Johns Hopkins Framework Orthopaedic Surgery NEWS FROM JOHNS HOPKINS MEDICINE Fall 2019 JHUAPL

Will Osseointegration Change the Future of Prosthetics?

t has been projected that more than 2.2 million Americans will be living with limb loss in 2020.* Jonathan Forsberg, associate professor of Iorthopaedic surgery in the Johns Hopkins Division of Orthopaedic Oncology, is helping to introduce alternative types of prostheses for these patients. Forsberg’s current research focuses on osseointegrated implants, which attach directly to the residual limb’s bone, eliminating the need for traditional, socket-based prostheses. “Our soft tissues Osseointegrated limbs (like the one shown were not meant to bear weight,” Forsberg says, noting sensory feedback. here) can accommodate advanced prosthetic the shortcomings of traditional prostheses. “Patients “Osseointegration is a complex process that components, such as the Johns Hopkins Applied Physics Laboratory’s Modular Prosthetic Limb, can develop ulcerations, perspiration may disrupt the requires a long rehabilitation period and a which uses pressure sensors embedded in the interface between skin and socket, and if the length multidisciplinary team, including orthopaedic and fingertips of the prosthetic hand to provide of the residual limb is shorter, patients may have less plastic surgeons, prosthetists, and rehabilitation artificial sensory feedback. control over the limb.” Osseointegration can greatly and mental health specialists,” Forsberg explains. improve quality of life by “increasing the amount of As a large, collaborative academic institution, To address these questions, Johns Hopkins time patients wear a prosthesis throughout the day Johns Hopkins can provide every aspect of the care will participate in an international registry to and enabling osseoproprioception (knowing where needed for these patients. Education is particularly collect inclusion criteria, surgical information the limb is without looking at it) and osseoperception important, given that osseointegration patients have a and outcomes data on osseointegrated implants (‘feeling’ the differences between surfaces),” says lifelong risk of infection. at institutions worldwide. The registry will also Forsberg. “Osseointegration as an orthopaedic field is still improve transparency in the field of osseointegration Osseointegrated limbs can also accommodate in its infancy,” Forsberg notes. “Several companies by helping to identify implant designs at risk for advanced prosthetic components, such as the Johns worldwide are developing osseointegrated implants, early failure. Participants will be able to respond to Hopkins Applied Physics Laboratory’s Modular but only one of them has data beyond 10 years. Given questions from the Food and Drug Administration, Prosthetic Limb, which the unique challenges, there are many areas that are which was involved in registry development, and uses pressure sensors ripe for research, such as the ideal patient population, from other investigators, as the field moves from first- embedded in the ideal implant types for various bony anatomy, generation prostheses to subsequent iterations. fingertips of the monitoring of bone health and the skin penetration “Once we address the ideal patient population prosthetic hand to site, and evaluating the ethics and costs associated and ideal implant types,” Forsberg says, “we can turn provide artificial with osseointegration.” our focus to other areas of research — in particular, deciding how best to convey the signals from the patient’s own nerves and muscles to a robotic limb. “Osseointegration as an orthopaedic field is still I’m very excited to continue to develop this project at in its infancy…There are many areas that are Johns Hopkins.” n ripe for research.” *Ziegler-Graham et al. Arch Phys Med Rehab. – Jonathan Forsberg 2008;89(3):422–429 NEW MULTIMODAL APPROACH Better Blood Management Improves Patient Outcomes After Joint Replacement

