LEADING ORTHOPEDICS & SPORTS MEDICINE 2014 - 2015 YEAR IN REVIEW
Our commitment to advancing medicine with global impact begins in Houston, Texas, where we pioneer a better tomorrow through research, innovation and breakthroughs to rewrite the future of health.
THAT’S THE DIFFERENCE BETWEEN PRACTICING MEDICINE AND LEADING IT.
CONTENTS WORLD CLASS CARE: AN OVERVIEW CORRECTING THE UNSTABLE HIP IN BALLET DANCERS PURSUING TRANSFORMATIVE MEDICAL DISCOVERIES GREATER PRECISION AND SHORTER WAIT FOR CARTILAGE TRANSPLANTS BRINGING THE LATEST ADVANCEMENTS TO KNEE SURGERY THE EMERGING PROMISE OF ANTIBIOTIC MICROSPHERES MINIMALLY INVASIVE SURGICAL TECHNIQUES DELIVER BETTER OUTCOMES UNIQUE THERAPEUTIC APPROACHES FOR HAND AND UPPER EXTREMITY PAIN FORGING COMPLEX PATHWAYS IN SPINE
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18
04 06 10
16
12 13 14 16
SURGERY AND MUSCULOSKELETAL ONCOLOGY
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EXPANDING THE REALM OF SPORTS MEDICINE
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EDUCATING FOR TOMORROW
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10
07 08
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2014-2015 AT A GLANCE ORTHOPEDIC SURGICAL CASES
23,832 24,229 2014
2015
JOINT REPLACEMENT PROCEDURES
2,882 2014
37
2,910 2015
Countries represented in patients treated at Houston Methodist Orthopedics & Sports Medicine 2014-2015
WORLD CLASS CARE: HOUSTON METHODIST ORTHOPEDICS & SPORTS MEDICINE From professional athletes and performing artists to everyday athletes and “weekend warriors,” our mission at Houston Methodist is to provide unparalleled orthopedic care. We accomplish this through highly skilled expertise and pioneering research combined with the most sophisticated technology and a steadfast dedication to compassionate, personalized care. Houston Methodist Orthopedics & Sports Medicine is a place of knowledge and progress where patients, educational institutions, governing bodies and the medical research community can turn for the best orthopedic treatment and rehabilitation. LEADING THE WAY IN COMPREHENSIVE ORTHOPEDIC EXCELLENCE Ranked as one of the top 25 orthopedic centers by U.S. News & World Report, Houston Methodist Orthopedics & Sports Medicine is one of the largest, most active in the nation. Our skilled team of orthopedic surgeons, primary care sports medicine physicians, rehabilitation and occupational therapists, and athletic trainers ensure delivery of exceptional care to patients with musculoskeletal disease or injuries. Our ongoing commitment to orthopedic research, through close partnerships with numerous research institutions, is the foundation of our continuing leadership in the diagnosis and treatment of orthopedic conditions. MORTALITY RATES
NEXT GENERATION OF CARE
Expected
0.72%
Observed
0.50%
We provide fully accredited resident and fellowship programs through our primary academic affiliations with Weill Cornell Medicine and NewYork-Presbyterian Hospital. Our curricula are Expected 0.68% designed to prepare the next generation of orthopedicObserved specialists through hands-on training and 0.42% extensive research programs. 2014
2015
MORE THAN
$10 MILLION in research funding
AVERAGE LENGTH OF STAY
MORTALITY RATES Expected
0.72%
Observed
Expected
21
0.68%
Observed
Active clinical protocols
2014
2015
2014
AVERAGE LENGTH OF STAY Days Expected
Days Expected Days Observed
0.42%
Days Observed
Days Expected Days Observed
0.50%
4.39
2015
4.39 4.30
4.42 4.22
MESSAGE FROM THE CHAIR It is a privilege to serve as chair of Houston Methodist Orthopedics & Sports Medicine, where we seek to provide our patients with the best care possible. Throughout 2014 and 2015, we were at the forefront of discoveries in our field and I am pleased to share them with you here. Our continued work with Houston’s elite athletes and performers provided us valuable therapeutic insight into hip microinstability and potential dislocation common in the repetitive, hypermobility of certain professions. For non-athletic patients who suffer from painful hip dysplasia, we are studying the use of preoperative techniques that will allow us to perform less invasive operations for hip preservation. We are investigating the development and use of antibiotic microspheres in joint replacement. The microspheres are tiny pellets that gradually release antibiotics at the site of the implanted device and help prevent infection. Platelet rich plasma (PRP) is also being studied as a viable nonoperative treatment for painful hand problems, testing whether growth factors secreted by PRP will help generate tissue recovery and regeneration in arthritis of the carpometacarpal joint. We continue to expand the realm of sports medicine, primary care sports medicine and endurance testing for athletes. In addition, our community outreach projects with athletic trainers are proliferating in schools as we broaden our reach. We have increased our community education by teaming up with General Electric and the Houston Texans to sponsor the Play Safe program, a series of events for youth athletes, parents and health care professionals. In addition, our partnership with the Biomechanical Environments Laboratory within the Department of Mechanical Engineering at Texas A&M University will significantly escalate the integration of cutting-edge medical research with clinical application. Last year, our faculty was enhanced by the addition of Rex Marco, MD, who brings innovative procedural approaches to advanced spine surgery and musculoskeletal oncology. Our commitment to leading medicine stems from our aspirations for outstanding care and the inspiration of our patients. We invite you to read further about the exciting developments in orthopedic care at Houston Methodist Orthopedics & Sports Medicine.
Kevin E. Varner, MD Chair, Houston Methodist Orthopedics & Sports Medicine
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Joshua Harris, MD, and Sara Webb, principal dancer for Houston Ballet, discuss rigorous positions in ballet, which include hip extension with external rotation.
CORRECTING THE UNSTABLE HIP IN BALLET DANCERS As team physicians for Houston Ballet, clinicians at Houston Methodist Orthopedics & Sports Medicine routinely assess injuries associated with extreme movement. One area of anatomy that frequently suffers from the rigors of balletic activity is the hip. The hips of dancers must maintain maximum flexibility, balance, coordination and strength. When such a hypermobile joint is frequently used to perform movements with extreme range of motion, it can become unstable — a situation called microinstability. This may lead to cartilage injury, labral tears and early arthritis. The anatomy of the hip provides natural stability through the depth of the acetabulum, the harmonious fit of the femoral head within the acetabulum, and the surrounding musculature and tissues. Dancers are at an increased risk for microinstability, which results from subtle anatomic abnormalities and repetitive hip joint rotation and axial loading. A series of four papers published in The American Journal of Sports Medicine, Athroscopy, Journal of Hip Preservation Surgery, and Orthopedics in 2015-2016, co-authored by Kevin E. Varner, MD, chair of Houston Methodist Orthopedics & Sports Medicine, David M. Lintner, MD, chief of sports medicine, Patrick C. McCulloch, MD, orthopedic sports medicine surgeon, and Joshua D. Harris, MD, orthopedic surgeon, shows that athletes whose sports demand flexibility and power, including dancers, gymnasts, yoga, pilates, mixed martial arts and figure skating, have a higher risk for hip microinstability.
“It is critical to determine through preoperative planning if the microinstability is due to capsular laxity,” said Harris. “Capsular plication tightens the hip capsule and the ligaments around the joint. Although the goal is to tighten the capsule, it is important not to over-tighten the iliofemoral ligament and restrict movement.” Dancers with Houston Ballet participated in these studies as part of the unique relationship between the Ballet and Houston Methodist’s Center for Performing Arts Medicine. This distinct partnership allows Houston Methodist physicians to conduct innovative research in how to better diagnose, treat, and prevent performing related injuries. “The center provides performing artists with easy access to Houston Methodist physicians who understand their specialized health care needs,” said James Nelson, executive director of Houston Ballet. “Houston Methodist helps keep our dancers and many other performers on the stage.”
“In athletes and dancers, there may be impingement-induced instability without abnormal cam or pincer deformities,” said Harris, who specializes in sports medicine and arthroscopy and is among the first to research this specific hip dysfunction in athletes. “The spectrum of hip instability in this population is broad and ranges from subtle microinstability to traumatic dislocation.” Nonoperative treatment of symptomatic patients includes rest, activity modification and a microinstability-specific strengthening physical therapy porgram. An intra-articular injection of local anesthetic may also be beneficial and further differentiate an intraand extra-articular disorder. If conservative treatment is unsuccessful, hip arthroscopy with treatment of hip impingement, labral preservation and capsular plication may be performed.
