Volume 3 Issue 3 Summer 2009 We see nearly 4,000 patients a year and provide treatment for a full range of sports injuries related to recreational, high school, collegiate and professional athletic performance. Brian Sennett, MD, Chief of Sports Medicine Penn Sports Medicine Helps Get Patients Back in Action Joint Replacement Improves Quality of Life Page 4 5............. Neuro-Orthopaedics Page 6................ Treatment of Orthopaedic Cancer Page 7................ New Therapy to Heal Injuries Page 8................ It happens to everyone at some time in their lives: They overdo it on the golf course, join the kids for some touch football, or forget they are no longer 17-year-old student athletes. From the weekend warrior to the professional athlete, the specialists at the Penn Sports Medicine Center provide comprehensive care for athletes of all abilities. Specially trained in the field of sports medicine, all of the physicians at the Penn Sports Medicine Center have one goal to help their patients get back in the game as quickly as possible. The center s multidisciplinary approach to care results in individualized treatment plans focusing on the most appropriate treatment and rehabilitation for every injury. A sports medicine patient can be anyone who is active and needs treatment in order to get back to work, weekend activities or organized sports. Our sports medicine team is really multifaceted, said Brian Sennett, MD, chief of sports medicine at Penn. We see nearly 4,000 patients a year and provide treatment for a full range of sports injuries related to recreational, high school, collegiate and professional athletic performance. The physicians at the Penn Sports Medicine Center are experts in treating serious injuries. They combine treatment, therapy and surgery for the least invasive approach to achieving the best possible outcomes. Arthroscopy, a key sports medicine procedure, involves the insertion of a fiberoptic camera into a joint, enabling the surgeons to watch their movements on a TV monitor while operating through small incisions. This type of minimally invasive surgery benefits patients because it results in minimal scarring, a shorter hospital stay, and a faster recovery. (Continued on page 2)
Penn Sports Medicine Helps Ge (Continued from front page) At hletic Training Program at Along with getting athletes back into the game, Penn Sports Medicine offers an athletic training program. The program consists of two distinct, but equally important elements clinical work and community outreach. The clinical element involves bringing athletic trainers to the Penn Sports Medicine clinical practice where they support the following functions: Penn Orthopaedics Assisting the surgeon(s) with office hours. Performing initial patient evaluations and tests. Fitting patients for braces, splints, casts and orthotics. Creating rehabilitation programs for patients. Facilitating overall patient care. The outreach element involves sending athletic trainers in the program to 16 participating high schools in the area. At the high schools, they are responsible for covering all sporting events and practices. The training program focuses on rehabilitation as well as injury prevention, said Dave Aliquo, certified athletic trainer and director of the program. Athletic trainers are taught preventative taping techniques to reduce the risk of further injury and proactively rehabbing weak points on athletes with respect to their sport or, even more specifically, their position. Athletic training programs like Penn s are growing rapidly in health systems throughout the country, providing participants the opportunity to work in a clinical setting, as opposed to the more traditional settings of colleges, universities and high schools. Along with providing the highest level of patient care, Penn sports medicine physicians are at the forefront of the research of athletic injury and recovery. The research done at the Penn Sports Medicine Center is widely published. Therapy services for the Penn Sports Medicine Center are provided by Good Shepherd Penn Partners. (See related article on page 3.) Repairing the ACL A tear of the anterior cruciate ligament (ACL) is a painful injury that can stop any athlete in his or her tracks. The ACL holds the knee joint together and when it is injured, it can make something as simple as walking painful and difficult. John Kelly, IV, MD, is focusing on ways to reconstruct the ACL that are minimally invasive and less painful. By using surgical instruments designed for the shoulder they are smaller and less invasive he can incorporate what he calls a kinder and gentler procedure. He refers to it as augmentation because it enhances the patient s own ACL instead of replacing or reconstructing the ligament. We leave the existing ACL in place and either repair it or reinforce it, Dr. Kelly said. By restoring the patient s normal anatomy, we can stabilize the knee joint and preserve the normal movement and feeling of the knee. While the procedure is not for every patient, young and active patients who have had the procedure have had good results with minimal pain. 2 ADVANCES IN MEDICINE Quarterly Medical Update