nowing that infection is one of the most with the same or better outcomes compared with a devastating complications for patients un- threshold of <8 g/dL. Overall, the transfusion rate dergoing hip or knee replacement, Harpal for joint replacements at Johns Hopkins dropped KKhanuja, Johns Hopkins associate profes- from 20% to 2%. This approach lowered infection sor of orthopaedic surgery, makes it his mission to rates and had the additional benefits of decreasing address the issue through a multimodal approach to hospital costs and conserving blood. blood management. With such progress, Khanuja says transfusion Blood transfusions can increase the risk of is no longer the primary concern in blood adverse outcomes, delay rehabilitation and extend management. The new focus is on the extent of a patient’s hospital stay, so limiting blood loss is anemia after surgery and how anemia affects crucial. “Transfusions have inherent risks,” says patient recovery. “Now most joint replacements Khanuja. “There is the potential for complications, are outpatient procedures in a hospital setting. We including infection and associated comorbidities.” are trying to get patients up the same day and get The multimodal blood management approach them moving, so anemia is the better indicator instituted at Johns Hopkins involves treating of patient outcomes,” says Khanuja. “We need to patients who are hypotensive postoperatively with think of anemia in terms of how a patient feels fluids first, then blood products as needed, using postoperatively. How much energy do they have? antifibrinolytic agents such How much better can we make them feel?” as tranexamic acid, and Patient health optimization is a key component lowering the restrictive to addressing the effects of anemia. “Our threshold for department policy is to have all anemia examined transfusions from if levels are not within a healthy range before <10 g/dL to <7 g/ surgery,” says Khanuja. Typically, the primary dL hemoglobin in physician would clear a patient for surgery who is hemodynamically slightly anemic because this low level is considered The same vigilance for anemia risks is applied to stable patients. “the patient’s normal.” Khanuja encourages other risk factors as well, through diabetes control, In a study of orthopaedic surgeons to question that assumption. weight loss, smoking cessation and nutritional patients with “If a patient is slightly anemic, I’m wondering if screening. “We want to give patients the best hip fractures, they have an underlying condition that could be outcome,” says Khanuja. “That is something that is Khanuja found exacerbated with surgery,” says Khanuja. “They important to us, and that we will always be on top the new restrictive could have a small bleeding ulcer made worse of at Hopkins.” n threshold of <7 g/dL by the anti-inflammatories or blood thinners was associated prescribed postoperatively. There are many reasons Harpal Khanuja to address the anemia.”

HIGHLY SKILLED EXPERTISE

Endoscopic Spine Surgery: Rare Minimally Invasive Approach Now Available at Johns Hopkins

urgeons in the Johns Hopkins Department of Orthopaedic Surgery’s spine division are now providing minimally invasive endoscopic surgery, which is used frequently in other specialties but is uncommon in spine Ssurgery. Sang Lee, assistant professor of orthopaedic surgery and direc- tor of complex cervical spine and spine tumor surgery, is leading implementa- tion of this approach, which the department began to offer over the last several months. “Endoscopic spine surgery has been historically more common in Asia and is recently gaining popularity in the United States. However, it is The technique treats less complicated spine conditions such as disc mainly performed by private surgeons, not academic practices,” Lee says. herniation and spinal stenosis, and can be performed in an outpatient He hopes to popularize endoscopic spine surgery among academic practices setting, says Sang Lee. in the U.S. because of its many benefits. “It is the least invasive surgery and

