pediatric Spine and Scoliosis Service atthe Morgan Stanley Children’s Hospital ofNewYork-Presbyterian. “Patients general-ly get back to normal activities muchmore quickly.”

Current methods and instrumentation,which have replaced internal fixation withthe Harrington rod (introduced in the

1960s by Paul Harrington, MD), enablesurgeons to greatly improve alignmentand restore a normal degree of kyphosis(bending forward of the thoracic spine)and lordosis (bending backward of thelumbar spine). Implanted rods are con-nected to the spine by hooks, wires, andpedicle screws.

According to Dr. Vitale, new tech-niques of segmental fixation enable “bet-ter correction of spinal deformity withoutpostoperative immobilization.” Rotationaldeformity can be rectified and properlumbar lordosis maintained.

Scoliosis can also occur in very youngchildren—even from birth. This frequent-ly arises from a congenital difference, asyndrome, or a neuromuscular disorder.These patients, who often also have poorlung function as a result of the effect ofthe scoliosis on the chest and lungs, are

not candidates for spinal fusion.Early-onset scoliosis is a particular

interest of the pediatric spine surgeons atMorgan Stanley Children’s Hospital ofNewYork-Presbyterian, who have beeninvolved in the innovation of treatmentoptions for young children with scoliosis.

“Everyone feels strongly that weshould not be performing fusion inyoung kids, under 7 or 8 years old,” saidDr. Vitale. “The lungs require a certainamount of space to develop, and if theydon’t have that space early on in life,they just don’t develop.”

New options include the use of “grow-ing rods” that can be periodically length-ened as the patient grows. Today, im-proved aspects of this procedure includedual-rod instrumentation, polyaxialscrews, and undersized and hybridimplants.

Current investigations, still at the pre-clinical stage, relate to servomechanismsand internally implanted motors that maybe used to lengthen the growing rodswithout further surgical intervention,according to Columbia researchers atMorgan Stanley Children’s Hospital ofNewYork-Presbyterian.

The VEPTR (vertical expandableprosthetic titanium rib) is an evennewer treatment option for childrenwith early-onset scoliosis. Dr. Vitale andDavid P. Roye, MD, have spearheadedthe implementation of the VEPTR atMorgan Stanley Children’s Hospital ofNewYork-Presbyterian, making it aregional center for the use of this noveldevice, which in essence enables lunggrowth while correcting scoliosis. TheVEPTR consists of a telescoping rodwith a hook on either end for attach-ment to the child’s ribs. The deviceallows surgeons to open the chest cavityto provide more room for lung growth.

Historically, thoracic insufficiencysyndrome has been treated by fusingtogether vertebrae of the spine, causingstunted growth in many cases. Accordingto Dr. Roye, however, “the VEPTR offersseveral significant advantages to young

Hospital Surgeons Use New Technology To ImproveOutcomes in Pediatric Scoliosis Surgery

see Scoliosis, page 6

According to Michael G. Vitale, MD, new techniques

of segmental fixation enable “better correction of

spinal deformity without postoperative immobiliza-

tion.” Rotational deformity can be rectified, and

proper lumbar lordosis maintained.

5

patients with scoliosis, but this programrequires the multidisciplinary strengthsof an institution like ours.”

Research published by Dr. Vitale andcolleagues (J Pediatr Orthop 2005;25:393-399) has shown a volume–outcome rela-tionship in scoliosis surgery. The retro-spective review of 3,606 cases showedthat patients treated in hospitals atwhich 5 or fewer scoliosis procedures areperformed annually were twice as likelyto require a second operation. Surgeons atMorgan Stanley Children’s Hospital ofNewYork-Presbyterian perform approxi-mately 125 such procedures every year.

David P. Roye, MD, is Chief, PediatricOrthopaedic Surgery at the Morgan StanleyChildren’s Hospital of NewYork-Presbyterian/Columbia University MedicalCenter, and is St. Giles Professor of PediatricOrthopaedic Surgery at Columbia UniversityCollege of Physicians and Surgeons. E-mail:dpr2@columbia.edu.

Michael G. Vitale, MD, is Chief, PediatricSpine and Scoliosis Service at Morgan StanleyChildren’s Hospital of NewYork-Presbyterian,and is Ana Lucia Associate Professor ofOrthopaedic Surgery at Columbia UniversityCollege of Physicians and Surgeons. E-mail: mgv1@columbia.edu.

Scoliosiscontinued from page 5

her skin and tented the skin withattempts to forward elevate. An elec-tromyogram and nerve conduction studyconfirmed damage to the axillary nerve.