“ The spectrum of hip instability in this population is broad and ranges from subtle microinstability to traumatic dislocation.” JOSHUA HARRIS, MD
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PARTNERING FOR GROUNDBREAKING ORTHOPEDIC CARE In a partnership that will significantly escalate the integration of cutting-edge medical research with clinical application, Houston Methodist Orthopedics & Sports Medicine and the Biomechanical Environments Laboratory within the Department of Mechanical Engineering at Texas A&M University are working to expedite the translation of advanced medical discoveries from bench to bedside. The newly formed Orthopedic Biomechanics Research Laboratory will be housed at Houston Methodist and unites the talents of some of the nation’s top researchers with the clinical skills of leading orthopedic surgeons.
The lab will soon feature a 16-megapixel, state-of-the-art motion capture system to help visualize and capture the fine details of human performance. “We’re one of the first medical institutions to have this system,” Moreno said. “The high resolution cameras will enable us to study the fine details of human motion. We’ll be able to see the effect of physical therapy on osteoarthritis. The inclusion of force plates on the floor provides the information necessary for us to calculate joint reaction forces during an example. For instance, we’ll be able to calculate the forces affecting the knee or hip during some activity of interest.”
“It is vital to the success of a new technology to engage clinicians who have expertise in that area,” said Michael R. Moreno, PhD, assistant professor in the Department of Mechanical Engineering at Texas A&M and research director of the lab. “Our clinicians provide meaningful feedback that informs the design of the devices and answers important questions such as ‘Will it be easy to deploy?’ It is so important to work with clinicians who understand the challenges that must be met to achieve a successful clinical outcome. I believe this partnership will spark a paradigm shift in the way medical research and discovery can be elevated.”
The overall goal of the partnership is to improve clinical outcomes through device-based intervention, postsurgical recovery via physical therapy, and/or prevention of injury through the study of human performance. Financial support for the lab will be through intramural monies and extramural grants from such entities as the National Institutes of Health, the Department of Defense and the National Science Foundation.
NEW APPROACH TO FIFTH METATARSAL REPAIR Currently, physicians at Houston Methodist are working with Texas A&M researchers to create a more effective and reliable procedure for repair of fifth metatarsal fractures. Kevin E. Varner, MD, chair of Houston Methodist Orthopedics & Sports Medicine, and his team are investigating a plantar plating technique as an alternative to intramedullary screw fixation. The procedure uses an implant that will resist rotational instability and plantarlateral gapping by way of a compression plate to the tension of the fracture. “You want to know that when you go in and solve the problem, it is completely solved,” Varner said. “Mechanically, this plate may be a better procedure. Under similar loading conditions, the screw is going to give way, but the plate is not likely to falter.” From left: Ronald Mitchell, MD; Kevin E. Varner, MD; Neil Duplantier, MD; Domenica Delgado, researcher; Bradley Lambert, PhD
NOVEL TECHNOLOGY LAB TRANSFORMS CARE FOR PATIENTS WITH MUSCULOSKELETAL DISORDERS The Surgical Advanced Technology Laboratory at Houston Methodist is a unique place where researchers identify novel technologies not typically used for orthopedic applications and develop them for the benefit of patients with musculoskeletal diseases, disorders and traumas. “Using polymers, scaffolds, unique population of stem cells and nanotechnologies, we have engineered platform technologies that have the potential to be transformational for patient care,” said Bradley K. Weiner, MD, orthopedic surgeon at Houston Methodist and founder of the lab. “At a time when most laboratories worked to develop tissue engineering approaches based on cells cultured ex vivo on scaffolds or in bioreactors, we developed unique materials that leverage the immune and stem cells’ activity as first responders after injury to heal damaged tissues. Our materials are capable of recruiting and instructing stem cells to promote tissue regeneration,” said Ennio Tasciotti, PhD, director of the Center for Biomimetic Medicine at Houston Methodist Research Institute and scientific director at the lab. Researchers at the lab are currently working on polymer shells that stabilize and encourage rapid healing of severe fractures, a tissue-engineered biomimetic periosteum to support bone growth, an improved mesh for hernia repairs, and resorbable nanodelivery systems that locally release analgesic drugs to relieve postoperative pain, eliminating the need for opioids. The lab includes between 25 and 30 physicians, scientists and students at any one time, and has garnered federal and philanthropic funding over ten million dollars. Houston Methodist researchers have applied for several patents based on work completed at the lab and multiple technologies designed here will enter human clinical trials within the next few years.
Bradley K. Weiner, MD, and Ennio Tasciotti, PhD
“ We have engineered platform technologies that have the potential to be transformational for patient care.” BRADLEY K. WEINER, MD
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“ We pioneered the synthesis of scaffolds and membranes that mimic native tissue at the nano- and micro-scale to bestow the function of natural tissues upon synthetic constructs.” ENNIO TASCIOTTI, PHD
BUILDING BLOCKS FOR BONE REGENERATION Significant research is underway at Houston Methodist to potentially revolutionize the orthopedic repair of complex long bone fractures. In 2015, the Department of Defense awarded approximately $6 million to Houston Methodist Research Institute to fund a study on the use of biomimetic scaffolds for the treatment of segmental defects in long bones as a result of massive bone trauma. Ennio Tasciotti, PhD, director of the Center for Biomimetic Medicine and scientific director of the Surgical Advanced Technology Laboratory at Houston Methodist, has helped lead a multi-institutional team of researchers in the development of a regenerative technique that would promote osteogenesis and effectively replace large segments of bone. The procedure could be accomplished during a single operation and would not require the use of any additional hardware — a true revolution in the context of orthopedic surgery. This regenerative strategy incorporates two materials into a structure that synergistically works within the body to mechanically stabilize the site of injury, while promoting faster and better bone healing. Known as BioNanoScaffolds, or BNS, the structure combines a weight-bearing, biodegradable shell made from L-phenylalanine poly(ester ureas), the strongest degradable polymer to date, with the biological function of a natural biomaterial scaffold made from highly porous, biomimetic collagen enriched with hydroxyapatite, the natural mineral component of bone.
“Our approach was to focus on the development of biomimetic scaffolds able to elicit the desired cell and tissue response,” said Tasciotti. “We recognized that the body has incredible healing capabilities and we have worked to harness these to their fullest potential through the design of materials that enhance tissue response during physiologic healing. Our technologies do not rely on externally introduced growth factors and other bioactive stimuli, which often have unintended side effects, but rely on the local activation of the healing cascade.” When implanted, the combined effort of immune and stem cells leads to the integration of the scaffold with the surrounding native tissue. Osteoblasts remodel the collagen fibers and create an additional extracellular matrix, eventually leading to its remodeling into a functional tissue. Within six weeks, the fracture is healed, the implanted materials reabsorbed by the body, and the tissue returns to function at the same levels as prior to the injury. “While surgical advances in the treatment of these severe injuries have been made, far too often the end result is significant disability or amputation. Novel approaches to the problem are warranted and our solution, based upon biomimetic tissue engineering, appears promising,” said Bradley Weiner, MD, vice chair of academics at Houston Methodist Orthopedics & Sports Medicine and clinical lead investigator of this study. Over the next three years, the research team will take the biomimetic scaffolds through the process of moving from the lab to first-in-human clinical trials.
NANONEEDLES: EXPLORING NEW MEDICAL FRONTIERS Ennio Tasciotti, PhD, and his team at Houston Methodist are performing groundbreaking research into the therapeutic uses of biodegradable silicon nanoneedles as a new frontier in the treatment of degenerative diseases, damaged organs and orthopedic injuries. The nanoneedles are made from biodegradable nanoporous silicon, which allows them to bypass the outer membrane and effectively penetrate the cell without harm. The nanoneedles are designed with sponge-like attributes that can load and release considerable amounts of nucleic acids, such as DNA and siRNA, more efficiently than any other system. In a study published in Nature Materials, researchers from Houston Methodist Research Institute showed they could achieve localized gene delivery and induce significant neovascularization in defined areas of the muscle tissue.
