30 OCTOBER 2019 / Improving Care for the most Challenging Cases at HSS’s SNF Complex Joint Reconstruction Center

When preparing for complex surgery, it’s about thorough planning and bringing together the right expertise to make the greatest challenges manageable, says Hospital for Special Surgery (HSS) orthopedic surgeon Peter Sculco, MD.

In marshaling the resources of world-leading orthopedists and the latest technology to address a problem that impacts hundreds of thousands Americans, HSS’s Stavros Niarchos Foundation Complex Joint Reconstruction Center is doing just this.

The Complex Joint Reconstruction Center (CJRC), supported by a landmark grant from the Stavros Niarchos Foundation (SNF) announced one year ago, deals with the most challenging cases in the already demanding field of joint replacement. Dr. Sculco, who specializes in patients whose operations have failed and need a second procedure—a “revision”—is part of an 18-surgeon team advancing care for patients in the Center, which has a trifold focus on clinical care, research, and education.

Revision surgeries, more costly and more challenging than the primary procedures, are a growing need in healthcare. The cumulative revision rate for joint replacements is around 10% at 20 years, but with over a seven million people living with an artificial hip or knee in United States alone, the number of revisions quickly adds up, estimated at more than 100,000 annually.

One patient, for instance, previously had two hip replacements in the 1970s. Dr. Sculco says the patient, who has rheumatoid arthritis, “had surgery as a young adult and lived a happy life for many decades.”

The artificial joints wore out over time and there was a significant amount of bone loss in the pelvis and migration of the implants.” The resultant impact on her quality of life was significant. “She was on a walker and could barely leave her home.”

Despite her obvious need, finding treatment proved difficult for the family. “No surgeon wanted to address the problem, because it required a lot of resources, and was high-risk.”

Eventually, she reconnected with HSS and with Dr. Sculco. “We came up with a comprehensive plan for how to treat this problem.”

The CJRC has at its disposal modeling technology that makes meticulous planning for an operation possible. “We make a 3D model of her pelvis based on pre-op imaging.”

 

HSS 1


Source: Hospital for Special Surgery

Next, based on the 3D model generated, the CJRC makes an implant out of titanium. “This is molded to fit the specific problem she has, and it’s customized to have the implant wrap around her bone and attach where good bone is available and ignore the areas where the bone doesn’t exist.”

HSS 3

Source: Hospital for Special Surgery

The CJRC team’s plan details exactly how many screws will be used to secure the implant and precisely where they’ll go.

HSS 2

Source: Hospital for Special Surgery

By the time surgery is complete, the titanium implant has essentially replaced “worn-out bone with metal. This allows her to walk without pain. That’s what we’re able to do today with 3D-printing technology.

The ultimate improvement Dr. Sculco is working toward goes beyond clinical measures, to the patient’s quality of life. “She’ll get out of the house and get back to her activities.

The alternative, without experience and resources like those brought to bear on this patient’s case, is not a happy one. Dr. Thomas Sculco, Surgeon-in-Chief Emeritus at HSS who led the creation of the CJRC and is Dr. Peter Sculco’s father, explains, “In the United States, there are many surgeons who can do a primary hip or knee replacement well.”

The problem we have is,” says Dr. Thomas Sculco, “should that fail for one reason or another, the attempt to redo that operation is far more complex, and in these situations most surgeons are far less experienced.” In revision surgeries, complications can compound themselves. “Less experienced surgeons may try to tackle those problems, and if they fail, the patient may face additional complications that lead to further and more complex surgery.”

By centralizing HSS’s world-class resources, including 3D-modeling and 3D-printing technologies, the CJRC serves as a one-stop shop that can preempt this unhappy sequence by providing expert care in the initial intervention. The concept of the Center”, says Dr. Thomas Sculco, “is to provide a place with the expertise to will tackle these challenging cases and develop best practices to prevent implant failure.” This, he says, “will ultimately be far less expensive to the healthcare system and better for the health of patients.”

When the goal is to address a need relating to a hundred thousand patients each year, consideration of cost is essential to the question of access to care. The CJRC is using its resources not only to provide stellar clinical care to individual patients, but also to train other surgeons in the United States and abroad to raise the level of care they are able to provide. “I’m hoping that as time goes on,” says Dr. Peter Sculco, “it becomes more universal, and can be done for lower and lower cost.”

The Center will also contribute to the state of care in the field through its creation of the Complex Joint Reconstruction Registry, the first of its kind in the world. Interdisciplinary research facilitated by the CJRC will seek to answer fundamental questions that bear on joint replacement outcomes around why implants fail, which populations might be at greater risk, and what role genetics play.

In June 2019, the CJRC convened its first International Consensus Meeting, a daylong conference on Acetabular Bone Loss, a condition where, as in the case of Dr. Peter Sculco’s patient, severe bone loss in the hip poses significant challenges in joint replacement surgery.

The meeting was attended by more than 30 orthopedic surgeons from nine different countries, and a published report will share knowledge with the broader medical community to advance care.

The aims of the CJRC are broad, commensurate to the scope of the need it was designed to meet, but those aims always come back to improving individual patients’ quality of life. Reflecting on the same patient, Dr. Peter Sculco says, “That patient is really the driver for why we created the Center in the first place.”