JISRF Activities August 2011

In This Activities Update

• John Testerman, M.D. His first Neck Sparing Hip Implant and the learning process he went through to ensure a positive outcome
• Southern Joint Replacement Institute A group of four leading orthopaedic surgeons in Nashville, TN devoted to the treatment of patients needing primary and revision total joint surgery
• Saint Francis Care
• Surgical Video Production
• Dr. Lorence Trick JISRF's New Medical Director and Board Member
• Comments

July 12, 2011

John Testerman, M.D

John Testerman, M.D., Bristol, TN

I have had the pleasure of getting to know Dr. Testerman over the past few months and was able to visit with him last week for his first implantation of the ARC^TM Tissue Sparing total hip stem.

As we have done over the past year as part of our commitment to the TSI^TM Study Group we highlight new experiences within this area of study. First a little background on Dr. John Testerman's experience and training.

A graduate of North Georgia College and State University (Summa Cum Laude) and the Medical college of Georgia, Dr. Testerman completed his general surgery internship and residency at Jacksonville Health Educations Programs in Jacksonville Florida. He practiced general Orthopedics in Albany Georgia for eleven years before moving north to Bristol Tennessee in 1994. He was Board certified in 1986 and re-certified in 1997 and his particular fields of interest are in total joint arthroplasty, operative arthroscopy, and pediatric orthopedics. He is a member of the Tennessee Medical Association, the Tennessee Orthopedic Association and a Fellow of the American Academy of Orthopedic Surgeons.

He is constantly evaluating and searching for new and innovative ways to improve the function and comfort of his patients using alternative bearings (rotating platform knees, metal on metal and ceramic on ceramic hips). He also pioneered computer assisted total knee Arthroplasty at Bristol. He is closely following the development of the Diamond on Diamond Bearings for Total Hip Arthroplasty.

ARCTM Stem

Dr. Testerman completed a mini-fellowship with Dr. Jim Andrews in operative arthroscopy of the shoulder and can repair rotator cuff tears, ACL tears and glenoid labrum tears as an outpatient with minimal scars and pain when compared with conventional surgeries. He was the director of Children's Medical Service Orthopedic Clinic in Albany, Georgia before moving to Bristol and continues to enjoy working with children's orthopedic problems having trained with Dr. Wood Lovell while in Jacksonville.

I am proud to announce John as a Member of the JISRF TSI^TM Study Group. His web site and contact information can be accessed by clicking on his name on the TSI page.

Dr. Testerman's Case

Dr. Testerman's cas is a forty-five year old female, morbidly obese with bilateral hip disease. She is currently household ambulatory and otherwise confined to a wheel chair, although able to independently transfer herself to and from bed. X-rays show destructive bilateral OA of the hip with such severity it is hard to determine if the underlying disease is hip dysplasia or not. The right hip head has collapsed making true measurement of femoral offset difficult.

Due to her relative young age, body weight and the likely fact that she will be facing one or more revisions in her lifetime Dr. Testerman decided a more bone conservative tissue sparing approach would be in her best interest. Although her body weight certainly did not lend itself to a conservative soft tissue approach this device does not require resection into the greater trochanteric and abductor musculature area.

Prior to Dr. Testerman scheduling his first case he went through a process that provided him with the necessary skills and experience to take on this level of surgery with a new ARC^TM hip device.

I first met Dr. Testerman at the 2010 AAHKS Annual Meeting in Dallas where John attended the JISRF Mini-Symposium on Neck Sparing THA - Lessons Learned. He was interested in this new approach to THA and we had some follow-up discussions at the AAOS 2011 Annual Meeting in San Diego and then again at the Cadaver Training Symposium sponsored by Omnilife Science^TM this Spring at the Merin Lab in Henderson, NV.

This was an excellent meeting with a balance of didactic and hands on training. The workshop provided Dr. Testerman with the hands on experience to give him the confidence that this new ARC^TM device was indeed a stem he would consider using.

Dr. Testerman is interested in learning the single incision anterior approach and feels this style stem would make the approach easier to switch to. That said, we have always advocated that surgeons should not switch to a new surgical approach while learning a new device. John agrees with this learning approach so he stayed with his standard posterior approach with this patient.

At 5' 2" and 250 lbs this was going to be a challenge for any approach, devise, and surgeon. In addition this was being done at a new hospital with a new team that had not seen this devise before. Prior to surgery, John and I had a chance to review the x-rays and we did not see anything that should hinder the selection of the ARC^TM Stem. We did have a conventional stem on backup and always recommend that a conventional stem be available. I did suggest that he take an intraoperative x-ray once the trials were implanted.

