With a long history of affiliation, Veterans Affairs and Penn Orthopaedics are moving forward now on plans to enable vets to more conveniently receive advanced treatments and ongoing care from Penn Orthopaedics providers. Leading this effort are Richard E. Grant, MD, the newly appointed Chief of Orthopaedic Surgery at the Corporal Michael Crescenz Veterans Administration Medical Center in Philadelphia, and L. Scott Levin, MD, FACS, Chair of the Department of Orthopaedic Surgery and Professor of Surgery, Division of Plastic Surgery at Penn Medicine—both of whom are veterans themselves. They and orthopaedic specialists Andrew F. Kuntz, MD, and Stephen J. Kovach, III, MD, FACS, discussed some of the advanced treatments they will be able to offer veterans, as well as opportunities for research that Penn and the VA will be conducting together through their shared resources.
“Having served 11 years’ active duty in the USAF and 20 years in the USAF reserves, I find it to be quite an honor and distinct pleasure to serve our veterans by leading these efforts to offer more orthopaedic services with Penn’s Orthopedic residents and highly skilled faculty providing the highest level of operative care. These health care initiatives benefit our veterans extensively.” – Richard E. Grant, MD
Dr. Levin says he has been heavily involved in military orthopaedics, having served in Desert Storm and in the US Army reserves, and is active in the Department of Defense–sponsored Extremity War Injury Symposium. “As a veteran and son of a veteran—my dad served in Korea—I have a passionate commitment to veteran care.”
Dr. Levin says the VA has long been an important part of the Penn program. “The VA is integral to the fabric of Penn orthopedics and I regard it as another domain or platform where we train our residents, do research, and provide superb clinical care. I myself go to the VA (without compensation) to do rounds and have case conferences with residents on a regular basis.”
Expanded outreach and outcomes
“Our outreach to VA hospitals in Coatesville, PA, and Wilmington DE—which has provided no surgical services in more than a decade— promises improved access to orthopaedic care for our vets who find it difficult to traverse back and forth to the Philadelphia VA”, says Dr. Grant, noting that his own appointment was rooted in the mutual desire of the medical centers to realize this and other collaborative goals. “They just needed someone to come in and get it going; it’s my job to roll the big boulder up the mountain.”
He says they will initially be bringing in two new services to these locations—orthopaedic surgery/joint replacement through arthroplasty services, and neurosurgical services—mainly lower back and some cervical spine surgery—per Steven Fulop, MD.
Returning Home: Limb Salvage and Functional Optimization
Dr. Levin, who has a special interest in extremity salvage and reconstruction—specifically of the hands—is also a board-certified plastic surgeon, training that serves him well in his work with Penn Orthoplastic Limb Salvage Center (POLSC). The POLSC, which is led by a team of orthopaedic surgeons, plastic surgeons, and vascular surgeons offers unique microsurgical expertise and advanced technology for patients at high risk for limb amputation and is the only program of its kind in the US. He says there has been discussion over the years to create a center such as POLSC at the VA in the future, and there are also plans to establish a regional hand surgery program there, where David Steinberg, MD, who is also Professor of Orthopaedic Surgery at Penn, is Chief of Hand Surgery. “We have well over 1,000 veterans who have lost their limbs in our conflict in Iraq and Afghanistan and many of those warriors would be candidates for hand and arm transplantation,” says Dr. Levin.
Among the advancements Penn Orthopaedics is able to offer veterans at the Philadelphia VA are improved surgical methods to improve the function of veterans with extremity injuries, and ease post-amputation phantom limb and neuroma pain. Associate Professor of Orthopaedic Surgery and Endowed Associate Professor in Plastic Surgery, Dr. Stephen J. Kovach, III, who is Co-director of the POLSC, discussed what he considers to be the greatly underestimated problem of ongoing pain following amputation using a surgical approach, he says, has remained almost unchanged for centuries.