In summary, the patient was a healthy,

active woman devastated by constantpain and poor function despite multiplesurgical attempts at correction. The situ-ation was complicated by significantremaining hardware, nerve injury, loss ofbone, immense scar tissue, and nonunionof bone.

Given the bone loss, failure of fixa-tion with allograft augmentation, andfailure of state-of-the-art plating sys-tems, the patient was offered the option

of shoulder replacement with a trabecu-lar metal coating.

“The features of this new trabecularmetal are that it allows bone healing intothe metal,” said Christopher Ahmad, MD.“Given her lack of healing and loss ofbone with previous standard approaches,

this option provided the most predictableability to facilitate healing, thereby pro-viding pain relief and improved function.”

After the prosthesis stem was manufac-tured and completed, the patient under-went surgery. It should be noted that thiswas the first application of the long-stemtrabecular metal prosthesis. The lengthyoperation required hardware removal,extensive lysis of adhesions near herbrachial plexus, placement of the stem,

osteotomy of the humeral head andtuberosities, and osteosynthesis oftuberosities.

Following surgery, the patient wasnoted to have progressive and significantrelief of her pain, and with time and phys-ical therapy, she began regaining motionin her shoulder. Almost 2 years later, shecan lift her arm over her head and she per-forms routine activities such as groceryshopping and getting dressed. X-raysdemonstrate union of her fracture andbone healing to the trabecular metal aswell as to the humeral shaft.

DiscussionTrabecular metal, fabricated with ele-

mental tantalum, has a cellular structurethat resembles bone and is 80% porous.This structure encourages bone formationand tissue ingrowth. Because surgeonsprefer to minimize the replacement ofnative bone in younger patients, trabecu-lar metal prostheses are mostly used forhip replacements and other surgeries morecommon in older patients.

In the case presented here, however, thepatient’s numerous operations had resultedin significant bone loss, so a prosthesiswas needed and trabecular metal seemedthe best choice.

“Patients who have 4-part proximalhumerus fractures are referred immediate-ly for shoulder replacement,” said

Prosthesiscontinued from page 1

“Everyone feels strongly

that we should not be

performing fusion in

young kids, under 7 or 8

years old. The lungs

require a certain

amount of space to

develop, and if they

don’t have that space

early on in life, they just

don’t develop.”

—Michael G. Vitale, MD

see Prosthesis, page 8

6 www.nyp.org/columbiaorthowww.nyp.org/columbiaortho

“This new trabecular metal allows bone healing into

the metal. Given [the patient’s] loss of bone with

standard approaches, this option provided the most

predictable ability to facilitate healing.”

— Christopher Ahmad, MD

COLUMBIA ORTHOPAEDICSN E W Y O R K – P R E S B Y T E R I A N

Although much has changed, thecurrent service for orthopaedics andorthopaedic trauma at NewYork-Presbyterian/Columbia has a long anddistinguished history. The unit is thesuccessor to the New York OrthopaedicHospital (NYOH), established in 1866to treat poor children with diseases ofthe musculoskeletal system. A fractureservice was instituted early in the 20thcentury, and NYOH merged with thePresbyterian Hospital Trauma Service in1945. In 1950, it became affiliated withthe Columbia Presbyterian MedicalCenter. Today, equipped with the per-sonnel and equipment for treatingpatients with critical injuries,orthopaedic trauma specialists atNewYork-Presbyterian Hospital/Columbia seek out all cases of musculo-skeletal injury that can benefit fromtheir unique level of expertise.

“We are here to take on all comers, todeal with very severe injuries, some ofwhich would cost a patient’s life orlimb,” said Melvin P. Rosenwasser, MD.“We welcome our orthopaedic col-leagues to look upon us as a resource.”Noting that except for Morgan StanleyChildren’s Hospital, NewYork-Presbyterian/Columbia has not officiallybeen designated a Level 1 TraumaCenter, Dr. Rosenwasser added, “allwe’re missing is the actual designation.For every aspect of Level 1 care, this isthe place to be.” Work has begun to for-mally achieve Level 1 designation.

Modern-day, high-energy traumaincludes a mix of motor vehicle andpedestrian accidents, as well as sportinginjuries from such sports as skiing and

horseback riding. Unfortunately, theurban environment continues to bringin falls from a height, which create theworst peri-articular fractures. The resultof these accidents is fractures withtremendous soft tissue injury. “It’s notjust bones,” Dr. Rosenwasser explained.“It’s joints, the way the bones move,their architecture, and the soft tissuesthat cloak them. Nerves, muscles, liga-ments, and bones all take the impact.It’s a whole constellation of injuries.”

