Ya l e O r t h o pa e d i c s Q u a r t e r ly Volume 1 • Number 1 • Summer 2016
INSIDE: 2 From the Chairman 3 Chairman’s Report 5 Dr. Friedlaender Celebration 6 YaleMedicine in Stamford 7 New Hand Recruits 7 In The News 8 Orthopaedic Research
9 Emerging Technology in the Management of Talus Osteochondral Lesions 10 Development of Risk Assessment Tools to Predict Outcomes of Shoulder Replacement 12 Yale Orthopaedics Hosts Perry Initiative for Third Consecutive Year
13 Dr. Friedlaender and Yale Orthopaedics Book Club 14 Orthopaedic Residency Update
FEATURE STORY
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YaleMedicine in Stamford
2 YALE ORTHOPAEDICS QUARTERLY
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From the Chairman Dear Colleagues, It is my pleasure to share with you this Summer 2016 issue of Yale Orthopaedics Quarterly, a new quarterly publication that profiles some of the most exciting clinical and research activities we have under way in Yale’s Department of Orthopaedics & Rehabilitation. In this inaugural issue, we highlight the imminent opening of our Fairfield County Stamford Office location, celebrate the 30 years of unparalleled leadership and success by Dr. Friedlaender as Department Chairman, thank our graduating chief residents, and welcome our new interns, fellows, and six new faculty to the Department. Within our clinical and research divisions, we are proud to be able to spotlight efforts across a wide range of orthopaedic practice areas. We lead with a profile by Dr. Mark Horowitz detailing the incredible work being done by our scientists and engineers in the Research Division. Dr. Walls provides an update on the role of orthobiologics for the surgical management for osteochondral lesions of the talus. Dr. Kovacevic discusses the importance of clinical prediction tools to improve patient engagement and enhance clinical outcomes for patients undergoing shoulder replacement here at Yale. These articles highlight the innovation and discovery that distinguish the Yale Department of Orthopaedics and Rehabilitation at YaleMedicine. I hope that you enjoy this first issue of Yale Orthopaedics Quarterly. I encourage you to provide feedback or to contact us anytime with questions about our programs and activities. Yours at Yale, Ted
Theodore A. Blaine, M.D. Professor and Interim Chairman Department of Orthopaedics & Rehabilitation Yale School of Medicine
medicine.yale.edu/ortho | www.yaleortho.com
Summer 2016 3
Chairman’s Report It is an honor and a privilege to address this distinguished group of Yale faculty and alumni in this inaugural Chairman’s Report, and I am thrilled to provide you with an update on all of the great progress in our Department!
Dr. Gary Friedlaender We began the year 2016 with the announcement that Dr. Gary Friedlaender, Wayne O. Southwick Professor of Orthopaedics and Chair of the department, would step down from his position on March 1, 2016. Gary has held this position for the past three decades, the longest-standing current Chairman in Orthopaedic Surgery. Over those thirty years, Gary trained more than 150 residents and garnered a long list of accolades, including President of the Orthopaedic Research Society (ORS), President of the Academic Orthopaedic Society (AOS), President of the Association of Bone and Joint Surgeons (ABJS), and President of the American Orthopaedic Association (AOA). His list of awards includes the Kappa Delta Award from the AAOS, the Nicholas Andry Award from ABJS, and the 2014 William Tipton Leadership Award from the AAOS. We had many opportunities this spring to celebrate Gary’s remarkable career this year, and some of those activities are highlighted in this issue. I would like to take this opportunity however, to thank Gary for all that he has done for Yale Orthopaedics and for all of our careers. We can only stand in awe of his great accomplishment.
Dr. Wayne Southwick Not long after Gary’s announcement, we were informed that Wayne Southwick passed away peacefully in April. Knowing that there is no way to summarize the career of the most cherished member of the Yale alumni, I am copying his obituary in the sidebar. Plans for a memorial service are underway by Kris Keggi and the YOA, and tentative date is October 14–15, 2016. More information will follow.