“It is a new field of investigation in the life sciences that tries to understand how cells are influenced by mechanical forces,” said Tasciotti. “We are using mechanobiology to train cartilage cells. New cartilage will not form unless it is subjected to force. The nanoneedles can train progenitor cartilage cells to experience the same mechanical stimuli they experience in their natural environment, adjust to these forces, and begin to generate cartilage.” Additional findings on nanoneedle trials by researchers at Houston Methodist and Imperial College London were published in the April 2015 edition of ACS NANO.
“This is a quantum leap compared to existing technologies for the delivery of genetic material to cells and tissues,” said Tasciotti, director of the Center for Biomimetic Medicine, scientific director of the Surgical Advanced Technology Laboratory at the research institute and senior author of the Nature Materials article. “By gaining direct access to the cytoplasm of the cell, we have achieved genetic reprogramming at an incredibly high efficiency. This will allow us to personalize treatments for each patient, giving us endless possibilities in sensing, diagnosis and therapy.” Tasciotti believes that it will be possible one day to help promote the generation of new blood vessels in people using nanoneedles. The nanoneedles will be able to provide transplanted organs or artificial implants with the necessary connections to the rest of the body and help the transplant to function properly with a minimal chance of rejection. Tasciotti’s research experience is frequently integrated into Houston Methodist Orthopedics & Sports Medicine, where he recently became an affiliate professor. Orthopedically, nanoneedles have shown additional benefit through a new and different venue: they initiate regeneration of cartilage by way of mechanobiology.
“ By incorporating nanoneedles on the surface of surgical tools, we will be able to deliver the genes necessary to repair and reset the cell programming to different parts of the body.” ENNIO TASCIOTTI, PHD
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LEADING ORTHOPEDICS & SPORTS MEDICINE
Patrick McCulloch, MD
GREATER PRECISION AND SHORTER WAIT FOR CARTILAGE TRANSPLANTS Houston Methodist orthopedic surgeons perform the highest volumes of cartilage transplants in Texas for both autologous chondrocyte implantation (ACI) and allograft cartilage transplant. Our physicians are also working to discover more effective treatments that will directly benefit patients. Patrick McCulloch, MD, orthopedic sports medicine surgeon at Houston Methodist, specializes in cartilage repair and transplant. Currently, he is leading several studies in meniscus repair, meniscus transplant and cartilage transplant. At the International Cartilage Repair Society World Congress, McCulloch recently presented a new system that results in more effective use of rare donor tissue in osteochondral allograft transplants. By using 3-D surface scans of donor grafts, physicians are able to find appropriate grafts from knees of varying sizes as well as from different areas of the knee, which expands the ability for tissue match.
“ Our research demonstrates that using 3-D scans shortens the wait for patients who need donor tissue and ensures a better fit for the transplanted tissue.” PATRICK MCCULLOCH, MD
“Our research demonstrates that using 3-D scans shortens the wait for patients who need donor tissue and ensures a better fit for the transplanted tissue,” McCulloch said. “We are also able to reduce the number of wasted grafts in tissue banks.” He also performs autologous chondrocyte implantation, which is the first and only FDA-approved cell therapy for cartilage problems. After a biopsy of healthy cartilage has been performed, the cells are grown in the lab and then implanted back into the patient’s own knee. “The ability to expand a patient’s healthy cells to regenerate cartilage is a reality in orthopedics today. We also are working on scaffolds and the use of other cell lines to further expand the indications for these types of procedures,” McCulloch said. Houston Methodist is a study center for a novel tissue-engineered cartilage therapy seeking FDA approval.
Houston Methodist residents and fellows are able to acquire and refine skills in cartilage transplant through didactic and hands-on learning opportunities at our advanced surgical training facility, the Houston Methodist Institute for Technology, Innovation & EducationSM (MITIE). Additionally, Houston Methodist specialists teach courses in cartilage injury and transplant at the Arthroscopy Association of North America each year.
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ADVANCES IN KNEE IMPLANTS IMPROVE FUNCTION, PAIN, SUCCESS RATES TKA: IMPROVING TECHNIQUES FOR ACCURACY OF PLACEMENT AND PRESERVATION OF NATURAL LIGAMENTS
ROBOTIC SURGERY MAKES PARTIAL KNEE REPLACEMENTS MORE ACCURATE
Although total knee arthroplasty (TKA) ranks as one of the most successful operative procedures in medicine, problems can develop from natural wear and tear or infection. Surgeons at Houston Methodist Orthopedics & Sports Medicine study advanced procedures, management techniques and the latest technology to provide excellent outcomes when knee revision surgery is required, regardless of the cause.
Incavo, who specializes in joint replacements, offers patients a new robotic procedure for partial knee replacements that provides customized accuracy for each patient.
When infection is the culprit, it may occur immediately after surgery or years later. In a study published in the Journal of Arthroplasty, Stephen Incavo, MD, section chief of adult reconstructive surgery at Houston Methodist and professor of clinical orthopaedic surgery at Weill Cornell Medicine, reported on successful two-stage revision arthroplasty for the infected knee using articulating spacers made of gentamicin-impregnated cement. At a two-year follow up, infection was eradicated in 90 percent of cases with no adverse effects on soft tissue, spacer fractures or dislocations. In further studies of TKA, Incavo and the research team looked at the importance of tibio-femoral conformity on anteroposterior knee stability during stair descent with a dished cruciate sacrificing design replacement. This stepping action, when simulated on cadaveric knees, showed that stair descent caused femur displacement anteriorly prior to quadriceps contraction. The team’s findings and proposed surgical correction were published in the June 2015 issue of Journal of Arthroplasty. Currently, Incavo and his team are improving techniques for accuracy of placement and preservation of natural ligaments, two crucial components of TKA that prolong the life of the replacement and reduce pain and recovery postsurgery. “We are also evaluating knee replacements that target the most demanding motions of everyday life, such as kneeling and squatting, as we look ahead to the possibility of more activity-specific functionality in the future,” said Incavo.
“A robotically assisted partial knee replacement is a unique surgical option for patients because accurate placement is the key to the implant working well and lasting a long time,” he said. Using a new robotic system called the NAVIO™ Surgical System, manufactured by Smith & Nephew, the surgeon generates patient-specific images and maps out exactly where the implant needs to go. The surgeon uses 3-D anatomical mapping of the patient’s knee to precisely control robotic movements that achieve a high level of accuracy and consistency.
Stephen Incavo, MD, performs robotic- assisted partial knee replacement.
THE EMERGING PROMISE OF ANTIBIOTIC MICROSPHERES Terry Clyburn, MD, orthopedic surgeon at Houston Methodist Orthopedics & Sports Medicine, believes that infection control in joint replacements — and wounds in general — can be greatly augmented by the use of antibiotic-containing microspheres. Clyburn has been working on the development of antibiotic microspheres, as well as orthopedic instrumentation and other surgical developments, for nearly 15 years. During this period, Clyburn and his team have published their incremental findings on microspheres research in such publications as The Journal of Bone & Joint Surgery and Clinical Orthopaedics and Related Research.
The microspheres are made from polylactic-co-glycolic acid (PLGA), which is commonly used for internal stitches or screws that are naturally resorbed by the body over time. The antibiotic is dispersed evenly within the PLGA structure. When placed at the site, the bioresorbable polymer microspheres dissolve and the antibiotic is gradually released over a controlled period of time. Clyburn and his research team have designed the structures to deliver antibiotics for up to six weeks. The antibiotic level in the tissue exceeds the minimum inhibitory concentration for the common organisms that cause infection, which significantly reduces the risk of infection while facilitating healing.
“The microspheres are tiny pellets that look like salt,” Clyburn said. “We have put these antibiotic microspheres into the tissue of murine models and we’ve cured infection with them. We have also put the microspheres on devices, implanted them, and shown that the antibiotic microspheres will protect the implanted device from infection.”
“There are approximately 1 million total joint replacements performed each year,” Clyburn said. “With an infection rate from 1-3 percent and with a cost of infection treatment of $70,000 or more per patient, we are hopeful that this material can be approved for clinical use. If we could cut the risk of infection in half, it would save billions of dollars per year in costs of treatment.” houstonmethodist.org/orthopedics
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Luis Pulido, MD
At Houston Methodist, surgeons use a less invasive approach through a smaller incision and fluoroscopy to enhance visualization and precision during surgery.