t Patients Back in Action Focusing on the Shoulder In many cases, sports medicine focuses on preventing injury. Shoulder injuries, especially rotator cuff tears, can be career ending for athletes making normal movement painful. The rotator cuff is the series of muscles and tendons that stabilize the shoulder. Penn orthopaedic surgeon and sports medicine specialist Russell Huffman, MD, focuses on shoulder issues and helping patients regain motion. A rotator cuff tear results in shoulder disability and in the case of large, untreated tears, can lead to arthritis, Dr. Huffman said. Fortunately, the majority of rotator cuff surgery can be done arthroscopically with less pain and quicker recovery for the patient. Dr. Huffman says many of his patients are young athletes experiencing shoulder instability. For those patients, he is able to restore stability and function through arthroscopic surgery. In more complex cases, he needs to rebuild the bone for added stability, and in extreme cases, shoulder replacement may need to be performed. In all cases, the role of surgical care is to restore function and eliminate pain. Dr. Huffman performs shoulder surgery at Penn Presbyterian Medical Center. Creating New Cartilage One of the newest members of the Penn Sports Medicine team, Fotios Tjoumakaris, MD, is excited about the research into building new cartilage. Cartilage is the smooth surface that lines joints and allows for fluid motion. Cartilage does not contain blood vessels so any damage or injury is slow to repair. We can generate new cartilage from the patient s own cells and transplant that material back into the joint, said Dr. Tjoumakaris. In the lab, we are looking at new ways to generate biologically compatible cartilage. The lab is the McKay Orthopaedic Research Lab at Penn. Robert Mauck, PhD, and the research team in the soft tissue biology and engineering lab are looking for new methods to grow cartilage. More than 25 million people in the U.S. have some form of osteoarthritis, said Dr. Mauck. Arthritis disrupts the rebuilding of the cartilage, and once that begins it is irreversible. For more information on the Penn Sports Medicine Center, call 800.789.PENN or visit PennMedicine.org. Getting Back in Action Good Shepherd Penn Partners (GSPP) Penn Therapy and Fitness provides outpatient physical therapy services for Penn Orthopaedics patients. The team of experts at GSPP treats a wide range of injuries and disabilities, and is committed to restoring function, optimizing potential and seeking the best outcome possible for patients. Outpatient physical, occupational and speech therapy services are available at eight locations throughout the Philadelphia region: 3624 Market Street, Philadelphia Penn Presbyterian Medical Center Pennsylvania Hospital Penn Medicine at Radnor Penn Sports Medicine Center Penn Medicine at Cherry Hill Arcadia University Woodlane Square, Westampton, NJ For more information about GSPP Penn Therapy and Fitness, call 877.9MYREHAB or visit www.phillyrehab.com According to Dr. Mauck, the team is working with the next generation of biocompatible materials that can be combined with cartilage stem cells to create materials for joints, knees and the spine. The research is in its early stages, but Dr. Mauck said the results so far are promising. Through research and advances in surgical and rehabilitation techniques, orthopaedic sports medicine specialists have been able to treat and rehabilitate athletes whose injuries were once career-ending and put them back in the game. ADVANCES IN MEDICINE 3
Joint Replacement Improv es Joint replacement surgery is undoubtedly one of the greatest medical advances for improving patients quality of life. Over the past 40 years, hip and knee replacements have been performed Currently, over 400,000 hip and knee replacements are performed in the United States annually. At Penn, orthopaedic surgeons perform more than 2,000 joint replacement procedures a year, treating painful and debilitating joint conditions caused or aggravated by arthritis, trauma, injury and infection. The number of people seeking relief from joint pain is increasing. Americans are living longer and staying active, and aging baby boomers don t want to stop participating in sports and other activities because of pain. Younger people aren t ready to slow down and they are not