New Beginnings In the presence and awe of these great giants of Yale Orthopaedics, it was a privilege to be asked to assume the role of Interim Chairman of the Department on March 1, 2016. I did so with the humble knowledge of the great tradition and legacy that is Yale Orthopaedics, and vowed to respect and honor this legacy as we moved into the future. Not surprisingly, the first 100 days have been filled with exciting new opportunities for our Department. Recruitment has been the mantra of Orthopaedics as the Department continues to grow and expand throughout the region. In 2016, we will add
DR. WAYNE O. SOUTHWICK (1923–2016) Dr. Wayne O. Southwick died peacefully in his sleep on April 10, at the Branford Connecticut Hospice. He was born in Lincoln Nebraska on February 6, 1923, to Dorothy Harpham and Philip Lee Southwick, and was raised in Friend, a farm town of 1,000. During the Depression, he woke at sunrise for his paper route, and bicycled down to the railroad tracks to retrieve his bundle of newspapers tossed from the speeding Grand Island steam train. Wayne loved competing in steeplechases with his horse Red, and helping his Mom bake cherry pies. He was proud of becoming an Eagle Scout and Valedictorian of his high school class. At the University of Nebraska, where he played football, he met J. Ann Seacrest, his wife of 71 years. After Wayne graduated from University of Nebraska Medical School, the couple moved to Massachusetts where Wayne interned at Boston City Hospital, and then to Maryland where he trained in Orthopaedics at Johns Hopkins. In the midst of his training, the Navy stationed him in Korea where he operated on wounded U.S. soldiers. In 1959 he brought his enthusiasm, energy, and Nebraska charm to New Haven as Chief of Orthopaedics. Under Wayne’s leadership, combined with Ann’s gracious social support, Yale Orthopaedics became a premier training program. Together they mentored many appreciative residents who progressed to illustrious academic careers. Wayne Southwick was the first awardee of the American Orthopaedics Association Diversity Award in recognition because he welcomed students, staff and faculty from all backgrounds to Yale Orthopaedics. During this time he also volunteered to serve in Haiti and Africa to correct orthopaedic deformities and injuries. He was a member of the Board of the Old Lyme Art Academy, served as Director of the Board for Connecticut Hospice, and organized the Old Saybrook Train Association, a citizen group instrumental in encouraging Amtrak to continue train service to the town. Upon retiring from Orthopaedics, Wayne embraced sculpture under the tutelage of Bruno Lucchesi and traveled to Italy to create many of his bronzes. Several of his statues are now displayed on the campuses of the Yale Medical School, the Hopkins School, and the Connecticut Hospice. First and foremost Wayne was the “Best Dad in the world” as his children often reminded him. He encouraged all those he mentored to “Do your best.” It didn’t matter if you won or lost as long as “you tried your hardest.” His humility, sense of humor, and mid-Western can-do attitude will live on in the hearts of all those he touched. He is survived by his loving sons and daughter: Frederick Southwick (and wife, Kathleen) Steven Southwick, and Marcia Southwick; his grandchildren: Nicholas Levis, Peter Southwick, Christina Baker, and Ashley Schivelbein; and his great grandchildren: Avery Baker, and Lennox Schivelbein. A memorial service, in Wayne’s honor, will be announced at a later date. In lieu of Flowers, donations may be sent to Connecticut Hospice, 100 Double Beach Road, Branford, CT. 06405. See online memorial @ www.wsclancy.com.
4 YALE ORTHOPAEDICS QUARTERLY four new surgeons to our full time academic faculty in New Haven and three new faculty to our new Fairfield County location in Stamford. These include two new faculty in Hand surgery (Dr. Andie Halim, Brown University, and Dr. Ken Donohue, Cleveland Clinic), a Hip and Knee Replacement Surgeon (Dr. Lee Rubin, Brown University), and a Clinician-Scientist and orthopaedic oncologist (Dr. Francis Lee, Columbia University.) In Stamford, we are partnering with Orthopaedic Surgery and Sports Medicine surgeons, Dr. Frank Difazio (Hip and Knee reconstruction) and Dr. Craig Tifford (Sports Medicine), and Dr. Vivian Shih (Physical Medicine) to bring elite-level care to Fairfield County. Our new flagship location will be located at 260 Long Ridge Road in Stamford, and further information on this site is highlighted in this issue of Yale Orthopaedics Quarterly. The growth of the Department of Orthopaedics parallels the growth of the musculoskeletal service line at Yale New Haven Health System through close collaboration with the Yale Center for Musculoskeletal Care, led by Dr. Mary O’Connor. This effort to bring comprehensive care to all musculoskeletal patients aims to bring together providers from Orthopaedics, Rheumatology, Neurosurgery, and Neurology.
Administration In New Haven, other new beginnings in 2016 included a move of our academic offices to 47 College Street, where we occupy nearly the entire second floor of the building. With this consolidation of our faculty to one location, we have also restructured the administrative and business functions of the Department, offering new leadership opportunities to our invaluable staff members. This effort is led by Stacey Lombardi, who brings a wealth of experience and energy to the position of Lead Administrator. Margaret Gilshannon has transitioned to become the Lead Administrator in the Department of Pathology, and Connie Rinaldi has taken the Manager position in the Workman’s Compensation Program at YaleMedicine. We continue to benefit from all of the great work that each of these individuals and all of our staff have performed over the years, allowing Yale Orthopaedics to be ideally positioned for the future.
Research The Orthopaedic Research Laboratory, led by Dr. Mark Horowitz, continues to make significant advances in the study of musculoskeletal diseases. Current Investigators include Dr. Jacob Eswarakumar, Dr. Jackie Fretz, and Dr. Steve Tommasini, and several recent grants have been received or are under renewal application. In September 2016, Dr. Francis Lee will join the laboratory from Columbia University, bringing $8M in NIH research funding and multiple lines of orthopeadic research. Dr. Lee’s NIH research grants include:
For referrals, call 203.737.5656 1) Modification of Bone Grafts for Orthopaedic Procedures 2) Bone and Breast Cancer Molecular Interactions 3) ERK signaling in inflammatory bone loss 4) Mechanobiological mechanism for inflammatory bone loss 5) The Role of MMP-13 in Multiple Myeloma To further promote and integrate translational research among the orthopaedic clinical faculty, a biweekly research conference has been organized and occurs in the 47 College Street Conference Room from 7–8 a.m. Friday mornings. A full schedule of conferences is available through Pat Jaekle in the Orthopaedic Research Lab.