PELVIC OSTEOTOMY PRESERVES HIP AND DELAYS ARTHRITIS Houston Methodist orthopedic surgeons offer a specialized treatment for young adults with painful hip dysplasia, called periacetabular osteotomy (PAO). Compared to other traditional pelvic osteotomies, PAO uses a small, single incision that allows the surgeon to preserve the posterior pelvis and provide for reorientation of the socket in all planes, while not impacting blood supply to the hip socket. “PAO is a true hip preservation operation. It reduces stress loads across the socket, improves hip pain, and may delay the onset of osteoarthritis,” said Luis Pulido, MD, orthopedic surgeon at Houston Methodist. Pulido specializes in hip preservation and replacement and was granted a special fellowship to train with some of the most renowned leaders of this technique in Switzerland, where the practice originated.
Since PAO was first described in 1988, the technique has evolved. At Houston Methodist, surgeons use a less invasive approach through a smaller incision and fluoroscopy to enhance visualization and precision during surgery. With this technique, the origin of the hip abductor muscles is preserved and, in some cases, the origin of the rectus femoris can also be preserved. Hip dysplasia is a complex misalignment issue and biomechanical concept, but the hip joint can be preserved after reorientation with a PAO. Physicians at Houston Methodist are also researching ways to improve outcomes for patients. Pulido’s current research interests include the use of advanced imaging in the preoperative evaluation and surgical planning of periacetabular osteotomy to improve postoperative outcomes.
UNPRECEDENTED SUCCESS WITH MINIMALLY INVASIVE HIP REPLACEMENTS Daniel Le, MD, orthopedic surgeon and joint specialist at Houston Methodist Orthopedics & Sports Medicine, is demonstrating that a less invasive approach to hip surgery can significantly impact patient outcomes from both a clinical and holistic perspective. At Houston Methodist Willowbrook Hospital, Le continues to be one of the few orthopedic surgeons in the United States currently performing minimally invasive hip replacement procedures by way of a micro-posterior approach. Using the HipXpert mechanical navigation system, together with the supercapsular percutaneously assisted total hip (SuperPATH) approach, Le has performed more than 250 hip replacements for patients who had a rapid recovery without any dislocation sequelae. “The acetabular component is very hard to position by hand,” Le said. “The HipXpert allows me to get a reference point based on a CT scan of the patient’s pelvis, and a 3-D model based on that scan. The HipXpert resembles a sextant. It is docked on the patient’s pelvis based on certain landmarks, and then I geometrically determine where the cup needs to point.” Le uniquely combines the HipXpert with the innovative SuperPATH technology. This supercapsular approach spares the soft tissue structures and does not require hip dislocation/relocation when performing the hip replacement. The SuperPATH procedure builds the tools and traditional hip implant in-situ, which also prevents the need for unnatural positioning during surgery. Superior outcomes for Le’s hybrid procedure have placed Houston Methodist Willowbrook in a position of leadership for hip replacement surgery. “Our work in subspecialized joint reconstruction care has led to Houston Methodist Willowbrook being designated as a Center of Excellence by BlueCross and BlueShield, as well as the Boeing Company,” Le said.
Daniel Le, MD
The SuperPATH procedure builds the tools and traditional hip implant in-situ, which also prevents the need for unnatural positioning during surgery. houstonmethodist.org/orthopedics
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Shari Liberman, MD
UNIQUE THERAPEUTIC APPROACHES FOR HAND AND UPPER EXTREMITY PAIN Physicians at Houston Methodist Orthopedics & Sports Medicine are exploring ways to broaden how we treat injuries of the hand and upper extremities. In two studies currently underway, Shari Liberman, MD, Houston Methodist hand and upper extremity surgeon, is examining the healing properties of platelet rich plasma (PRP) — commonly used in operative procedures to promote healing — as an alternative to surgery for arthritis of the carpometacarpal (CMC) joint and de Quervain’s tenosynovitis. LESS INVASIVE TREATMENT FOR CMC JOINT ARTHRITIS Although current noninvasive treatment options, such as splinting or steroid injections, can be effective for CMC joint arthritis, the duration of pain relief can be limited. According to Liberman, regenerative medical treatment with PRP injection therapy may offer a more viable nonsurgical treatment option. “PRP is derived by collecting a sample of the patient’s blood and separating the platelets from whole blood by way of centrifuge,” Liberman said. “The PRP is then injected into the intra-articular area of injury where the platelets secrete growth factors that stimulate tissue recovery through a healing cascade. This includes an influx of blood, increased collagen production, a proliferation of cells and tissue remodeling.”
Ongoing studies by Liberman and her team ideally will demonstrate the potential superiority of PRP injections for CMC arthritis. HEALING THE TENDON ENTRAPMENT OF DE QUERVAIN’S TENOSYNOVITIS Entrapment of the abductor pollicis longus and the extensor pollicis brevis tendons — either through thickening of the tendon sheath or inflammation of the tendons — can ultimately result in de Quervain’s tenosynovitis, the most common overuse injury of the upper extremity. “Once the sheath or tendons thicken, they don’t fit anymore,” Liberman said. “It’s a vicious cycle: the more you move your thumb, the more you hit against the sheath, which causes pain.” She sees PRP therapy as a potentially more viable treatment option, similar to what she envisions for CMC arthritis therapy. “We hypothesize that injecting PRP into the area will reduce the inflammation and decrease the size of the tendon, allowing it to glide easily within the sheath,” Liberman said. “I’m in the early process of studying it, but PRP is something exciting that I’m offering patients.”
“ PRP is injected into the intra-articular area of injury where the platelets secrete growth factors that stimulate tissue recovery through a healing cascade.” SHARI LIBERMAN, MD
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REX MARCO, MD, BRINGS DISTINCT TRAINING TO HOUSTON METHODIST
With the arrival in January 2015 of Rex Marco, MD, as vice chair of orthopedic surgery and chief of reconstructive spine surgery and musculoskeletal oncology, Houston Methodist further enhances its reputation for excellence through the treatment of complex spinal disorders and benign and malignant tumors of bone and soft tissue. Marco’s path of training was unique, beginning with a research fellowship at the National Institutes of Health, followed by his medical training at the University of California, Los Angeles School of Medicine. After completing his residency in orthopedic surgery at the University of California’s Davis Medical Center, Marco double-specialized and completed two fellowships: a musculoskeletal
oncology fellowship at Memorial Sloan Kettering Cancer Center in New York City and a spine surgery fellowship at Rush-Presbyterian-St. Luke’s Medical Center in Chicago. “I wasn’t aware of any other surgeon who had training and expertise in both complex spine surgery and musculoskeletal oncology, so I felt it was important to combine these two fields to provide improved care for patients with spinal column tumors,” Marco said. “It is critical to fully comprehend the indications for resection, chemotherapy, radiation therapy and surgery to optimize treatment for these patients.”
Marco’s goal is to build a nationally and internationally recognized reconstructive spine surgery and musculoskeletal oncology center. “The creation of such an unprecedented center summarizes our objectives,” Marco said. “We want people to fly in from all over the world to receive care from our team.”
Right-sided internal hemipelvectomy
Jenny Chang, MD, director of the Houston Methodist Cancer Center, agreed. “The addition of Rex Marco and his unique skills in musculoskeletal oncology will help us offer some of the most aggressive and sophisticated cancer care in the country,” Chang said. Essential to excellence in care was the assembly of an elite multidisciplinary team to treat patients with complex spinal disorders or musculoskeletal tumors. “We have an elite team of oncologists, radiation oncologists, bone and soft tissue pathologists and musculoskeletal radiologists who help us optimize the care of our patients with bone and soft tissue tumors,” said Marco. “We also have a fantastic team of physiatrists, pain management specialists and neuropsychologists who help us manage our patients with spinal disorders.” Marco is distinguished, in part, by the challenging, sophisticated resections he and his team perform on patients who otherwise might not survive. “Very few doctors in the world do what we do,” Marco said. “We perform hemipelvectomies, which are resections of the leg and half of the pelvis on one side. A hemipelvectomy is one of the rarest forms of lower extremity amputation. I also have had success with hemicorporectomies, where we actually cut the body in half for patients who have severe problems with their pelvis or lower body.” In addition, Marco performs en bloc resections of spinal and sacral malignant primary bone tumors, a very complex operation that decreases the likelihood of tumor recurrence. Moreover, Marco is recognized for his treatment of spinal deformities such as scoliosis, spondylolisthesis and kyphosis. These disorders often require spinal osteotomies and reconstructive spine surgery.