going to let their pain dictate their activities, said Craig Israelite, MD, orthopaedic surgeon at Penn Presbyterian Medical Center. It used to be we wouldn t even consider joint replacement for a patient under the age of 60. But now, with new materials that are more durable and longer lasting, we can help younger patients and get them get back to their life. Studies show that the more procedures surgeons perform, the more successful their results, or outcomes. In addition to performing a large number of surgeries, Penn orthopaedic surgeons also perform more complex and complicated joint replacement procedures, as well as many minimally invasive procedures. At Penn, we offer advanced, individualized care and we see many patients with complex and complicated problems, said Gwo-Chin Lee, MD, orthopaedic surgeon. Along with providing the highest quality patient care, Penn Orthopaedics is involved in educating future orthopaedic surgeons and developing new procedures and joint replacement components. for millions of Americans, easing pain, improving range of motion, and keeping them active. Building a Better Knee As leaders and innovators in orthopaedics, Penn physicians are continually working to improve the fit and function of joint replacements. The ultimate goal is to make the replacement feel and act as normal as possible, especially for knees. We do our best to mimic the normal kinematics of the knee, said Jonathan Garino, MD, orthopaedic surgeon. One of the new prosthetics that we developed replaces both of the patient s own cruciate ligaments, which makes a huge difference in how the knee feels. It also mimics the normal, asymmetrical anatomy of the knee. The result is a knee that is more stable and feels more natural to the patient. Patients with arthritis in the knee may also be candidates for partial, or unicompartmental, knee replacement. If an injury results in pain or arthritis on just one side of the knee joint, Penn surgeons are able to use a mini-incision to replace the affected part of the knee joint, with minimal damage to the surrounding muscles and tendons. Patients recover much more quickly from a partial knee replacement, Dr. Garino said. The new prosthetics we are using result in less pain than a traditional knee replacement, and patients can often walk unassisted (without a cane or crutches) within a week after the surgery. 4 ADVANCES IN MEDICINE Quarterly Medical Update
At P e n n, o r t h o pa e d i c s u r g e o n s p e r f o r m m o r e t h a n 2, 0 0 0 j o i n t r e p l a c e m e n t p r o c e d u r e s a y e a r. Quality of Life Dr. Lee uses a knee system that includes a rotating platform placed on the tibia (shin bone) that decreases wear on the knee system and allows for some rotation of the knee. He said this helps provide more natural movement of the joint. One of the latest innovations is the development of customized cutting blocks, designed to improve the accuracy of fitting the knee system. Software analyzes X-ray, MRI and CT images and creates a model of the patient s knee. Cutting blocks are fabricated from the models and attached to the femur and tibia, allowing the surgeon to precisely fit the knee prosthesis. Called Patient-Matched Custom Knee Replacement, or PMI, the method provides a custom fit and correctly aligns the new joint. New Hip Materials Offer Durability For hip replacements, the newest advances are in the types of surfaces being used. The ball and cup implants may be ceramic-on-ceramic, metal-on-metal or metal-on-plastic. Penn surgeons have also seen some success with a new multi-bearing cup for hip replacements. The U.S. Food and Drug Administration (FDA) recently approved use of the cup that can be fitted with a liner of any of the materials. All have unique benefits and all have risks. Hip replacements are not one-size-fits-all, said Dr. Israelite. All patients are evaluated to determine the best material for their lifestyle and activity level. Penn orthopaedic surgeon Charles Nelson, MD, has been involved in studies with delta ceramic, a high-performance biocompatible material that combines low wear and high hardness with good mechanical performance. These new ceramics are harder, stronger and experience less wear than other materials, Dr. Nelson said. They provide a better surface, have lower risk of fracture and have a long life. Our patients are living longer, active lives and the implants need to last. Penn orthopaedic surgeons often perform a minimally invasive hip replacement. The smaller incisions allow the surgeon access to the hip joint while preserving muscle function, enabling patients to return more quickly to their favorite activities. Is Joint Replacement Surgery Right for You? You don t need to stop doing the activities you love or suffer with stiff and painful joints. If the answer to any of these questions is yes, you may want to contact Penn Orthopaedics to find out if joint replacement surgery can help you. Does your affected joint hurt one or more days per week? Does the pain interfere with your sleep? Is it painful for you when you perform everyday activities? Are pain medications no longer working? Is joint pain limiting your participation in activities you love? To contact Penn Orthopaedics, call 800.789.PENN (7366) or visit PennMedicine.org. ADVANCES IN MEDICINE 5