They use a two tier back table which I think is a good approach and reduces the need for side tables. I first saw this with Kris and John Keggi in Connecticut. It is especially helpful when filming a case because you can get closer to the action with less risk of contamination.

If you have not seen a two tier back table used you should consider trying it.

I always emphasize the three key factors in my opinion to a successful outcome with this devise.

Surgical Technique Perls

Use of the marking template helps him not only to guide the level of the neck resection but also the angle. Approximately 8mm sub cap at about a 50º angle provides our target neck resection	Not only did he use it as a reference he used it as a cutting guide. The guide is kept in place while he resects the neck.
He used the starting awl to open the femoral canal and then moved to the rat tail to define the medial curve.	He then progressed to the starting rasp to gently file the medial curvature of the femur.
He progressed to the size one definitive rasp. The rasp easily fit but was impressively tight and stable. Since this was his first case I suggested that he implant the trial stem then move on to the cup and take an intraoperative x-ray.	Trial stem was easily inserted. The acetabular preparation was carried out.
There was no difficulty with the trial femoral stem in place for either preparation or insertion of the acetabular component.
X-ray confirmed our impression that we could go up in size of the stem and neck length. The offset appeared to be good with a neutral modular neck and 0 head with a 36 mm poly insert.	The trial stem extractor works well and functions as a reminder of how to extract the final stem if it ever becomes necessary.
A number two definitive rasp was used and was able to seat flush as a result of using the neck resection guide.	Good contact was acheived around the entire conical flair of the proximal femur.
The entire cortical rim intact
Stems starts to bite at this level and gentle tapping is required to seat the stem.
Careful checking for anterior osteophytes should be done to reduce chances of impingement.
	Skin to Skin less than 60 minutes / with intraoperative x-rays, a new device in a challenging patient profile with a new O.R. team. This only happens because of the preoperative training of the surgeon.

Southern Joint Replacement Institute

I had the pleasure of visiting my old friend Dr. Michael Christie from Nashville, TN last month. Dr. Christie and I had collaborated in the past during the early S-Rom® Stem days. We both were part of the co-development team that created the S-Rom Oblong acetabular component from Joint Medical Products Corp.

Oblong Acetabular Component
Granted March 9, 1993
Co-Inventors:
Michael Christie
Fred DeCarlo
Timothy McTighe
Douglas G. Noiles
Patent number: 5,192,32

Michael was our lead inventor which led to additional international patents in Canada, Denmark and other European countries.

We both have continued our product development interest in acetabular components.

Michael was instrumental in creating the Southern Joint Replacement Institute.

SJRI has developed a very successful surgeon-owned practice committed to providing state of the art technology and excellence in non-surgical and surgical interventions.

Dr. Michael J. Christie

Dr. Michael J. Christie came to Nashville in 1984 as an assistant professor of Orthopaedics and Rehabilitation at Vanderbilt University Medical Center. In 1989, he founded the Vanderbilt Arthritis and Joint Replacement Center, serving as its director until co-founding the Southern Joint Replacement Institute in 1999.

Dr. Christie received his medical training from Loyola University Stritch School of Medicine in Chicago, and completed a fellowship at Harvard University's Combined Orthopaedic Program for Joint Replacement and Adult Reconstructive Surgery. Dr. Christie also holds a master's degree in epidemiology from Johns Hopkins University.

An internationally-recognized lecturer and author in the field of joint replacement, Dr. Christie has a special interest in complex revision procedures of the hip and knee. He participates in the design of new implant components and holds international patents on several.

Dr. Christie is a member of the American Academy of Orthopaedic Surgeons, the American Association of Hip & Knee Surgeons, the Society for Arthritic Joint Surgery and the International Society for Technology in Arthroplasty.

• Associate Clinical Professor, Orthopaedic Surgery
  Vanderbilt Medical Center, 1998-present
• Chief, Section of Joint Replacement and Reconstructive Surgery
  Vanderbilt Medical Center, 1989-1998
• Director, Arthritis and Joint Replacement Center
  Vanderbilt Medical Center, 1989-1998
• Board Certification 1988, 1998, 2008
• Fellowship in Joint Replacement and Adult Reconstructive Surgery
  Harvard University Combined Orthopaedic Program, 1983-1984
• Residence, Orthopaedic Surgery
  Loyola Medical Center, 1979-1983
• Medical Doctorate
  Loyola University Stritch School of Medicine, 1978
• Master of Public Health, Epidemiology
  Johns Hopkins University, 1975
• Bachelor of Science, Zoology
  DePauw University, 1974

Memberships

Fellow, American Academy of Orthopaedic Surgeons, Society for Arthritic Joint Surgery, American Association of Hip and Knee Surgeons, International Society for Technology in Arthroplasty, Mid-America Orthopaedic Association

He is joined in this venture by his partners:

David K. DeBoer, MD	J. Craig Morrison, MD	Jeffery T. Hodrick, MD

SJRI based in St. Thomas Hospital in Nashville has four dedicated operating suites. They are state-of-the art with large layouts and two rooms. They also have the most sophisticated surgical video capabilities that I have seen.