“ Very few doctors in the world do what we do.” REX MARCO, MD
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SPECIALIZED CARE FOR ATHLETES OF ALL TYPES Houston Methodist Orthopedics & Sports Medicine integrates the medical field’s most sophisticated diagnostics, procedures and clinical research in response to the unique injuries and health requirements of both professional and everyday athletes.
Houston Methodist is the destination of choice for Houston’s premier sports teams and fine arts organizations.
Whether treating elite professionals, high school competitors or everyday athletes, the specialists at Houston Methodist Orthopedics & Sports Medicine strive to maximize all aspects of human performance. The close collaboration among our orthopedic surgeons, primary care sports medicine experts, athletic trainers and physical therapists has led to a stellar reputation of excellence in sports medicine, and has made us the health care destination of choice for Houston’s premier sports teams and fine arts organizations. We are extremely proud to be the official health care provider for the Houston Texans, Houston Astros, Houston Dynamo, Houston Dash, RodeoHouston® ®, Rice University Athletics, Houston Ballet, Houston Symphony and Houston Grand Opera. “We provide these professionals with the best care out there,” said David Lintner, MD, chief of sports medicine at Houston Methodist. “Even better is that in treating these elite athletes we can study and apply the effects of high-level performance on the mechanics of the human body.” DISTINCTIVE CARE Houston Methodist Orthopedics & Sports Medicine is distinguished by its sophisticated diagnostics and innovative procedures, both for the professional and the amateur athlete. Excellence in medical care begins at the research level, in which Houston Methodist has a rich legacy. “In 2015, Houston Methodist had more than 30 published manuscripts and 15 international presentations on sports medicine,” said Patrick McCulloch, MD, orthopedic sports medicine surgeon and director of fellowship research. “Currently, our physicians and fellows have more than 40 ongoing research projects.”
In a recent study, Joshua Harris, MD, orthopedic surgeon at Houston Methodist, evaluated the return-to-sport rate after anterior cruciate ligament (ACL) tears in National Football League (NFL) quarterbacks, National Basketball Association (NBA), National Hockey League (NHL) and Major League Soccer (MLS) players, due to the cutting and pivoting demands of these sports. “There are nearly 250,000 ACL tears each year in the United States and that number is increasing,” Harris said. “Research in causes, treatment and recovery of ACL tears is important because it helps us better understand ways to treat and potentially prevent these injuries.” Active research studies are evaluating injury risk factors in certain athlete groups. “We are looking at the predisposition toward injury with abnormal hip motion in baseball, using digital photography and sophisticated motion capture systems,” Lintner said. “We’re also looking for new ways to accurately measure the range of motion and power of various joints by testing the accuracy of digital photography versus traditional measurement methods.” PRIMARY CARE SPORTS MEDICINE For overall care of the athlete, primary care sports medicine is an excellent match to the sporting lifestyle. “We have the expertise to help manage a broad list of injuries or medical conditions as they relate to the active individual,” said David A. Braunreiter, MD, primary care sports medicine physician at Houston Methodist Sugar Land Hospital and team physician for the Houston Dynamo. According to Travis W. Hanson, MD, orthopedic surgeon at Houston Methodist Willowbrook Hospital and team physician for Rice University, primary care sports medicine physicians treat the nonoperative injuries and the nonmusculoskeletal aspects of an athlete — areas not often considered in a strictly orthopedic discipline. “Houston Methodist offers more all-encompassing management of an athlete’s health than most centers because of the high quality of collaboration between our orthopedic surgeons and primary care sports medicine physicians,” Hanson said.
Patrick McCulloch, MD, team physician for the Houston Astros PHOTO: Alex Bierens de Haan, Houston Astros
HUMAN PERFORMANCE LAB
COMPREHENSIVE SPORTS MEDICINE PROGRAM
To further help athletes understand their own stamina and physiological response to extreme activity, Houston Methodist Willowbrook Hospital developed a human performance lab. “Our human performance lab started as a metabolic lab where athletes of all levels were tested to determine their fitness level,” said Scott Rand, MD, Houston Methodist primary care sports medicine physician and medical director of the lab. Ultimately, the performance lab can help place athletes in training programs that will help improve their times in endurance events. “Our lab is similar to the metabolic testing done at the Olympic training center and at NASA,” Rand said.
Houston Methodist’s commitment to excellence in sports medicine is evident at all levels, including in its support of the Houston community student athletic programs. Physicians serve as team doctors and consultants to many of the area’s middle and high school teams. As part of this program, doctors hold Saturday morning clinics to help student athletes get treatment for injuries during practice and games. These clinics provide easy access to specialists and physical therapists, as well as on-site imaging and rehabilitative services. Parent education is also provided. houstonmethodist.org/orthopedics
22 LEADING ORTHOPEDICS & SPORTS MEDICINE
BRINGING SPORTS MEDICINE TO THE COMMUNITY In a first-of-its-kind collaboration of sports, science and medicine, Houston Methodist is working with the Houston Texans and General Electric (GE) to improve sports medicine education in the Greater Houston area. Houston Texans Play Safe program is a platform with three dynamic components: football clinics for student athletes, emphasizing concussion awareness and the importance of proper hydration and nutrition; a moms clinic covering the same topics from a parent’s perspective; and a summit for athletic trainers and health care providers that features current trends in sports medicine. “At GE, we are working with the National Football League and some of the leading academic hospitals on a research and innovation partnership around concussions,” said Jeff Hersh, chief medical officer at GE Healthcare. “In Houston, we wanted to start making a difference on the front lines of the issue — with kids, parents, coaches and trainers. Injury prevention is key to staying healthy and in the game.” “Parents are often the first to recognize when their child is in pain or needs medical attention,” said Kevin Varner, MD, Houston Methodist orthopedic surgeon and Houston Texans team orthopedist. “Educating parents on how to properly prepare their young football player for the game and what to watch for during and after the game can help prevent small issues from becoming serious injuries.” The Houston Texans also hosted the Play Safe Sports Medicine Summit, an interactive continuing education event for athletic trainers, physical therapists, and strength and conditioning coaches at the Houston Methodist Training Center. Attendees learned about the latest trends in sports medicine and proper nutrition for young athletes and participated in hands-on sessions to practice dynamic warmups and administering EKGs to check for heart abnormalities.
“The Houston Texans Sports Medicine staff is honored and privileged to partner with two great companies in GE and Houston Methodist, who are leaders in medicine,” said Geoff Kaplan, Houston Texans director of sports medicine and head athletic trainer. “We pride ourselves in being leaders in sports medicine and partnering on the Play Safe Sports Medicine Summit gives us the ability to share our experiences and knowledge with fellow athletic trainers, physical therapists and the community.” In another large community endeavor, the Houston Texans Foundation presented a $25,000 NFL Certified Athletic Trainer Grant to Houston Methodist’s athletic training services program. The grant will help send athletic trainers to communities where medical professionals are not readily available to provide care during sporting events or consultations on injury prevention. “Our mission is to take the standards of care for which Houston Methodist is known and share it with the community,” said Jace Duke, ATC, LAT, manager of athletic training services at Houston Methodist. “We have 72 athletic trainers and we each do something different to meet the specific requirements and needs of the communities we serve.”
The Houston Texans Play Safe program is a first-of-its-kind collaboration in the NFL for GE and Houston Methodist.
Vijay Jotwani, MD; Kim Akers, physical therapist; Steven Potter, GE Healthcare
24 LEADING ORTHOPEDICS & SPORTS MEDICINE
ENDURANCE MEDICINE HELPS ATHLETES GO FARTHER The Houston Methodist Endurance Medicine Program addresses the specialized needs of a popular and growing cohort: endurance athletes. Marathon runners, triathletes, cyclists, swimmers and others are a distinct breed of athlete with unique needs. “We are one of the first centers in the United States to establish an endurance medicine program,” said Joshua Harris, MD, orthopedic surgeon and founder of the program. “Our orthopedic and sports medicine specialists, along with experts in radiology, cardiology, physical therapy and rehabilitation, work together to address injury prevention, evaluation, diet and performance. The program is designed to keep endurance athletes active in the sports they love.” In addition to treatment, the program drives research on injuries that are common to this class of athlete, including impingement, microinstability and stress fractures.