Education With the growing orthopaedic faculty (now 33), the residency program is ready for expansion and the addition of new trainees. In July, we welcomed five new interns to our program as well as three new clinical fellows. A new GME-approved Trauma fellowship was added, recognizing the skill and stature of our trauma surgeons led by Dr. Michael Baumgaertner and including Dr. Mike Leslie, Dr. Natalie Casemyr, and Dr. Adrienne Socci. The inaugural trauma fellow is Dr. Lee Yaari, who brings, in addition to orthopaedic skills, his Israeli Navy SEAL training to New Haven. More information on the new trainees follows in this Yale Orthopaedics Quarterly issue. Thanks to the herculean efforts of the incoming Chief Resident class together with program directors Brian Smith, Melinda Sharkey, and Dieter Lindskog, the resident education schedule has been completely updated and reorganized. Friday education is no more, and morning lectures now occur at 6:30 a.m. Monday through Wednesday, subspecialty conferences on Thursday mornings, and Grand Rounds on Friday at 8 a.m. This new schedule has been well received by faculty and residents alike, and allows residents to participate in more surgery while engaging faculty in their weekly education. While there is much more to report, I will end here and leave further updates to future issues of Yale Orthopaedics Quarterly. Please contact me if there are any updates you would like to include in our report, and I encourage you to provide feedback or to contact us anytime with questions about our programs and activities. Yours at Yale, Ted Theodore A. Blaine, M.D. Professor and Interim Chairman Department of Orthopaedics & Rehabilitation Yale School of Medicine
Summer 2016 5
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Wonderful Weekend Celebration Honoring Dr. Friedlaender and His Incredible Leadership as Yale Orthopaedics Chief A celebration of Dr. Gary Friedlaender’s chairmanship was held on June 18, 2016. The day began with a barbeque lunch held on Cross Campus in front of Sterling Memorial Library. Festivities continued that evening, when 102 past and present members of the Yale community gathered at the Yale Center for British Art to enjoy a cocktail reception commemorating Dr. Friedlaender’s impressive leadership and contributions to the Yale Department of Orthopaedics over his 30 years as Chairman. Attendees included former orthopaedic residents and Deans of the School of Medicine as well current faculty, staff, and family members. Deans Alpern and Rosenberg were among the many speakers who shared fond recollections of Dr. Friedlaender’s chairmanship. Those who spoke highlighted Dr. Friedlaender’s many personal accomplishments as well as his leadership in fostering growth of the department and his dedication and mentorship to the residents and faculty. Dr. Mark Horowitz and his wife Sharon Horowitz presented Dr. Friedlaender with a lithographic vintage advertising poster, printed in 1986 by Jules Cheret, to add to his extensive art collection (image at right). It was a wonderful gathering to celebrate a truly extraordinary physician and chairman. For those interested in making donations to honor Dr. Friedlaender’s extraordinary career, the Department has established the Gary E. Friedlaender Resource Fund. These funds are used to support orthopaedic research and education, recognizing the legacy that Gary began 30 years ago. Your gift, regardless of its size, symbolizes your trust in our leadership; it is an investment in the training of tomorrow’s orthopaedic physicians and scientists at Yale.
Checks can be made payable to “Yale University” and sent to: Yale School of Medicine c/o Erin Shreve, Director of Development PO Box 7611 New Haven, CT 06519 For further questions regarding giving opportunites at Yale Orthopaedics and Rehabilitation, please call 203-436-8529 or email erin.shreve@yale.edu to discuss further.