Regaining Movement through Neurology and Orthopaedics Brain injury, stroke and central nervous system disorders can often result in a loss of movement. As a result, ordinary daily activities like walking, eating, and dressing become difficult, and sometimes impossible. The Penn Neuro-Orthopaedics Service helps patients with impaired movement regain that lost function and mobility. Part of the Penn Comprehensive Neuroscience Center and Penn Orthopaedics, Penn Neuro-Orthopaedics offers a multidisciplinary approach to the diagnosis and treatment of impaired movement of the arms and legs. We see patients from all over the world, said Mary Ann Keenan, MD, director of the service. We are one of the only full-service programs in the United States and have a great deal of experience in managing movement problems. We understand muscle pattern activity so we can identify the problem and develop a treatment plan for the best result. Strokes or brain and spinal cord injuries often affect patients ability to control the muscles in their arms and legs. Surgery can rebalance the muscles and help patients regain control of their movements. Dr. Keenan says the evaluation is key to planning the treatment. By observing each muscle s behavior, she can determine the proper surgical combinations and the sequence in which they should be performed to provide the best correction. Stroke patients commonly lose movement on one side of the body. Many develop adult club foot, in which the foot is pulled into a toe-down position and tilted in, and the toes curl. Once the evaluation is completed, Dr. Keenan said the treatment usually starts with the affected foot. By lengthening the tendons in the toes, Dr. Keenan can reroute those tendons to strengthen the calf muscle. To correct the inward twisting of the foot, she can split the tendon supporting the muscle in the front of the leg. One section of the split tendon is attached to the inside of the foot and the other section to outside of the foot. With the muscle now pulling equally on each side, the foot straightens. If patients still have movement problems, Dr. Keenan continues up the leg working with the ankle, knee, quadriceps (thigh muscle) and hip. She can perform a similar series of procedures on the hand, elbow and shoulder. These procedures are minimally invasive and usually only require a one-day hospital stay, Dr. Keenan said. Patients recover quickly and are able to begin therapy to regain their mobility. Dr. Keenan is a pioneer in neuro-orthopaedics. She is the only full-time neuro-orthopaedic surgeon in the country and has developed many of the evaluation and surgical techniques used in the field. She is also actively involved in the training of future orthopaedic surgeons at the University of Pennsylvania School of Medicine. Two of her current residents are interested in specializing in neuro-orthopaedics and expanding the program. Dr. Keenan said she is pleased to see increasing interest in the field and anticipates continued expansion of the specialty. For more information about neuro-orthopaedics or to schedule an appointment, please call 800.789.PENN (7366) or visit PennMedicine.org/ortho. 6 ADVANCES IN MEDICINE Quarterly Medical Update
All of the team members are based at Pennsylvania Hospital so that we can meet and collaborate. We all have experience treating these tumors and together we develop the appropriate treatment plan for every patient. Richard Lackman, MD, Orthopaedic Surgeon Advancing the Treatment of Orthopaedic Cancer It wasn t that long ago that cancer in the bone or soft tissue was a serious diagnosis that usually meant amputation of the affected limb. The orthopaedic oncology program at Penn Medicine has a long history of successfully treating these tumors and is one of the largest musculoskeletal tumor referral practices in the country. Richard Lackman, MD, Penn orthopaedic surgeon, established the program in Philadelphia in the 1980s. He sees approximately 1,100 new orthopaedic tumor patients each year and performs about 700 surgical procedures. He specializes in the treatment of malignant (cancerous) and benign (non-cancerous) tumors of bone and soft tissue with a special interest in limb preservation. I was