As part of a new study, Harris and his research team at Houston Methodist will use delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) to measure the biomechanical and biochemical function of cartilage in the hips and knees of endurance runners. They will compare results of dGEMRIC images of 20 elite professional marathoners who participated in the Houston Marathon with a similar group of 20 first-time marathoners. The study will evaluate whether the body adapts over long periods of training, resulting in fewer stress fractures or other injuries in elite athletes, compared to weekend warriors who train for a few months to run a marathon. A similar study will be conducted with triathletes. As the official health care provider for the Houston Texans, Houston Astros, Houston Dynamo, Houston Dash, Rice Athletics, RodeoHouston and the Houston Ballet, our orthopedics and sports medicine experts can leverage their experience to provide the best care for all endurance athletes.
“ We are one of the first centers in the United States to establish an endurance medicine program.” JOSHUA HARRIS, MD
RUNNING ON EMPTY: FEMALE ATHLETE TETRAD Physicians at Houston Methodist Orthopedics & Sports Medicine understand that female athletes are uniquely prone to develop what is known as the female athlete tetrad, a group of disorders characterized primarily by poor calorie balance, amenorrhea and stress fractures. The female athlete tetrad is instigated by the athlete consistently burning more calories than she ingests. The body will compensate for insufficient caloric intake by conserving and scrimping on other areas of function, such as menstruation or bone regrowth, which can lead to osteopenia, osteoporosis and stress fractures. “Physicians have long known about the connection between calorie imbalance, missed periods and stress fractures, but new research is indicating impacts on the vascular system, which is how the female athlete triad became the tetrad,” said Vijay Jotwani, MD, a Houston Methodist primary care sports medicine physician and team physician for Rice University Athletics. “Studies have shown that flow-mediated dilatation (FMD), which is considered by some to be an endothelium-dependent function, can be a serious consequence of caloric imbalance.” The FMD response may be an early risk marker of cardiovascular disease. “The cardiovascular association is a new finding,” Jotwani said. “One theory suggests the tetrad creates an inhibiting mechanism in the calcium channels that allow the blood vessel to dilate properly.” According to Jotwani, it is critical to understand that this tetrad of dysfunction is not necessarily temporary. “It potentially can have long-lasting effects on bone and cardiovascular health,” he said.
“ New research is indicating impacts on the vascular system, which is how the female athlete triad became the tetrad.” VIJAY JOTWANI, MD
26 LEADING ORTHOPEDICS & SPORTS MEDICINE
EXPANDING SCOPE OF REGIONAL ATHLETIC TRAINERS According to Duke, the job of the athletic trainers is to successfully integrate medical care where it is needed in the sporting community. “The hospitals in the Houston Methodist system are doing orthopedics sports medicine, primary care sports medicine and concussion care. This provides the resources for our wide reach,” said Duke. Continued growth of this successful sports outreach program requires consistent monitoring of sporting trends and medical technologies. “In addition to schools, we have expanded our services to the Houston sports athlete, the weekend warrior and adult league athletes,” said Duke. “We will continue to place an emphasis on making sure we take care of the complete athlete on all levels.”
Throughout the past year, Houston Methodist Orthopedics & Sports Medicine has doubled the number of athletic trainers who assist student athletes in the community. This service extends to elementary, junior high and high schools, and an increasing number of community programs outside of school.
72
55
LICENSED ATHLETIC
SATURDAY SPORTS
TRAINERS
INJURY CLINICS AT FIVE LOCATIONS
This healthy boost in athletic trainer staffing results from several factors: an overwhelming reception from the community; grant support from the Houston Texans to help schools in underserved communities; and additional monies from the Houston Texans and General Electric to promote Play Safe, an education initiative for athletes, parents and health care providers on critical medical issues that affect student athletes. The coverage area for Houston Methodist athletic trainers spans more than 500 schools. “Some locations serviced are roughly 100 miles from our nearest facility,” said Jace Duke, ACT, LAT, manager of athletic training services at Houston Methodist. “We strive to provide programs that fit specific sporting environments and regions. Of our 72 licensed athletic trainers, none truly has the same job.”
MORE THAN
2,500
COMPREHENSIVE
MORE THAN
500
SCHOOLS SUPPORTED THROUGH THE ATHLETIC
PROVIDED EACH YEAR
TRAINING OUTREACH
MORE THAN
MORE THAN
3,500 CONCUSSION
PROGRAM
20,000
COACHES, PARENTS AND
STUDENT PHYSICALS
BASELINE TESTS
ATHLETES IMPACTED
PROVIDED EACH YEAR
PERFORMED ON AN
THROUGH SPORTS MEDICINE
ANNUAL BASIS
EDUCATION EACH YEAR
TWITCHING THE PAIN AWAY Functional dry needling is the latest technique used by physical therapists at Houston Methodist Orthopedics & Sports Medicine to help quell acute or chronic pain associated with a musculoskeletal injury. “This procedure involves insertion of a solid fine filament needle into a trigger point, a small knot or painful area in a muscle to stimulate a small twitch,” said Matt Holland, PT, CSCS, Houston Methodist physical therapist. “The twitch can help release tight muscles and decrease pain.” Insertion of the fine filament needles causes little discomfort in healthy muscles. If the muscle is sensitive, a brief cramping sensation — referred to as a “twitch response” — can occur. A National Institutes of Health study demonstrated that the twitch response can cause favorable biochemical changes that help to ameliorate pain and appears to be the first step in stopping the cycle of pain. “This is a great tool for athletes to decrease muscle soreness, increase muscle function, and increase flexibility,” said Geoff Kaplan, Houston Texans director of sports medicine and head athletic trainer. “The research behind functional dry needling supports the benefits to patients, but the biggest reason we use it regularly with our players is because our athletes feel significantly better after the procedure.” Dry needling can be used to treat a variety of conditions and provide pain relief. Treatment with functional dry needling requires an assessment of the deficits in the musculoskeletal system and identification of the trigger points associated with those deficits. Any muscle that contains a trigger point can benefit from dry needling. Common treatment areas are the neck, shoulder, hip, quadriceps, foot and ankle.
PHOTO: Brett Coomer/®©Houston Chronicle Used with permission.
“ This is a great tool for athletes to decrease muscle soreness, increase muscle function, and increase flexibility.” GEOFF KAPLAN, HOUSTON TEXANS DIRECTOR OF SPORTS MEDICINE AND HEAD ATHLETIC TRAINER
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28 LEADING ORTHOPEDICS & SPORTS MEDICINE
Joshua Harris, MD, (left) with orthopedic surgery residents
Residents at Houston Methodist receive hands-on training with fellowship-trained mentors in all subspecialties during the five-year program.
PREPARING THE NEXT GENERATION: ACADEMIC PROGRAMS IMMERSION TRAINING ELEVATES SURGICAL RESIDENCY
PHYSICAL THERAPY RESIDENCY
For more than 50 years, Houston Methodist has served as a teaching hospital for orthopedic surgery residents. In 2012, we established an independent Accreditation Council on Graduate Medical Education-accredited residency program, which includes rotations in all subspecialties: joint reconstruction, spine, sports medicine, hand and upper extremity, foot and ankle, trauma, pediatrics, orthopedic oncology and general orthopedics.
The Houston Methodist physical therapy residency is an American Physical Therapy Association (APTA)-credentialed postprofessional residency for licensed physical therapists who wish to pursue board certification in sports physical therapy. The year-long program accommodates two physical therapists and provides intensive exposure to elite athletes and professional sports teams that are affiliated with Houston Methodist.
Residents at Houston Methodist receive hands-on training with fellowship-trained mentors in all subspecialties during the five-year program. They also work exclusively with one or two attending physicians on each rotation in the clinics, on the floors, in the operating rooms and in personalized didactic and case sessions.
“Residents have the unique opportunity to work with the Houston Texans, Astros, Dynamo, Dash and Rice University to get experience caring for higher level athletes,” said Matt Holland, PT, CSCS, sports rehabilitation specialist at Houston Methodist Orthopedics & Sports Medicine and director of the physical therapy residency program.
“Our immersion-style educational setting is designed to fully prepare residents to enter directly into practice, to pursue fellowship training, or to enter academics,” said Bradley K. Weiner, MD, residency program director at Houston Methodist. Basic, clinical and translational research is expected. The program offers individual surgeons as mentors for clinical research and access to all the resources of Houston Methodist Research Institute to support basic research interests. Residents are actively engaged in the Surgical Advanced Technology Laboratory, a translational research lab that is dedicated to developing novel technologies to benefit orthopedic patients.