“If you look at patients who have had amputation of an extremity, a high percentage go on to have significant pain or disability. The two forms that typically occur are phantom limb pain or pain from the neuroma that is a common aftermath when mixed motor and sensory fibers are severed,” he explains. Dr. Kovach notes that the standard of care for amputation “since time immemorial” has been neurectomy. “This just means at the time of the amputation, you pull down on the nerve, cut it in some way, and let it retract back into the amputated limb.” This, he says, results in a number of patients experiencing either persistent pain from a neuroma or phantom limb pain, described as a feeling that the limb is still there, that there’s a cramp, or feeling like their toes are always curled.
He says for a large number of patients “a better path forward” is targeted muscle re-innvervation (TMR), an enhancement he performs and recommends. Instead of just cutting the nerves at the time of the amputation, he says, TMR involves finding these mixed motor sensory nerves in the extremity and then tracing them back, or finding other small motor branches in the surrounding muscle, cutting a motor branch, then coapting or putting the cut end of the nerve into the cut motor branch into the muscle. “In this way, you give the cut end of the nerve somewhere to go; it’s something to re-enervate, instead of sprouting a ball of scarred axons at the end of the cut nerve.”
Dr. Kovach says the open circuit left when a nerve is just cut means there’s no longer real feedback to that nerve, which he says may result in phantom pain. In contrast, he says, “With TMR, you are completing that circuit, so you have a complete circuit that allows some feedback within the nerve and then significantly reduces the chance of having phantom limb pain as well.”
Another approach to preventing post amputation pain, says Dr. Kovach, is a technique called regenerative peripheral nerve interface (RPNI). For this he says, “You take the cut end of the nerve and cut a small piece of muscle and then wrap the end of the nerve with this piece of muscle.” As with TMR, he says, “it gives the nerve something to grow into and completes some type of circuit—which hopefully reduces likelihood of phantom limb pain.”
He says the jury is out on which is better but says, “In my own hands, the higher up the amputation is on the extremity, sometimes trends toward RPNI, only because there may not be as many motor branches or the size mismatch between nerves and motor branch is significant.”
Dr. Kovach says, other than additional time under anesthesia, these approaches have no downside, and they can vastly improve quality of life for amputees. “Although best done at the time of primary amputation, this offers amputees their best shot at long-term reduction in pain/phantom limb sensation; I believe it is still worth doing in a delayed fashion for those with chronic pain after traditional amputation surgery,” he says.
Dr. Kovach says he is among few who perform these procedures—and may be the only one in the Philadelphia area now—but says there are good reasons to spread the word. “The way people do an amputation has not changed in hundreds of years, and it’s time for that to change by publicizing and teaching this technique.”
Then, too, there is research. As Dr. Grant notes, “Besides the clinic efforts, we also conduct important research, and [as mentioned by Dr. Levin above] we are pushing to become more innovative with centers of excellence for hand surgery and microvascular reconstruction.”
Research Collaboration for Better Care
Although Dr. Kuntz subspecializes in shoulder surgery, and says the Philadelphia VA is the only one in the region that does shoulder replacement surgery—including standard anatomic replacement, reverse shoulder replacement, and revision shoulder replacements, he says the most “cutting edge” aspect of his practice now is in basic science research—mostly examining tendon healing as it pertains to the rotator cuff and shoulder.
Dr. Kuntz stresses the importance of the collaborative relationship between the McKay Lab at Penn and the Translational Musculoskeletal Research Center (TMRC) at the VA. “Our basic science research aims to advance future care. We are conducting fundamental studies looking at why rotator cuff tears—which are very common in the VA population, as well as the general population—don’t heal well. Our research in the lab focuses on how to improve rotator cuff healing, in order to prevent re-tearing and improve patient outcomes.”
Dr. Levin, too, hailed the strides made by the two medical centers in advancing research. “The research program we have built at the VA over the last 11 years is world class. Many of our faculty have received merit grants, including Harvey Smith, MD, Cheif, Orthopaedic Spine Surgery, who received funding from the VA Office of Research & Development for two rehabilitation projects, and Robert L. Mauck, PhD, the Mary Black Ralston Professor of Orthopaedic Surgery and Professor of Bioengineering at the University of Pennsylvania, who co-directs the Program in Musculoskeletal Regeneration in the Penn Institute for Regenerative Medicine, and is also a Research Health Scientist at the Philadelphia VA Medical Center, and co-Director of the Translational Musculoskeletal Research Center (TMRC) at the VA.