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Johns Hopkins Framework Orthopaedic Surgery NEWS FROM JOHNS HOPKINS MEDICINE Winter 2016 Rotationplasty Offers Greater Functionality for Patients with Cancer aya oberstein was diagnosed with osteosarcoma of Mthe distal femur in 2012, at age 9. After she completed chemotherapy, Maya’s treatment options Since Maya Oberstein’s initial 9.5-hour procedure, Carol Morris has been following were an above-knee up every six months to monitor her progress. amputation, limb salvage side. Cosmetically, if you’re sitting, it’s nice if the with an internal prosthesis or a knees are even.” Morris recalls her initial reluctance about the more unconventional approach: Post-op procedure. “I thought it was a physically challenging If you believe in yourself, rotationplasty. Carol Morris, thing to do to a child when prosthetics had made chief of Johns Hopkins’ tremendous advancements,” she says. “As I gained you can do anything.” more experience in the field, I began to appreciate —MAYA OBERSTEIN Orthopaedic Oncology Division, the limitations of internal prostheses and the is one of a select group of surgeons functionality rotationplasty could provide. For the in the United States who perform right parents and the right child, under the right set of circumstances, rotationplasty is a good operation. this alternative reconstructive It’s much more functional than an above-knee procedure. Morris counseled Maya amputation.” Traditional prostheses, especially growing and her family on the available protheses, are more restrictive than the modified options. “She was the first doctor transtibial prosthesis, limiting a patient’s ability to who asked me how I was feeling,” participate not only in sports, but in typical activities such as running, dancing and jumping. says Maya, “how I was doing.” “It’s a great option for patients with cancer Developed in 1930 to treat femoral deficiency in a around the knee. It’s great for kids who want to be patient with tuberculosis, rotationplasty today may very athletic. It’s even great for adults who want be indicated for lower-extremity bone sarcoma. The to maintain a high level of function,” says Morris. procedure involves resecting the knee while retaining Although there is concern that the cosmetic issue the femoral artery and sciatic nerve. The distal could affect quality of life, Morris says patients who segment is rotated 180 degrees and reattached to the choose rotationplasty “turn out to be some of my proximal segment, converting the reversed ankle happiest patients.” n joint into a functional knee joint. The foot acts as a tibia, fitting into a modified transtibial prosthesis. Rotationplasty presents unique challenges that Morris considers when preparing for the procedure. In younger patients, she says, “you have to calculate Three years after her surgery, Maya has adjusted well to the prosthesis. She is an how much growth they have left in the foot and in active cyclist and gymnast, and she recently the ankle of that side so when they’re done growing, completed a 25-mile bicycle ride to raise the heel matches the level of the knee on the other money for cancer research. TRANSLATIONAL RESEARCH Training in Orthopaedic Team Science homas Clemens is no stranger to transla- tional research. “I’ve spent my entire career in clinical departments working with physi- Tcians on translational research projects,” says the vice chair for research in the Johns Hopkins Department of Orthopaedic Surgery. “What struck me when I joined Hopkins was that the surgeons and residents were so busy, they simply had no time to Thanks to an NIH T32 grant, orthopaedic surgery resident collaborate with us on research projects. We may as John Thompson is taking a year off from his residency to devote himself to research with clinical and research mentors, well have been on different planets.” This separation, including Thomas Clemens, right. popularly known as the “bench-to-bedside gap,” se- verely impedes the translation of new discoveries into clinical practice. faculty and a basic science team to address an to deliver biologic molecules during surgery, but I can Today, however, Clemens has a powerful new important question related to diagnosis or treatment learn the basics from my surgical colleagues. It’s all mechanism for closing the bench-to-bedside gap: of a musculoskeletal disorder. about teamwork: the surgeons to provide input on the a National Institutes of Health-sponsored training The first TOTS-sponsored project joins faculty most pressing clinical questions and the researchers to program called TOTS, short for Training in from several Johns Hopkins departments, including develop the methods to study them. Orthopaedic Team Science. dermatology, orthopaedic surgery and radiology, “The applied nature of orthopaedic science is ideal Clemens believes that the key to developing to study infection in bone via a mouse model in for translational approaches,” he continues. “The great meaningful translational research studies is to create which they can monitor the bacterial burden