6 YALE ORTHOPAEDICS QUARTERLY
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YALE ORTHOPAEDICS TO BRING FIRST-RATE MUSCULOSKELETAL CARE TO FAIRFIELD COUNTY YaleMedicine is partnering with Greenwich Hospital, a member of the Yale New Haven Health System, to open a new location in Stamford on August 15, 2016. Dr. Theodore Blaine, Interim Chairman of the Yale Department of Orthopaedics and Rehabilitation, states, “This was a long time coming. We are ready to deliver on our promise of bringing all that Yale Orthopaedics has to offer to the outstanding communities in Fairfield County.” This state-of-the-art medical facility will provide first-rate medical and surgical care for those patients with musculoskeletal disorders by bringing together providers from Orthopaedics, Rheumatology, Neurosurgery, and Neurology. YaleMedicine is working with the newly established Yale Center for Musculoskeletal Care and its inaugural Director, Dr. Mary O’Connor to establish the new facility, providing comprehensive care to all musculoskeletal patients. Yale Orthopaedics is leading the way and will have a strong presence at the former General Electric building. We have prioritized this effort by bringing on two longtime Stamford orthopaedic surgeons, Dr. Frank Difazio and Dr. Craig Tifford. “Not only are these two exceptional surgeons, but they are part of this great community, and we are excited that they have joined our Yale Orthopaedics family,” says Dr. Blaine, who has worked together with Orthopaedic Surgery and Sports Medicine of Stamford for the past 12 years. The longtime Greenwich resident and Chairman of Yale Orthopaedics says, “We are committed to this community for the long haul, and our providers have all the bases covered from head-to-toe.” The following Yale Orthopaedics providers will be at Stamford starting this August:
Office Information 260 Long Ridge Road Stamford, CT 06902
Appointments: 203-737-5656, 866-470-YALE (9253) yaleortho.com yalestamford.com yalegreenwich.com
Theodore A. Blaine, M.D.—Shoulder, Elbow and Sports Medicine Frank DiFazio, M.D.—Hip and Knee Reconstruction Ken Donohue, M.D.—Hand, Wrist , and Elbow Andrea Halim, M.D.—Hand and Wrist David Kovacevic, M.D.—Shoulder, Elbow and Sports Medicine Francis Lee, M.D., Ph.D.—Orthopaedic Oncology, Tumor Reconstruction Michael Leslie, M.D.—Trauma, Hip Reconstruction Vivian Shih, M.D.—Physical Medicine and Rehabilitation Karen Sutton, M.D.—Knee, Shoulder and Sports Medicine Craig Tifford, M.D.—Knee, Shoulder and Sports Medicine Raymond Walls, M.D.—Foot and Ankle Peter Whang, M.D.—Spine and Pelvis James Yue, M.D.—Spine and Pelvis
Summer 2016 7
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Yale Orthopaedics and Rehabilitation is Pleased to Welcome Two New Hand and Upper Extremity Surgeons this September Dr. Ken Donohue will be joining the department following his shoulder and elbow fellowship at Cleveland Clinic. Prior to this fellowship, he completed a fellowship in hand and microvascular surgery at Baylor College of Medicine, preceded by his orthopaedic residency at Drexel University in Philadelphia. He earned his master’s degree and medical degree from Georgetown University. Dr. Donahue will be seeing patients in Stamford, New Haven, and Guilford. He is coming to New Haven with his wife, Diane, who is a native of Branford.
Dr. Andie Halim will be returning to Yale after recently completing a hand and upper extremity fellowship at Brown University in Providence, RI. Dr. Halim graduated from the Yale Orthopaedic Residency in 2015 and also was an undergraduate at Yale College. She will be seeing hand and upper extremity patients in Stamford, New Haven, Guilford, and at the West Haven VA Medical Center. She is moving to East Rock with her husband, Dr. Teddy Long.
We look forward to their arrival!
IN THE NEWS Dr. Michael Baumgaertner and Dr. Michael Leslie establish new Trauma Fellowship Dr. Michael Baumgaertner and Dr. Michael Leslie have established a new orthopaedic trauma fellowship training program at Yale, together with trauma faculty Dr. Natalie Casemyr and Dr. Adrienne Socci. The Yale Trauma Service is an internationally recognized service in the Department of Orthopaedics and Rehabilitation, and a tertiary referral center for complex trauma care throughout the region. Dr. Michael Baumgaertner, Chief of Orthopaedic Trauma, has led the Orthopaedic Trauma Service at Yale New Haven Hospital for more than 25 years. He has also served as Chairperson of Education for both the Orthopaedic Trauma Association (OTA) and AO North America (AONA), and recently completed his 4-year term as President of AONA, a nonprofit organization of more than 1,000 surgeons that is dedicated to the optimal care of patients with fractures and/or deformity. He currently serves as Chairperson of AONA’s Board of Directors. The training program will be part of the OTA selection process and will participate in the OTA Fellows match.
Dr. Theodore Blaine Named Editor-in-Chief of JSEA Dr. Theodore Blaine has been Named Co-Editor-in-Chief of the Journal of Shoulder & Elbow Arthroplasty (JSEA). “I am thrilled to be named the founding editor-in-chief of JSEA,” says Dr. Blaine, a dream that is finally realized through collaboration with
Dr. J. Michael Wiater, Chief of Shoulder Surgery and Vice Chairman at the William Beaumont School of Medicine in Beverly Hills, MI, and through SAGE publishers in Los Angeles. “I have seen patient demand for shoulder replacement increase substantially over the past 15 years, and we now have numerous surgical options to address a complex array of shoulder pathology. This journal will help meet a growing need for shoulder and elbow surgeons performing shoulder arthroplasty who desire a journal specifically dedicated to this field.” Dr. Blaine has served in various leadership and editorial roles at the AAOS and ASES, and he will use this experience with the launch of this new journal together with Dr. Wiater and his deputy editors. The first issue will launch online in late 2016.