the first fellowship-trained orthopaedic tumor surgeon in Philadelphia, Dr. Lackman said, and I was part of the early movement to treat these tumors. Over the years, we have advanced that treatment so patients have other options besides amputation. Bone and soft-tissue sarcomas mainly occur in the spine, pelvis and extremities. The most common bone sarcomas osteosarcoma and Ewing s sarcoma normally occur in adolescents and young adults, and chondrosarcoma usually occurs in older adults. Treating Sarcoma A three-pronged treatment approach can be used to treat sarcoma chemotherapy, radiation and surgery. Most tumors start in the bone and then quickly spread beyond, making them too difficult to treat surgically without other treatment. Many of the new chemotherapy agents shrink the size of sarcomas and radiation stops their growth. The smaller tumor can then be safely removed. If part of the bone is removed with the tumor, modular prosthetics are now available to preserve the limb. The replacement can be exactly sized, allowing patients to maintain their mobility. A Team Approach Patients at Penn are treated by a multidisciplinary orthopaedic oncology team. The team meets weekly to discuss all patients and the next steps in their treatment plan. Team members specialize in: Orthopaedic oncology Pathology Musculoskeletal radiology Hematology-oncology Radiation oncology Interventional radiology Surgical oncology Plastic surgery The team is vital to our program, said Dr. Lackman. All of the team members are based at Pennsylvania Hospital so that we can meet and collaborate. We all have experience treating these tumors and together we develop the appropriate treatment plan for every patient. Future Treatments The Roberts Proton Therapy Center at Penn, scheduled to open later this year, could provide another treatment option for bone and soft-tissue sarcomas. Proton therapy allows the most precise targeting of dosage to the tumor and lowest unintended radiation dose to normal tissues. The protons can be energized to specific energies or velocities that precisely target the tumor, with little dose beyond the target area. Little research currently exists on using proton therapy to treat sarcoma, said Dr. Lackman. This puts Penn in the unique position of researching this technology and the role it may play in treating bone and soft-tissue tumors in the future. ADVANCES IN MEDICINE Summer 2009 7
3600 Market Street Suite 210 Philadelphia, PA 19104 Non-Profit Org. U.S. Postage PAID Permit No. 2563 Phila., PA 19104 ADVANCES in Medicine Advances in Medicine is published quarterly by the University of Pennsylvania Health System. 2009 by the Trustees of the University of Pennsylvania. All rights reserved. No part of this publication may be reproduced without permission. Hospital of the University of Pennsylvania Penn Presbyterian Medical Center Pennsylvania Hospital New Therapy Uses Patient s Blood to Heal Injuries An innovative treatment for traumatic musculoskeletal and sports injuries involves using the patient s own blood. Commonly called platelet-rich plasma (PRP) therapy, the technique is being used by professional athletes and could eventually improve the treatment of stubborn injuries like tennis elbow and knee tendonitis for athletes of all types. Samir Mehta, MD, chief of orthopaedic trauma at Penn Medicine, is involved in the research with PRP therapy. According to Dr. Mehta, the treatment is straightforward to perform and focuses on injecting portions of a patient s blood directly into the injured area, stimulating the body to repair muscle, bone and other tissue. The technique appears to help regenerate ligament and tendon fibers, which could shorten rehabilitation time and eliminate the need for surgery. Dr. Mehta has been using platelet-rich therapy in situations of massive bone loss after trauma to help regenerate bone. Platelets contain proteins and other particles involved in the body s self-healing process. Platelet-rich plasma is derived by separating the platelets from the patient s red blood cells in a high-speed centrifuge or through filtration. The remaining platelet-rich plasma is injected into the damaged area. Often the injury is in an area where blood otherwise does not go, so a high concentration of the healing platelets and other growth factors can be delivered to stimulate the growth of new soft-tissue or bone cells. It s a better option for problems that don t have a great solution it s nonsurgical and uses the body s own cells to help it heal, Dr. Mehta said. The guy who plays softball on weekends, and the woman who runs a 5k race every now and then, they suffer very common injuries. We hope this therapy can be used to help those people who suffer from common injuries. ADVANCES IN MEDICINE 8