“There’s one Penn Medicine. Now, there’s one Penn Orthopaedics.”
That’s how L. Scott Levin, MD, chair of Orthopaedic Surgery, described the changes occurring in orthopaedics throughout the Health System. With the expansion of orthopaedic services at Pennsylvania Hospital, “we’re working towards a musculoskeletal product line that’s collaborative and multidepartmental, to meet the needs of the community and the country.”
Noting that both PAH and Penn Presbyterian will provide treatment in 10 orthopaedic specialties (see below) – and that HUP will provide multiple orthopaedic services as well -- he called it “bookends of care…. east and west.
With its wide range of services, Penn orthopaedic surgeons can treat any musculoskeletal problem. But, beyond total joint replacement and other routine procedures, its patients are receiving cutting-edge treatments that are unique in the region.
After a stroke or brain injury, a patient may experience a severe loss of movement. As neuro-orthopaedist Keith Baldwin, MD, explained, the signal going from the brain to a muscle gets scrambled. The result: Muscles don’t work the way they should.
That’s what happened to a woman who suffered a stroke at 48. By the time she came to see Baldwin two years later, she had developed a neuromuscular club foot which had left her unable to walk and in a wheelchair. “The stroke caused her foot to curve inward, with the toes pointing down,” he said. “A club foot is very difficult to walk on. In fact, it’s one of the most debilitating deformities.”
A club foot generally results from a muscle imbalance –- too much pull on one side and too little on the other. Such was the case with Baldwin’s patient. Correcting imbalance involved making the overactive muscle relax and performing tendon transfers, which allowed the foot to straighten. “The patient is now able to walk almost totally without assistance.”
This approach and others have helped many patients affected by spasticity, fixed muscle shortening, and loss of mobility which left them with problems such as stiff-knee gait, hip and knee deformities, and stiff shoulder. One patient with a brain injury couldn’t throw a ball due to his arm “catching involuntarily.” Baldwin compared it to how a person’s leg jerks involuntarily when the doctor taps the knee.
The patient had a simple goal: being able to throw a ball to his son. Baldwin lengthened the patient’s bicep, which weakened the muscle and eliminated the involuntary movement. “Now the triceps work the way they’re supposed to and he’s reached his goal.
“We can’t fix a brain or spinal cord, but, by relaxing or redirecting a muscle or tendon, we can give the patient a better quality of life.”
Helping to Regrow Cartilage
Joint cartilage is the flexible connective tissue that coats the ends of bones to keep them moving against one another smoothly. According to James Carey, MD, director of the Penn Center for Advanced Cartilage Repair and Osteochondritis Dissecans Treatment, cartilage is 1000 times more slippery than ice! “That’s why we can take a million steps a year without a problem.”
Unlike skin, cartilage cannot heal itself. Therefore, left untreated, tears get bigger and bigger, often leading to arthritis.
Cartilage tears most frequently happen when the knee cap dislocates or there’s an injury to the anterior cruciate ligament. “It generally occurs in contact and collision sports,” Carey said, adding that year-round athletes are also more likely to develop osteochondritis dissecans (OCD), a rare –and often misdiagnosed – condition in which a fragment of bone and cartilage separates, causing pain, swelling and mechanical issues.
While cartilage isn’t self-healing, certain procedures can help it regrow. But repairing cartilage is not easy. “It requires special training and there’s a steep learning curve,” Carey said. Plus there are specific rehab protocols for these patients. As a result, Penn’s Center is one of only a few in the nation dedicated to repairing cartilage and treating OCD.
Procedures to repair cartilage differ according to the size of the tear. For example, in smaller defects in the cartilage, Carey uses microfracture, making small holes in the bone to stimulate cartilage growth. “It’s the most common procedure.” An autologous chondrocyte implantation fills a large defect with millions of cells grown from a small piece of the patient’s own cartilage.
An osteochondral allograft transplantation, which uses cartilage and bone from a cadaver donor, is often “the last step before a knee replacement,” he said. “But, for a 20-year-old patient, that’s a new replacement every 10 years. We do everything to avoid metal and plastic.”
Giving New Life to Dead BonesAvoiding total joint replacement is also the goal of another unique procedure offered at Penn Orthopaedics: Free Vascularized Fibular Graft (FVFG).
While most artificial hip joints in use today will last 10 to 20 years, for younger patients, the artificial hip joint – which replaces the natural hip bone with a metal ball and resurfaces the hip socket with a metal shell and plastic liner – still means a second surgery … or possibly a third. This was the situation facing a 26-year-old patient with bilateral osteonecrosis -- also known as avascular necrosis, a condition that occurs when bones lose their blood supply.
The patient, who was a law student when he started experiencing hip pain in 2011, pushed his pain to the back burner while he concentrated on studying for the Bar exam. Some time later, as the pain got worse, he sought help. But, by this time, an MRI showed that he had advanced beyond the point where typical therapeutic procedures would help. “I didn’t want to get an artificial joint that would wear out but my options were limited.”
Then he heard about the FVFG, an alternative to total hip replacement that replaces the dying piece of bone in the hip with a segment from the fibula. “Once the blood vessels are connected, the hip is given a new blood supply that allows it to regenerate,” said Levin, the surgeon who performed the procedure. FVFG requires special training in both orthopaedics and microsurgery, a unique skill set that limits the number of hospitals capable of offering the procedure.
In a few months, the patient will be able to walk, run and go back to his daily life. Although recovery from this procedure takes longer than the typical six weeks of a total hip replacement, the benefit of not undergoing multiple hip replacements over the course of a patient’s life greatly outweighs the extra time in rehab!
10 Orthopaedic Specialty Areas
Penn Orthopaedics offers treatment in 10 specialty areas as well as same-day service. “You call with any musculoskeletal need and we’ll see you that day,” Levin said. “No exceptions.”
- Foot and ankle
- General orthopaedics
- Hand and wrist
- Joint replacement
- Neuro orthopaedics
- Orthopaedic oncology
- Shoulder and elbow
- Sports medicine
- Trauma and fracture care
To learn more about Penn Orthopaedics, go to pennmedicine.org/orthopaedics.