Dr. Felicity Fishman Named Director at YNHCH Dr. Felicity Fishman has been named Director of Hand and Upper Extremity Services at the Yale New Haven Children’s Hospital and Associate Director of the Hand and Upper Extremity Service at Yale Department of Orthopaedics and Rehabilitation. Dr. Fishman completed her residency in Orthopaedic Surgery at Duke University Medical Center, followed by the University of Minnesota/Regions Hospital fellowship in Hand and Upper Extremity surgery and a fellowship in Pediatric and Congenital hand and upper extremity surgery at Children’s Healthcare of Atlanta Scottish Rite hospital. Dr. Fishman specializes in the treatment of congenital and pediatric hand and upper extremity conditions, including traumatic injuries, brachial plexus birth palsy, and congenital hand differences. continued on p. 13
8 YALE ORTHOPAEDICS QUARTERLY
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Accomplished Scientist Leading Orthopaedic Research Division in Difficult Funding Times Mark Horowitz, Ph.D., is no stranger to the challenges of leading a first-rate group of scientists and engineers. Despite tight NIH paylines, he and the cadre of scientists are finding success as both early-career and established investigators have active grants and research programs. Dr. Horowitz is able to steer a steady ship with a healthy dose of optimism and a pinch of skepticism that keeps this group at the top of their game. Their research interests, active projects, and the history of Yale Orthopaedics Research Labs are detailed below. The Department of Orthopaedics has had a keen interest in research since its inception in 1986. The Orthopaedic Histology and Histomorphometry Laboratory (OHHL), headed by Nancy Troiano, was supported by Dr. Gary Friedlaender when Orthopaedics was a section of Surgery. This state-of-the-art laboratory continues to support the research efforts of our faculty as well as providing the very best in histological analysis to numerous investigators at Yale and across the country. Support for the OHHL as well as basic, translational, and clinical research continues today, with the outstanding support of Dr. Ted Blaine. Today three scientists and two engineers constitute the basic science research in the Department. Dr. Paul Ivancic, Associate Research Scientist, one of our engineers, trained with Manohar Panjabi, a long-time member of the Department and now retired, continues his research on the biomechanical analysis of whiplash due to trauma. Dr. Steve Tommasini, Assistant Professor, our other engineer, works on the relationship of biology and biomechanics. As an example, he is analyzing bone strength in an animal model of hypophosphatemia. In a second project, Dr. Tommasini is determining the relationship of marrow fat to bone strength. In addition, he has resurrected our Instron machine (biomechanical testing instrument) and does biomechanical testing for many investigators both at Yale and at other institutions. He is currently supported by grants from the NIH. Dr. Jacob Eswarakumar, Associate Professor, focuses on the biology of craniofacial development, with special interest in FGF signaling in the skull. Dr. Eswarakumar is a member of a Special Emphasis Panel Study Section at the NIH. Dr. Jackie Fretz, Assistant Professor, and our newest faculty member, works on kidney development and its interactions with the skeleton. She recently identified a gene Early B-Cell Factor-1 (Ebf1) as a new regulator of glomerular development. She has received a K award from the NIH, which is highly competitive, and most recently a grant from the The O’Brien Kidney Center. Dr. Mark Horowitz, Professor and Vice Chair for Research, has been a member of the Department since 1986. One of his major research focuses is the development of marrow fat and its effects on bone. His work indicates that marrow fat is distinct from white, brown, and beige fat. He is supported by grants from NIAMS and NIDDK. He recently was a member of the Skeletal Biology Development and Disease Study Section at the NIH and is currently reviewing for NIDDK. This, however, is only the tip of the iceberg. Many members of the clinical faculty are engaged in their own translational research and clinical trials, and are training our residents and students. As an example, Dr. Dieter Lindskog works with Dr. Horowitz and Dr. Tommasini on developing a bone graft made from a polymer that is 3D printed. Dr. Dave Kovacevic is leading a group of students who are evaluating biologics for improving shoulder repair in a preclinical model supported by a grant from the American Shoulder & Elbow Surgeons.
Summer 2016 9
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Emerging Technology in the Management of Talus Osteochondral Lesions Osteochondral lesions of the talus (OLTs) are a relatively common condition of the ankle characterized by articular cartilage injury and associated bone trauma (Fig 1). Although repetitive microtrauma has been identified as a precipitating factor, OLTs are typically caused by an acute ankle sprain or fracture. Damaged articular cartilage is avascular and has limited potential for repair. While smaller lesions with mild symptoms can occasionally heal with conservative management, surgical intervention is usually necessary. Bone marrow stimulation (BMS) is the mainstay of surgical care and involves arthroscopic removal of damaged cartilage with microfracture of the subchondral plate (Fig 2). Bone marrow fills the chondral defect to form fibrocartilage. This tissue is inferior to native hyaline cartilage and may not withstand mechanical loading over time. Augmenting BMS with biologic adjuncts aims to enhance the quality and durability of the repair tissue. Current options include focal delivery of the patient’s own stem cells (BMAC; bone marrow aspirate concentrate), injectable hyaluronic acid (HA), and platelet rich plasma (PRP). Emerging technology that forms a scaffold matrix for new cartilage has proven successful in preclinical trials and is gaining increasing use in patients. At Yale, we are at the forefront with biologic augmentation and discuss all options with our patients so they can make an informed decision in their care. We have the ability to utilize bone marrow concentrate for stem cell augmentation with marrow stimulation techniques and, when an appropriate OLT is identified on advanced imaging, a cartilage scaffold will also be considered (Fig 3). We believe these advanced arthroscopic techniques will translate into better long-term results for this difficult condition.