Physical therapy residents also participate in structured learning programs with surgeons and fellows, which includes weekly hands-on training and use of the cadaver lab in MITIE℠. Last year’s residents performed preseason screenings for the Houston Astros organization. “We evaluated the athletes through balance testing and specialized strength testing to determine areas for enhancement,” said Holland. “The residents performed preseason and mid-season measurements and were able to compare findings.”
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30 LEADING ORTHOPEDICS & SPORTS MEDICINE
PRIMARY CARE SPORTS MEDICINE FELLOWSHIP Houston Methodist Orthopedics & Sports Medicine continues to set precedents for athletic care. One venue is through the provision of a fellowship program in primary care sports medicine. As a subspecialty of several different boards, enrollment in the fellowship requires certification in an additional specialty such as family, internal, emergency, physical/rehabilitation medicine or pediatrics. It is a one-year fellowship accredited by the Accreditation Council on Graduate Medical Education. “We offer two of only three primary care sports medicine fellowships in the Houston area,” said Scott Rand, MD, director of the primary care sports medicine fellowship at Houston Methodist Willowbrook Hospital. Although the fellowship training offers a broad exposure to musculoskeletal disorders, more than half of the program focuses on other problems that can affect athletes, such as cardiac issues, asthma, concussion and unique complications associated with the endurance athlete. ADULT RECONSTRUCTIVE SURGERY FELLOWSHIP A one-year fellowship in adult reconstructive surgery is designed to provide clinical and research experience in total knee and hip replacement. Fellows gain extensive hands-on experience in muscle-sparing reconstructive surgical approaches and advanced arthroscopic and reconstructive surgery of the knee, shoulder and elbow. “Our fellows get a broad exposure to a high volume of diverse patients. They see straightforward and complex hip and knee replacement cases and learn a variety of state-of-the-art techniques and procedures,” said Stephen Incavo, MD, orthopedic surgeon and hip and knee replacement specialist at Houston Methodist. Research is a highlight of this fellowship program, and the Houston Methodist research facilities are available to each fellow to help facilitate investigation that is performed in direct collaboration with teaching faculty and our dedicated staff of engineers, clinical research specialists and computer scientists.
ORTHOPEDICS SPORTS MEDICINE FELLOWSHIP The Houston Methodist orthopedics sports medicine fellowship is an intensive one-year training program in advanced techniques within sports medicine, with extensive exposure to caring for elite athletes, both collegiate and professional. “Our fellows spend almost as much time in the field as they do in surgery and clinic,” said David Lintner, MD, chief of sports medicine at Houston Methodist and director of the orthopedics sports medicine fellowship program. The sheer volume of clinical experience our fellows get – both in scope and breadth – makes our program unique. They are able to work with athletes from high school and Division I college athletics to professionals in the MLB, MLS, NWSL and NFL. Lintner believes the education fellows receive while working with elite sports performers translates into exemplary care for the everyday athlete.
SPINE FELLOWSHIP PROGRAM
“ The sheer volume of clinical experience our fellows get – both in scope and breadth – makes our program unique. They are able to work with athletes from high school and Division I college athletics to professionals in the MLB, MLS, NWSL and NFL.” DAVID LINTNER, MD
The new spine fellowship at Houston Methodist offers extensive training in the evaluation and treatment of diverse spinal disorders for both orthopedic surgeons and neurosurgeons. Specific rotations provide comprehensive assessment and treatment of degenerative disorders of the cervical and lumbar spine, spinal column trauma, tumors of the spinal cord, pain management, and adult and pediatric spinal deformities. Fellows rotate to locations within the Houston area with pain management specialists, neurosurgeons and orthopedic spine surgeons. According to Rex Marco, MD, vice chair of reconstructive spine surgery, chief of musculoskeletal oncology at Houston Methodist, and director of the fellowship, the purpose of the fellowship is ambitious and thorough. “We want to provide our fellows with maximum surgical and clinical experience from occiput to sacrum, with minimally and maximally invasive procedures in all aspects of the spine,” he said.
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32 LEADING ORTHOPEDICS & SPORTS MEDICINE
HOUSTON METHODIST: GLOBAL EDUCATIONAL REACH 2015 HOUSTON METHODIST STATISTICS
RESEARCH EDUCATION LEARNERS: 363 128 Postdoctoral trainees 112 Graduate students 63 Summer students 6 Undergraduate students 7 High school students
CONTINUING MEDICAL EDUCATION PHYSICIAN LEARNERS: 10,141 103 Courses
GRADUATE MEDICAL EDUCATION 2015 residents: 262 2018 fellows: 303
GLOBAL HEALTH CARE SERVICES LEARNERS: 1,207 29 countries
697 CME credit hours awarded 8 International partnerships 58 Institutions 16 Lectures
HOUSTON METHODIST INSTITUTE FOR TECHNOLOGY, INNOVATION & EDUCATIONâ„ 2006-2014 learners: 35,000 2015 learners: 6,697 554 Courses
OTHER LEARNERS Rotating residents: 430 Nursing students: 1,191 Pharmacy students: 315 Allied health students: 141
THE WORLD’S FIRST VIRTUAL INTELLIGENCE FOR THE OPERATING ROOM The Houston Methodist Institute for Technology, Innovation & Education℠SM, known as MITIE — one of the largest and most comprehensive education facilities in the world — is a place where surgeons and other health care providers continually refine their skills and acquire new expertise to perform at optimal levels throughout their careers.
“Currently, surgeons cannot track multiple technologies or see what is happening in the body during surgery in a satisfactory way because a system that can analyze overlapping technologies has not been developed yet,” Dunkin said. “RETINA brings the information together, analyzes it, and provides the surgeon with the necessary, real-time information.”
To address the challenges of the modern operating room (OR), physicians and researchers at MITIE are designing a virtual intelligence system. The complexity of larger medical teams and overlapping technologies in the OR requires surgeons to interpret and evaluate an abundance of data while performing surgical procedures. To improve performance and decrease variability, the Intelligent OR brings surgeons and computational scientists together to develop safer, more accurate methods of managing patient care in real time.
The Intelligent OR also houses the Smart OR, a group of sensors placed at specific locations of the OR that automatically detect key steps of the surgery, such as when a patient is brought in and moved out of the room.
“In today’s operating room, we are overwhelming surgeons with information from multiple technology platforms and staff who can distract them from the procedure at hand,” said Brian Dunkin, MD, Houston Methodist endoscopic surgeon and medical director of MITIE. “The Intelligent OR is designed to provide surgeons and staff with necessary information at the point of care without unneeded distractions.”
“By adding sensors to the operating room, we are able to track a variety of data points,” said Marc Garbey, PhD, research director of MITIE and professor of computational science at the University of Houston. “We believe the ability to track instrumentation and movement in the operating room will increase efficiency and reduce costs.” Intelligent OR technology will help surgeons perform operations and image-guided procedures more efficiently and accurately. Incorporation of an intelligence system that combines and computes essential OR data will allow surgeons to focus on the patient and the operation in the provision of an unparalleled level of care.
Inside the Intelligent OR is the Smart Trocar, a device with a small camera that can attach to a traditional laparoscopic trocar and connect to a Real-time Interactive Navigation Assistance (RETINA) system. RETINA uses multiple technologies to track changes in the body during surgery. In most cases, each step of an operation requires a different surgical tool. The Smart Trocar and RETINA work in concert to track tools identified by a unique color. With this, the RETINA system can track the progress of a surgery.
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34 LEADING ORTHOPEDICS & SPORTS MEDICINE
NEW HIRES TERRY A. CLYBURN, MD, joins Houston Methodist Orthopedics & Sports Medicine as a nationally recognized orthopedic surgeon who specializes in hip and knee joint replacement. Clyburn has led numerous advancements in the treatment of hip and knee pain, and has designed and developed several joint replacement products.
JASON LEASEBURG, MD, brings a passion for helping active adults and athletes with their foot and ankle orthopedic injuries to Houston Methodist St. John Hospital. Leaseburg attained his postdoctoral clinical fellowship in orthopedic foot and ankle adult reconstruction at the Mayo Clinic.
ASHVIN K. DEWAN, MD, arrives at Houston Methodist Sugar Land Hospital having recently completed a sports medicine fellowship — including training in the most current arthroscopic surgical techniques — at Washington University in St. Louis, Missouri. Dewan served as assistant team physician for the St. Louis Rams and St. Louis Blues, as well as the university’s athletic teams. Dewan specializes in knee and shoulder surgery with an emphasis on sports medicine.