In my travels I have been impressed with many teaching facilities. Three stand out:

• SJRI located at St. Thomas Hospital, Nashville, TN.
• CJRI located at St. Francis Hospital, Hartford, CT
• Mount Carmel New Albany Surgical Hospital, New Albany, OH

These are great facilities that were developed by the creative spirit and drive of private practice orthopaedic surgeons. If you have not had the pleasure of visiting one of these sites I certainly recommend you put it on your to do list.

Saint Francis Care

I also had the pleasure of visiting CJRI at St. Francis Hospital in Hartford, CT last month to video tape Dr. John M. Keggi performing "A Single Incision Anterior THA Utilizing the Apex ARC^TM Tissue Conserving Stem".

Saint Francis Hospital and Medical Center is proud to offer patients a dedicated, comprehensive joint replacement service which has performed over 2,700 joint replacement surgeries in its first year.

A "hospital in the hospital", the Connecticut Joint Replacement Institute at Saint Francis (CJRI), is comprised of leading-edge orthopedic surgeons who are fellowship-trained and nationally recognized as experts in the field of joint replacement.

Dr. Steven Schutzer	Dr. McAllister

As with SJRI at St. Thomas in Nashville, CJRI at St. Francis Hospital has a team that drives the work and Co-Directors Dr. Steven Schutzer and Dr. McAllister oversee the strategic mission of CJRI.

Dr. Steven Schutzer completed his general surgery internship at the University of Rochester, Strong Memorial Hospital and his orthopedic surgery residency at the University of Connecticut School of Medicine. Dr. Schutzer also served as a fellow within the hip and implant unit at Massachusetts General Hospital.

Dr. McAllister is a graduate of the University of Connecticut School of Medicine and Orthopedic Residency Program. His specialty training includes a fellowship in total joint, adult reconstruction, and orthopedic trauma surgery at the Minneapolis Orthopedic and Arthritis Institute in Minneapolis, Minnesota. His area of specialty includes Arthritis Management, Joint Replacement Surgery, and Revision and Complex Joint Reconstruction Surgery, as well as Major Orthopedic Trauma Surgery.

John M. Keggi, MD	Robert "Ted" Kennon, MD

Two of our TSI^TM Study Group Members have started moving some of their surgical practice to this new hospital in a hospital (CJRI) .

Both John and Ted have been evaluating the new neck sparing / tissue sparing Apex ARC^TM Stem.

View Dr. J. Keggi's surgical videos

Apex ARC^TM Stem / Anterior Surgical Approach by John Keggi, MD - Part 1

Apex ARC^TM Stem / Anterior Surgical Approach by John Keggi, MD - Part 2

John and his O.R. team getting set for our JISRF video team getting John and equipment set for filming.

Dr. Steven Schutzer stopped by for a quick photo op with Jason Heath, Director of Marketing and Brad Wood sales Rep for Omnilife scienceTM. Steve was kind of enough to give me a personal tour of the CJRI facility. I was very impressed.

Stephanie Kelly

Stephanie Kelly, RN "The Boss" made our job very easy. This was the first time they were using their new video equipment and the entire staff made this a delightful day. John had nine total joints and we did four ARC stems and videotaped two.

I think you well see more from this Institution in the form of Learning Center Activities.

Surgical Video Production

JISRF has been busy since May 2011 capturing some exciting total hip and total knee technology.

Just posted:

August 2011	By John M. Keggi, MD
July 2011	By Lou Keppler, MD
May 2011	By Charles Bryant, MD

View all surgical videos produced by JISRF.

Dr. Lorence Trick

Dr. Lorence Trick

Again, we want to welcome Dr. Lorence W. Trick as JISRF's New Medical Director. Larry joined us this July after retiring as Professor Adult Reconstructive Surgery from UT Health Science, San Antonio, TX.

Comments

Stay tuned, our next issue will highlight four recent explants of the ARC stem and the reasons for these explants. None of the explants were due to any complications of the implant design. We are pleased with the design and the instruments that allowed for ease of retrieval with little to no bone destruction. We also have first hand evidence of bone attachment to the proximal porous surface. This stem is meeting our overall design objectives!

Timothy McTighe, Dr. H.S. (hc)
Executive Director
Joint Implant Surgery & Research Foundation