Dr Raymond Walls, M.D., FRCS (Tr&Orth) Assistant Professor Orthopaedic Foot and Ankle Surgery Department of Orthopaedics and Rehabilitation Yale School of Medicine
Figure 1. T2 weighted magnetic resonance image (MRI) of a medial talar osteochondral lesion.
Figure 2. Intraoperative arthroscopic image demonstrating the result obtained from a standard microfracture technique
Figure 3. Intraoperative arthroscopic image demonstrating biologic augmentation of BMS with bone marrow concentrate (BMAC) and a cartilage scaffold matrix
10  YALE ORTHOPAEDICS QUARTERLY
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Development of Risk Assessment Tools to Predict Outcomes of Shoulder Replacement YaleMedicine orthopaedic surgeons from the Yale Shoulder and Elbow Service (yaleshoulder.com, yaleelbow.com) perform more shoulder replacement procedures than at any other center in Connecticut. This high volume of shoulder replacements follows a national trend, where shoulder arthroplasty, compared to hip and knee arthroplasty, is the fastest growing type of joint replacement procedure. The annual volume of shoulder replacement in the United States has more than quadrupled over the past 15 years and it is projected to increase at a higher annual rate than hip and knee replacements in the next twenty years. To meet this demand, there is increasing pressure to decrease length of stay in the hospital while optimizing patient outcomes. Efforts to improve efficiency and decrease length of stay require appropriate prehospital planning and patient risk stratification. A tool that can effectively predict length of stay may allow caregivers to better prepare for support at home following surgery. Recently, physicians from the Yale Shoulder and Elbow Service developed a preoperative predictive nomogram for length of stay after shoulder replacement. (Figure 1) The physicians found that patient-specific factors such as diabetes and anti-coagulant therapy, among other factors, were responsible for increased length of stay following shoulder replacement. Using this tool, they were able to identify which patients would be appropriate candidates for outpatient shoulder replacement procedures. (Figure 2) This nomogram has the potential to improve patient experience by increasing their confidence with length of stay and timely discharge. Yale shoulder and elbow surgeons are currently developing prediction tools to determine the probability of patients being discharged to home following shoulder surgery. An area of future research is predicting the prolonged use of opioid pain medication following shoulder replacement surgery.
About the Yale Shoulder and Elbow Service The Shoulder & Elbow Service serves as a tertiary referral center for shoulder and elbow replacement and complex shoulder and elbow surgery. The service also offers comprehensive fracture care as well as state-of-the-art minimally invasive arthroscopic procedures for tendon and sports-related injuries. Dr. Theodore Blaine (Theodore.blaine@yale.edu, 203-7372348) is the Interim Chairman of the Yale University Department of Orthopaedics and Rehabilitation and Chief of Shoulder and Elbow Surgery. A recognized specialist in minimally invasive and replacement surgery of the shoulder and elbow, he has pioneered several new medical and surgical techniques including injectable medications for shoulder arthritis, minimally invasive shoulder replacement, and arthroscopic rotator cuff repair. Dr. David Kovacevic (david.kovacevic@yale.edu; 203-7372843; @KovacevicMD) is a shoulder and elbow specialist in the Shoulder & Elbow and Sports Medicine Divisions in the Department of Orthopaedics and Rehabilitation. He specializes in complex primary and revision shoulder and elbow repair, reconstruction, and replacement utilizing all-arthroscopic, arthroscopic-assisted, and open surgical techniques to relieve patients of their pain, restore their function, and improve quality of life. His primary research interests are focused on biologic augmentation of tendon-bone healing and preventing rotator cuff muscle fatty atrophy.
medicine.yale.edu/ortho | www.yaleortho.com
Summer 2016 11
Figure 1. Preoperative Prediction of Length of Stay after Shoulder Arthroplasty. Caregiver and patient instructions for calculating probability: Locate the procedure type on the “Type of Surgery” axis and then draw a line directly upward to the “Points” axis to determine how many points toward the probability of staying at least 2 days in the hospital. Repeat this process for the remaining predictors, each time drawing a line directly upward to the “Points” axis. Add the points for all the predictors and locate the total point value on the “Total Points” axis. Then draw a straight line downward to find the patient’s probability of staying at least 2 days in the hospital.
Figure 2. Preoperative and postoperative x-rays of a middle-aged man with shoulder arthritis who underwent a stemless, canal-sparing shoulder replacement. He was discharged from the hospital the day after surgery. Based on our nomogram, healthy middle-aged males not on anticoagulation or diabetic medications undergoing resurfacing or canal-sparing total shoulder replacement would qualify for outpatient surgery.