Optimal and timely care for patientswith such injuries, often multiple,requires orthopaedic physicians and sur-geons to operate in concert with otherspecialists who, working in close prox-imity, are accessible for consultation andcollaboration. Orthopaedic trauma atNewYork-Presbyterian/Columbia func-tions in just such an environment. TheDivision of Orthopaedic Trauma alsoincludes the Trauma Training Center(TTC), founded in 1992, which providesboth an educational arm and an opera-tional base. The TTC archives clinicalinformation and fosters both clinical tri-als and basic research, emphasizing evi-dence-based medicine. The TTC, whichincludes state-of-the-art laboratories andboasts an international staff, representsthe full range of capabilities of the trau-ma unit and its larger aspirations.

“We are in the middle of a majorresearch and teaching university settingand gain much from the immediate con-tact and ability to draw on all theseexperts, in the same building, on thesame floor,” said Dr. Rosenwasser. “Wecreated this center specifically to look atcontroversial issues in orthopaedic trau-ma. We’re advancing the science behindthe specialty to improve our knowledgebase, to give surgeons best practices tofollow and justification for what theydo. We have all the pieces of these puz-zles, and we’re manipulating thosepieces to try to move the orthopaedictrauma world forward.”

Justin Greisberg, MD, is AttendingSurgeon at NewYork-PresbyterianHospital/Columbia University MedicalCenter, and is Assistant Professor ofOrthopaedics at Columbia UniversityCollege of Physicians and Surgeons. E-mail: jkg2101@columbia.edu.

Melvin P. Rosenwasser, MD, is Director,Hand and Orthopaedic Trauma, andMicrosurgery Services at NewYork-Presbyterian Hospital/Columbia UniversityMedical Center, and is Robert E. CarrollProfessor of Orthopaedic Surgery atColumbia University College of Physiciansand Surgeons. E-mail: mpr2@columbia.edu.

Traumacontinued from page 1

“We are here to

take on all comers,

to deal with very

severe injuries.”

—Melvin P. Rosenwasser, MD

7

Case study pre-op (left): X-rays (AP/Lat) after debridement of grade IIIB open tibia with 15 cm loss of substance.Case study follow-up (right): X-rays (AP/Lat) post-reconstruction in 1 stage using an osteocutaneous vascularizedfibular graft, which shows union and hypertrophy of the graft at 1 year with excellent function.

Pho

tos c

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f Melv

in P

. Ros

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asser

, MD

.

Dr. Ahmad. “The blood supply to thehumeral head is compromised, so the headis going to become necrotic, requiringreplacement right away. A major issue

with doing the humeral head replace-ment is getting the tuberosities to healto the shaft. If that bone doesn’t heal,the patient has very poor function. Thetrabecular metal enhances the healing ofthat bone, so it’s much improved withthis operation.”

The technology for this particular pros-thesis was newly developed and requiredthe patient to wait 6 months for sur-gery—despite being in extreme pain—until a stem could be manufactured.Initially, Dr. Ahmad looked into having apiece custom-made for the patient, butthe manufacturers decided instead to

begin mass production. The patientreceived the first standardized piece theyproduced. The surgical techniques usedalso had to be customized for the newtype of prosthesis.

Despite its novelty, Dr. Ahmad notedthat the trabecular metal stem is not costprohibitive for either the patient or theHospital. He added, “If the patient has afailed operation and then needs multiplefuture operations, or if they then have adisability where they can never get backto work, the value of the prosthesis in thatsituation far outweighs its cost.”

Christopher Ahmad, MD, is AssistantAttending Orthopaedic Surgeon, andAssociate Director, Center for Shoulder,Elbow and Sports Medicine at NewYork-Presbyterian Hospital/Columbia UniversityMedical Center, Director of the Center forPediatric and Adolescent Sports Medicine atMorgan Stanley Children’s Hospital ofNewYork-Presbyterian/Columbia, and isAssociate Professor of Orthopaedic Surgery atColumbia University College of Physiciansand Surgeons. E-mail: csa4@columbia.edu.

Prosthesiscontinued from page 6

X-ray of a trabecular metal prosthesis for proximal humerus fracture. NewYork-Presbyterian/Columbia orthopaedic surgeons havefound the trabecular metal prosthesis to be a cost-effective, and effective, option.

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NONPROFIT ORG.U.S. Postage PAID

Permit No. 37

Utica, NY

Important news from NewYork-Presbyterian/Columbia Orthopaedics, at the forefront of

research and practice in the diagnosis, treatment, and rehabilitation of musculoskeletal

conditions in adults and children.

Fall 2007

NewYork-Presbyterian Hospital622 West 168th StreetNew York, NY 10032

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X-rays demonstrate

union of her fracture

and bone healing to

the trabecular metal

as well as to the

humeral shaft.

NewYork-Presbyterian Hospital • Columbia University College of Physicians and Surgeons