with diversity of problems that affect the musculoskeletal multidisciplinary teams. “I took a page from what fluorescent bacteria. The aim is to apply their research system provides unique opportunities for training in industry does,” he says. “They form big teams that to treating infection after orthopaedic implant a wide range of fields, including basic cell biology, comprise people from very different backgrounds. surgery, with the goal of avoiding costly revisions. genetics, bioengineering, biomechanics, regenerative Here, we’re consolidating the entire program, Clemens believes this project exemplifies how medicine and public health.” With the support of the bringing surgical faculty, residents and Ph.D. basic effective the team approach can be in developing T32 grant, the Hopkins Orthopaedic Department scientists together on projects.” translational research. “You can’t expect busy is poised to take a lead role in developing the next Because residents are key to its success, the TOTS surgeons to make a genetically altered mouse or generation of therapies that will greatly benefit program sponsors a dedicated research year for an to work in a wet lab culturing cells. That’s our patients with disorders of the musculoskeletal system, orthopaedic resident to collaborate with clinical bailiwick,” he says. “Conversely, I wouldn’t know how such as osteoporosis and arthritis. n CLINICAL DECISION-MAKING Ahead of the Curve: How Clinical Research Drives Pediatric Care aul Sponseller, director of the Many families come to Johns Division of Pediatric Orthopaedic Hopkins because of the specific Surgery at The Johns Hopkins Chil- expertise he offers. Payton Mueller, dren’s Center, has been treating chil- 15, for example, was diagnosed with P spinal muscular atrophy (SMA) after dren at Hopkins for 30 years. His practice is a prime example of the Center’s mission his first birthday. At age 7, he and his to lead innovative research for the treat- mother, Rachele, traveled from their ment of childhood diseases while providing home in North Dakota to a Families continuity of care as children grow. of SMA conference. There they “What’s noteworthy about my connected with Johns Hopkins pediatric practice,” says Sponseller, “is that we neurologist Thomas Crawford, who recommended a thoraco-lumbar-sacral see many difficult syndromic, genetic, “ It’s important to know when not to, as well as when neuromuscular and idiopathic patients orthosis for Payton’s scoliosis. “Dr. to operate,” says Paul Sponseller. “Sometimes the with severe deformities.” Crawford was the one who told us about right decision is a brace, a cast or therapy. Judgment developed over many decades of seeing children grow up can often change the decision.” 2 • framework winter 2016 WWW . HOPKINSORTHO . ORG THOSE WHO GIVE Never Finished: A Commitment to a Healthy Life arid Srour believes that orthopaedic surgeon Srour to come to the hospital immediately. In the first small property in Wheaton, Maryland, and Edward McFarland might have saved emergency department, radiographs showed a screw then another. Soon he was involved in commercial his life. “He is the reason I’m here at Johns protruding from the bone into Srour’s pelvis, which development and continues working to this day, even FHopkins,” says Srour. “Maybe that saved my was ultimately treated by Paul Khanuja, chief of as his four children, three of whom are physicians, life.” adult reconstruction. are retiring. Recently, Srour, who is in his 90s, experienced Pantos describes McFarland as “the lightning His oldest son graduated from the Johns Hopkins unbearable hip pain. He immediately thought to force that organized everything,” helping ensure the School of Medicine and introduced Srour to his call McFarland, who had treated Srour’s shoulder in timely and exceptional care for which The Johns teachers, who gradually became Srour’s doctors. the past. Srour’s companion, Barbara Pantos, drove Hopkins Hospital is known. “My son found McFarland, and that was a lucky him to the Johns Hopkins Emergency Department. A recent article in the journal BMJ Quality & break. He is a wonderful man,” Srour says. When he “It was a miracle that I told Barbara, let’s go to Safety analyzed patient complaints about their first saw McFarland with shoulder pain that Srour’s Hopkins. I want to see McFarland. And when we health care experiences. It found that nearly 14% local doctor said would require surgery, McFarland arrived, they found out what the trouble was. Had I of complaints were related to “communication.” recommended nonoperative treatment, which not done that, I believe I would have died.” In Srour’s experience, a single, dedicated physician ultimately healed the shoulder. That experience Months earlier, Srour had fractured his hip, like McFarland can be the key to avoiding such instilled in Srour deep confidence in McFarland’s which was repaired at his local hospital. Now, he problems. But even beyond McFarland and Khanuja, clinical judgment. was experiencing excruciating pain.

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