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Yale Orthopaedics Hosts Perry Initiative for Third Consecutive Year On Saturday, May 21, 2016, Yale Orthopaedics partnered with the Perry Initiative to put on a full-day outreach program for more than 40 local high school students. Founded in 2009, this organization seeks to “build the pipeline for women in engineering and medicine” by promoting an interest among young women for future careers in the STEM fields—science, technology, engineering, and mathematics (http://perryinitiative.org). Programming geared toward young women in high school is the primary means of advancing this mission, and Yale Orthopaedics has proudly sponsored an outreach program annually since 2014. The day began with a handful of didactic lectures given by Yale Orthopaedics faculty members, representing various orthopaedic subspecialties. (See top photo, from left to right: Adrienne Socci M.D., pediatric orthopaedics and trauma; Felicity Fishman M.D., pediatric and adult hand; Elizabeth Gardner M.D., sports medicine; Mary O’Connor MD., tumor and arthroplasty; Karen Sutton M.D., sports medicine; Cordelia Carter M.D., pediatric orthopaedics and sports medicine; and Melinda Sharkey M.D., pediatric orthopaedics, who has played a pivotal role in bringing the program to Yale each year). While some knowledge is relayed through lectures, the substance of the Perry programs is typically hands-on learning, and over the course of the day, each student rotated through six different orthopaedic skills stations run by our faculty in conjunction with Perry staffers. Program participants practiced basic orthopaedic skills such as suturing and casting in the morning session (see photos). More advanced skills were learned in the afternoon, including femoral intramedullary nailing, external fixator placement, and reduction and plate fixation of simulated ankle fractures. The program concluded with a panel discussion and open question-and-answer session for both students and their parents. Providing guidance, mentorship, and modeling of a successful career in orthopaedic surgery for young women is something Yale Orthopaedics is extraordinarily well-equipped to do, boasting nine (and rising!) female faculty members, a number that is unusually high given that the proportion of female orthopaedists nationwide remains well below 15%. With luck, the goal of the outreach day will be met, and some of these young women will have been inspired to become future leaders in the field of orthopaedic surgery.
For referrals, call 203.737.5656
medicine.yale.edu/ortho | www.yaleortho.com IN THE NEWS (contd. from p.6)
Dr. David Kovacevic Named Associate Director of Shoulder and Elbow Fellowship Dr. David Kovacevic, a member of the Shoulder and Elbow Section, has been named Associate Director of the Yale Shoulder and Elbow Fellowship training program. The Yale Shoulder and Elbow Fellowship was established in 2012 and is considered one of the top fellowship training programs in the world, training both U.S. and international fellows in the practice of shoulder and elbow surgery. David Kovacevic, M.D., joined Yale Orthopaedics in 2015 after completing his clinical fellowship at Columbia University and the Center for Shoulder, Elbow and Sports Medicine. The Yale Shoulder and Elbow Fellowship training program is part of the ASES Fellows selection process and participates in the ASES Fellows match.
Dr. Karen Sutton Named Fellowship Education Faculty Advisor Dr. Karen Sutton, an Associate Professor of Orthopaedic Surgery at the Yale School of Medicine and graduate of the Yale Orthopaedic residency training program, has been named Fellowship Education Faculty Advisor in the Yale Department of Orthopaedics and Rehabilitation. In this important position, Dr. Sutton will work with Yale orthopaedic residents throughout the 5-year program to identify and prepare for fellowship training opportunities at the completion of residency. Fellowship education is pursued by 99% of orthopaedic resident graduates and is an important step in advancing their careers. Dr. Sutton began her academic career at Duke University and received her medical degree at University of Maryland. Having completed fellowships in sports medicine at Massachusetts General Hospital/ Harvard School of Medicine and pediatric sports medicine at Boston Children’s Hospital/Harvard School of Medicine, Dr. Sutton is ideally suited to this faculty advisor position.
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The Gary E. Friedlaender Book Club Thinking outside the box is a way of life here in New Haven. The Gary E. Friedlaender Book Club at Yale Orthopaedics is a perfect example of the rigorous scholarly pursuit that occurs outside of medicine at Yale. This activity, started 15 years ago by Dr. Friedlaender, has seen countless book titles devoured by our group. The primary intention is to promote interaction amongst all and, secondarily, remind us that our jobs do not dictate who we are; we should embrace and explore thoughts and ideas that we may not typically encounter. While it is strongly encouraged, it is not always necessary to read the book to participate in the lively discussion that occurs. The book ignites the discussion, but inevitably the discussion departs from the main themes of the book and takes on a life of its own, as it delves into the intricacies of life and beyond. We meet 4 times a year (spring, summer, fall and winter) and leisurely sip wine and munch tasty hors d’oeuvres and launch into discussion. The next meeting will take place on September 6, 2016, and the selected book is When Breath Becomes Air, by Paul Kalanithi. All are welcome. The summer location will be downtown in the second floor common room/courtyard at the College and Crown Apartment Complex. Start time is 7 p.m.