EDWARD LEE, MD, brings his expertise in orthopedic sports medicine and joint replacement to Houston Methodist St. John Hospital. Lee specializes in minimally invasive arthroscopic procedures, using the latest technology to repair acute ligament, tendon and cartilage injuries to the shoulder. Lee also does extensive work with athletic shoulder injuries and has published numerous scientific articles.
JOHN FACKLER, MD, comes to Houston Methodist The Woodlands Hospital as an orthopedic surgeon with an interest in sports medicine. Fackler completed a combined orthopedic residency at Texas Tech/William Beaumont Army Medical Center in El Paso, Texas.
KENNETH FIRST, MD, joins Houston Methodist St. John Hospital. First completed a combined orthopedic residency program at Harvard Medical School and was awarded the Jack McDaniel traveling fellowship in Switzerland, where he studied joint replacement. First then completed a trauma fellowship at The University of Texas Health Science Center, Houston, followed by a sports medicine fellowship at Johns Hopkins.
B. CHRISTOPH MEYER, MD, brings 20 years of experience in the diagnosis and treatment of complex spinal disorders and deformities to Houston Methodist West Hospital. As an orthopedic surgeon, Meyer instructs international surgeons in advanced techniques and is a member of the North American Spine Society.
LUIS PULIDO, MD, comes to the Houston Methodist Orthopedics & Sports Medicine team with experience in cutting-edge orthopedic surgical techniques, such as minimally invasive hip replacement surgery. Pulido completed a postdoctoral research fellowship at Rothman Institute Orthopaedics in Philadelphia and a fellowship in hip and knee adult reconstruction at the Mayo Clinic.
JAVIER RIOS, MD, comes to Houston Methodist St. John Hospital with a specialty in the nonsurgical management of all musculoskeletal orthopedic conditions and sports injuries. Rios completed his fellowship in primary care sports medicine at The University of Oklahoma, College of Medicine in Tulsa.
ORTHOPEDICS & SPORTS MEDICINE MEDICAL STAFF CHAIR Kevin E. Varner, MD
M. NAMEER SIDIQUEE, MD, offers his expertise in medical and nonsurgical orthopedic care in the Houston Methodist Orthopedics & Sports Medicine French Quarter Office in Spring, Texas, and at Houston Methodist Willowbrook Hospital.
ORTHOPEDIC SPORTS MEDICINE Winfield Campbell, MD Ashvin K. Dewan, MD John Fackler, MD Kenneth R. First, MD Mark Franklin, MD Joshua Harris, MD Edward Lee, MD David Lintner, MD Mark W. Maffet, MD Eddie T. Matsu, MD Patrick McCulloch, MD Bruce Moseley, MD James G. Pyle, MD John Seaberg, MD Timothy C. Sitter, MD Christopher K. Smith, MD Leland Winston, MD
MARK VANN, MD, comes to Houston Methodist Sugar Land Hospital with a goal to provide and restore maximum function to the lower limbs of individuals affected by age, injury, deformity or other pathology. Vann completed his fellowship in foot and ankle reconstruction at the Michigan International Foot and Ankle Center in Pontiac.
PRIMARY CARE SPORTS MEDICINE David A. Braunreiter, MD Vijay Jotwani, MD Jeffrey A. Kozak, DO Scott Rand, MD Kenneth M. Renney, MD Javier Rios, MD Christian Schupp, MD, FACSM Gregory M. Seelhoefer, MD M. Nameer Sidiquee, MD
ALAN ROSEN, MD, brings his clinical expertise in hand and upper extremity surgery to Houston Methodist Willowbrook Hospital. Rosen completed his fellowship in hand and upper extremity and microvascular surgery at the Hospital for Special Surgery, Weill Cornell Medical School in New York. Rosen is board certified in orthopedic surgery and holds a Certificate of Added Qualification, Surgery of the Hand and Upper Extremity.
FOOT & ANKLE Pedro Cosculluela, MD Travis Hanson, MD Jason Leaseburg, MD Ray R. Valdez, MD Mark A. Vann II, MD Kevin E. Varner, MD
NECK & SPINE HoSun Hwang, MD Rex A.W. Marco, MD B. Christoph Meyer, MD Anthony J. Muffoletto, MD Bradley Weiner, MD Jeffrey B. Wood, MD HAND & WRIST D. Dean Dominy, III, MD Shari Liberman, MD Vincent C. Phan, MD Alan Rosen, MD JOINT REPLACEMENT William J. “Bill” Bryan, MD Plinio “Tony” Caldera, MD Terry A. Clyburn, MD D. Dean Dominy, III, MD Kenneth R. First, MD Mark Franklin, MD Carl A. Hicks, MD Stephen Incavo, MD Daniel Le, MD Mark W. Maffet, MD Eddie T. Matsu, MD Luis Pulido, MD James G. Pyle, MD Timothy C. Sitter, MD Christopher K. Smith, MD Leland Winston, MD ORTHOPEDIC ONCOLOGY Rex A.W. Marco, MD
36 LEADING ORTHOPEDICS & SPORTS MEDICINE
HOUSTON METHODIST: BUILDING A LEGACY OF INGENUITY From humble beginnings as a 30-bed hospital more than 90 years ago, Houston Methodist has evolved into one of the nation’s largest private nonprofit hospitals, an academic medical center and a center for visionary medical research. Our reputation for excellence in patient care and commitment to improving outcomes represent a significant motivation in the development of seven Houston Methodist Orthopedic & Sports Medicine locations in the Greater Houston area: • Houston Methodist Hospital - Texas Medical Center • Houston Methodist San Jacinto Hospital • Houston Methodist St. John Hospital • Houston Methodist Sugar Land Hospital
Together, we collaborate to advance clinical medical research and train the next generation of physicians and researchers. For Houston Methodist clinicians and researchers, leading medicine is a call for excellence in every aspect of patient care. We consistently rank in U.S. News & World Report’s “Best Hospitals” list. The 2015 issue named Houston Methodist among the country’s top hospitals in 11 specialties, No. 1 in the metro area and No. 1 hospital in Texas. Additionally, Houston Methodist unfailingly achieves Magnet® distinction for exceptional nursing. Our research ranks in the top 20 for federal funding, and supports early phase clinical trials and FDA-certified manufacturing for research. Because of this commitment to excellence, the finest researchers and clinicians are joining us to accelerate the discovery and delivery of better care and better cures. That’s the difference between practicing medicine and leading it.
• Houston Methodist West Hospital • Houston Methodist Willowbrook Hospital • Houston Methodist The Woodlands Hospital (opening in 2017) Primary academic affiliates of Houston Methodist are top-ranked Weill Cornell Medicine and NewYork-Presbyterian Hospital. Houston Methodist also has affiliations with The Texas A&M University System and the University of Houston.
MORE THAN 790 clinical studies and trials $130 MILLION total research portfolio
2015 HOUSTON METHODIST STATISTICS
2,043 OPERATING BEDS
101,508
814,309
12,406
297,906
INPATIENTS
OUTPATIENT
INTERNATIONAL PATIENT ENCOUNTERS (from 84 foreign countries)
EMERGENCY ROOM VISITS
VISITS
4,500
603
36
AFFILIATED PHYSICIANS
FACULTY
RESIDENCY
44 GME
PROGRAMS
PROGRAMS
LEADERS IN RESEARCH At Houston Methodist, we are dedicated to defining the future of medicine. We engineer discoveries in the lab to become clinically useful products, channel the best innovations through early-stage clinical trials, and actively transition those innovations to our industry partners. Our commitment to the full cycle of discovery and delivery sets us apart as leaders who provide patients from around the world access to the latest health care advances.
Visit houstonmethodist.org/research to see all the ways we’re leading research. Š2015 Time Inc. FORTUNE and 100 Best Companies to Work For are registered trademarks of Time Inc. and are used under license. FORTUNE and Time Inc. are not affiliated with, and do not endorse products or services of Houston Methodist.
Houston Methodist Hospital 6565 Fannin St., Houston, TX 77030 877.790.DOCS
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LEADING MEDICINE YESTERDAY, TODAY AND TOMORROW
At Houston Methodist, we have a proud tradition of revolutionizing medicine. Our past achievements have built a legacy that spans multiple decades and disciplines, and that same culture of excellence inspires us to be the pioneers of tomorrow.