2 • framework fall 2019 w w w . hopkinsortho . o r g THOSE WHO GIVE

Orthopaedic Surgeon’s Ethics Inspire Gifts for Bioethics Research

ometimes, deciding when not to have surgery Humbyrd says surgeons have an ethical responsibility is just as important as deciding when to have to adhere to the principle of nonmaleficence or surgery. No one understands this better than “do no harm,” which is a key tenet of bioethics. SCasey Humbyrd, chief of the Foot and A decision about surgery is often complex, but a Ankle Division, and assistant professor of orthopae- surgeon who is well trained in bioethics can present dic surgery and associate faculty member at the Johns the nuances of the options to help a patient make Hopkins Berman Institute of Bioethics. Humbyrd the best choice. “That was a fascinating discussion,” researches surgery, ethics and decision-making, and says Stuart. “We became very fond of Dr. Humbyrd she brings this expertise to her patients like Stuart through that conversation.” and Suzanne Drake. For the Drakes, Humbyrd’s Humbyrd’s research currently includes the ethics guidance was instrumental in their own decision- of new payment models for total joint replacement making, and it inspired them to support the surgeon’s and their potential effects on access to care for bioethics research. vulnerable patient populations. Future research will “It’s very important to support old-fashioned consider ethical issues related to limb-threatening Casey Humbyrd medical ethics, which begins with understanding the injuries — issues such as whether to reconstruct patient,” says Stuart. “Dressed up as it may be in the or amputate an injured limb, understanding the new discipline of bioethics, Dr. Humbyrd epitomizes attitudes of orthopaedic surgeons about ethical issues it by the way she handles people who are in pain and examining the ethics of opioid prescribing. and who have uncertainty about the best course of This year, Humbyrd is running a nationwide treatment.” He says Humbyrd’s approach recalls symposium on ethical considerations when Supporting Our Work the medical ethics of his uncle, who, in the 1940s, prescribing opioids after orthopaedic surgery. The Johns Hopkins Department of was one of the first board-certified pediatricians in “Through my work as a delegate to the American Orthopaedic Surgery provides outstanding Southwestern Virginia. “She is the closest that I have Medical Association and my recent appointment treatment of musculoskeletal disorders, fosters found to a physician with the same type of empathy to the board of the American Orthopaedic Foot & innovation and nurtures the next generation of that I saw in my uncle.” Ankle Society,” she says, “I have a national platform orthopaedic surgeons. When Stuart’s wife started having tremendous to help promote ethical care in orthopaedic surgery, pain in her foot, they made an appointment with especially with regard to opioid prescribing.” Your support and partnership will help us Humbyrd. During the visit, they discussed the Donations like those from the Drakes help make better diagnose and treat disabling conditions. surgical options. “Dr. Humbyrd put my wife’s research possible, and improve patient care and To make a tax-deductible gift, please visit n dilemma about whether to have surgery, which would strengthen the health care system. bit.ly/orthogift, call 410-955-6936, or send a have involved three to six months off her feet, in the check payable to Johns Hopkins Orthopaedics context of our personal situation,” says Stuart. “She Watch a Q&A with Casey Humbyrd at 601 N. Caroline Street, Suite 5251 understood and related to us. When somebody is in on foot and ankle injuries, at pain, that attitude is enormously reassuring.” bit.ly/humbyrd. Baltimore, MD 21287. The Drakes and Humbyrd discussed the bioethics involved in operating on a foot that may not need it.

HIGHLY SKILLED EXPERTISE

uses an incision of less than 1 centimeter,” Lee to treat less complicated spine conditions such as says. “Outcomes are similar to traditional open disc herniation and spinal stenosis, and can be “Outcomes are similar to traditional surgeries, but there are quicker recovery rates, performed in an outpatient setting. open surgeries, but there are shorter hospitalization times, and it is the better Incorporating this technique will also provide option cosmetically.” Endoscopic surgery is used valuable learning opportunities for surgeons in the quicker recovery rates, shorter spine division’s residency program. “There is a steep hospitalization times, and it is the learning curve of at least 20 initial cases. It requires better option cosmetically.” a steadier hand,” says Lee. Surgeons training in endoscopic surgery participate in cadaver training – Sang Lee courses to refine their techniques. Initially, the endoscopic approach may take one to two hours longer than more invasive procedures. However, the in the clinic, you should be able to picture the skills required are similar to those needed for open spinal cord, nerve roots, vessels, and all the critical surgery. “I explain to students that you need to be structures.” able to see every anatomical characteristic in your Lee is excited by the opportunities available in mind’s eye,” Lee explains. “When you see a patient the spine division, which he says “have expanded greatly in the past two years.” He is eager to help This endoscopic discectomy procedure uses a Johns Hopkins become a leader in endoscopic spine transforaminal approach with access through the surgery among academic institutions, and to provide flank. The incision is less than 1 centimeter long. an option with less tissue damage, less blood loss, and shorter hospitalization and recovery. n

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Johns Hopkins Fall 2019 Framework Orthopaedic Surgery 1 2 3 Will Better Blood Orthopaedic

Inside Osseointegration Management Surgeon’s Ethics Change the Improves Patient Inspire Gifts Future of Outcomes After for Bioethics Prosthetics? Joint Replacement Research