14 YALE ORTHOPAEDICS QUARTERLY
For referrals, call 203.737.5656
Orthopaedic Residency Update Thank You to Our Chief Residents The Graduate Club was the site of this year’s graduation celebration and dinner, and we collectively thank all of our outstanding chief residents and wish them much success in their future endeavors. Amy Fenoglio, M.D., now a fellow in hand surgery at the University of Utah in Salt Lake City, Utah.
Coridon Huez, M.D., now a fellow in adult reconstruction at Lenox Hill Hospital in New York, NY.
Paul Tomaszewski, M.D., now a fellow in sports medicine at Union Memorial Hospital in Baltimore, Maryland.
Jason Toy, M.D., now a fellow in spine surgery at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania.
Arya Varthi, M.D., now a fellow in spine surgery at Rush University Medical Center in Chicago, Illinois.
Welcome to New Haven the Orthopaedic Residency Class of 2021 Erin Cravez, M.D., a Hamilton College alumna and graduate of University of Washington School of Medicine.
Janelle Greene, M.D., who went to Columbia and Case Western Reserve University School of Medicine.
Justin Kuether, M.D., who did his undergraduate studies at the United States Air Force Academy and medical school at University of Chicago Pritzker School of Medicine.
Adam Lukasiewicz, M.D., a Yalie for both university and medical school as well as Imperial College London for graduate school.
Kenneth Milligan, M.D., a graduate of Colorado State University and University of Colorado School of Medicine.
medicine.yale.edu/ortho | www.yaleortho.com
Orthopaedic Fellowship Update Graduating Fellows Spine Fellow Charles Chang, M.D., will be joining Los Angeles Kaiser Permanente in Los Angeles, CA.
Shoulder and Elbow Fellow Ana Mata-Fink, M.D. M.S., will be joining Blackstone Orthopaedics in Rhode Island.
New Fellows Spine Fellow Yi Guo, M.D., completed his residency training at Peking University School of Medicine in Beijing China. He has completed fellowships in Orthopaedic Oncology at University of Washington Medical Center in Seattle, WA, and Foot and Ankle at MedStar Union Memorial Hospital in Baltimore, MD.
Shoulder and Elbow Fellow Steven Wiseman, D.O., completed his residency at Ohio University Heritage College of Osteopathic Medicine/Doctors Hospital in Columbus, OH.
Trauma Fellow Yale Orthopaedics has added a Trauma Fellowship. The first fellow will begin in the fall of 2016. Lee Yaari, M.D., completed his residency at Rabin Medical Center in Tel-Aviv, Israel. He has completed a fellowship in Sports Medicine at Lenox Hill Hospital in New York, NY.
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Yale Orthopaedics & Rehabilitation faculty Interim Chair
Shoulder and Elbow
Theodore A. Blaine, MD
Theodore A. Blaine, MD David Kovacevic, MD
Adult Reconstruction Frank A. DiFazio, MD Kristaps J. Keggi, MD, DrMed Mary I. O’Connor, MD Richard R. Pelker, MD, PhD Lee E. Rubin, MD
Spine
Foot and Ankle
Elizabeth C. Gardner, MD Peter Jokl, MD Michael J. Medvecky, MD Karen M. Sutton, MD Craig D. Tifford, MD
John S. Reach, Jr, MD, MSC, FAAOS Raymond J. Walls, MD, FRCS (Tr&Orth), MBBCh
Fractures/Fracture Problems Michael R. Baumgaertner, MD Natalie E. Casemyr, MD Michael P. Leslie, DO Adrienne R. Socci, MD
Hand and Upper Extremity Kenneth W. Donohue, MD Felicity Fishman, MD Andrea Halim, MD Carrie R. Swigart, MD
Musculoskeletal Oncology
Jonathan N. Grauer, MD Peter G. Whang, MD, FACS James J. Yue, MD
Sports Medicine
West Haven VA Lawrence Weis, MD *Chairman Emeritus **Residency Program Director
Yale Access Line
Cordelia W. Carter, MD Daniel R. Cooperman, MD Melinda S. Sharkey, MD Brian G. Smith, MD**
Yale Access Line offers a streamlined patient transfer service that ensures quick and easy admission to Yale New Haven Hospital. With one call—888.YNHH.BED (888.964.4233)— referring physicians can speak directly with an attending specialist for an immediate transfer. Trained paramedics assist with admission processing, bed assignment, and critical-care air transport, using Yale New Haven Health System’s interhospital emergency helicopter, SkyHealth, when necessary.
Physiatry
Scope of Service
Gary E. Friedlaender, MD* Frances Y. Lee, MD, PhD Dieter M. Lindskog, MD
Pediatric Orthopaedics
Marc Rosen, MD David Woznica, MD Vivian Shih, MD
• 24-hour single access point for all patient transfers • Quick connection to on-call attending specialists for patient transfers
Research Faculty Mark C. Horowitz, PhD Jacob V. Eswarakumar, PhD Jackie A. Fretz, PhD Steven M. Tommasini, PhD
• A dedicated physician referral director available for urgent appointments, hospital care, or ambulatory evaluations • Trained paramedics ready to expedite your request for a transfer
Learn more at www.yaleortho.com