Orthopedics

From new toes to new cartilage — innovations for fixing our aching joints

 

Special to the Miami Herald

For much of his career as a Miami Beach firefighter, Luis R. Garcia Jr. ran about three miles a day, five days a week. Later, after he was elected to the Florida House of Representatives, Garcia played in an annual softball game between legislators. He was a catcher, a position notoriously hard on the knees.

A few days after one of those games, six years ago, Garcia felt a pronounced and painful “pop” in his right knee. It would be the end of the knee as he knew it.

Although he underwent arthroscopic surgery at the time, Garcia’s doctor told his 62-year-old patient that eventually he would need a new joint. Some 18 months after that, his other knee made the same sickening sound, and the doctor delivered the same prognosis.

“He showed me something that looked like a hinge that you buy at Home Depot,” Garcia recalled. “It just freaked me out.”

Garcia sought the counsel of another orthopedic surgeon, Dr. Marc E. Umlas, at Mount Sinai Medical Center in Miami Beach, who ultimately replaced both of Garcia’s knees. In so doing, he used a procedure that involves obtaining a specially calibrated magnetic-resonance image of the knee to create implants that are individually crafted to each patient’s particular contours and measurements.

“What they’re doing is amazing,” said the retired Garcia, whose left knee was swapped out a year ago and the right one on Jan. 21. “They custom-make the part that they put into you. Within a couple of weeks I had full range of motion. Before I had my knee surgery I felt like a cripple — I was basically bone on bone. Now I feel much, much better. For a 68-year-old guy, I’m in pretty good shape. I hope to be playing tennis pretty soon.”

The procedure that seems to have boosted Garcia’s prospects for regular sets of serve-and-volley is one of several innovations in orthopaedic surgery developed at hospitals in South Florida.

Orthopedic surgeons at the University of Miami’s Miller School of Medicine are increasingly focused on what they call biological solutions, rather than prosthetic implants, as a way to repair defects in joints. The reason, according to Emeritus Professor of Orthopaedics Dr. Theodore I. Malinin, the founder of the university’s Tissue Bank, is that artificial devices often become problematic over time, primarily because they are fundamentally incompatible with human tissue and bone.

Instead, Malinin and his colleagues in the tissue bank have developed a procedure, now used under the brand name BioCartilage, under which shavings of cartilage are removed from a cadaver, desiccated, and pulverized into tiny particles to form a powder. The powder is mixed with saline and fibrin — a protein formed during the clotting of blood and which acts like glue — and the resulting paste is injected into defects or injuries in cartilage.

The mixture prompts the patient’s own cells to repopulate the wound, essentially allowing the cartilage to heal itself. In the last two years, more than 4,000 units of the BioCartilage mixture have been shipped from the tissue bank for use in surgeries around the world.

“This is a bridge to newer technologies, to something very special,” said Dr. H. Thomas Temple, the Tissue Bank’s director and vice chairman of Miller’s Department of Orthopaedics, who pointed in particular to a development — set for launch this summer — known as the MIAMI cell, an acronym that stands for Marrow-Isolated Adult Multilineage Inducible.

Developed over 15 years, primarily by Dr. Paul C. Schiller, a professor of orthopaedics, biochemistry and molecular biology at UM, the procedure under which the MIAMI cell is used acts much like BioCartilage, but with the addition of stem cells, which stimulate cell growth in laboratory conditions.

The aim, Temple said, is to enable repairs of various parts of the body without using any artificial components whatsoever. The MIAMI cells, which originate in bone marrow and have a unique signature, share many of the genes found in embryonic stem cells. Under appropriate conditions, Temple went on, the cells can be induced to form not only cartilage but bone, nerves and even liver and skin.

“We may be able to make a joint,” he said, “a true biological replacement, rather than metal or plastic.”

Another University of Miami surgeon, Dr. Lee Kaplan, chief of the sports medicine division, is tackling contained lesions in cartilage by making plugs or dowels of cartilage taken from a cadaver — usually from around the femur — and injecting them directly into defects in the patient’s troubled joint.

One of those who appears to have benefited from Kaplan’s procedure is Sergio Campos, a 35-year-old police officer and Marine who injured his right knee playing basketball. A doctor who treated him diagnosed a sprained knee, prompting Campos, a self-described fitness buff, to go ahead with plans to run in an endurance race known as Tough Mudder only a week after he had sustained the basketball injury. Not surprisingly, he conceded, the knee felt much worse after the race. “I couldn’t put any weight on it,” he said. “I couldn’t go up the stairs.”

Campos was referred to Kaplan, who concluded that the officer had damaged his knee and chipped a piece of bone from the femur, and that surgery was required. The operation took place last August, and involved taking cartilage from both a cadaver and Campos and using a blend of it to “cork” the bone — the term the patient remembers the surgeon using. Later, Kaplan gave him pictures of the surgery.

“They were a little gory, but it looked like a perfect little cork,” Campos recalled. “My physical therapist said, ‘Wow, this is like textbook. It looks great.’ 

Campos has been able to resume jogging, although he is avoiding basketball. “For now,” he said, “I’m just running in a straight line.”

In the area of ankle replacements, most surgeons concede that there was a high rate of failures in such procedures some years ago, and even these days the field “is still in its infancy,” said Dr. Steve Steinlauf, a surgeon at Memorial Regional Hospital in Hollywood.

“But we’re as close to a successful procedure as we’ve ever been,” he said, describing a method in which a computerized tomography image— usually abbreviated to CT scan — is taken of the precise shape of the ankle. The image is then used to create a model for so-called cutting blocks,which in turn shape the bones to which the new ankle joint will be attached.

“The benefit of this new system is that we’re more accurate in cutting the old bone so that the new ankle goes in correctly,” said Steinlauf, who spoke by telephone from Xi’an, China, where he was lecturing to trauma surgeons. After prior iterations of ankle surgery, the foot was sometimes not properly aligned with the ankle, or would become unaligned over time, an anomaly that would place greater stress on a new ankle than it could tolerate.

Additional procedures were often required to either repair or balance the ligaments so that the ankle was stable, and on occasion the foot would need to be realigned to lie “flat on the ground,” he said.

“But if you put all the parts together — the right candidate, one who has the right stability and alignment — then they can get good function out of a total ankle replacement,” Steinlauf said. “The mechanics have improved.”

One of Steinlauf’s patients, Arlene Cohen, 81, could not be more pleased with the polyurethane joint he placed in her right ankle four years ago. “I thank him every day for this,” said Cohen, a former pre-kindergarten teacher and mother of three whose ankle was badly broken in a car accident in the early 1980s. The doctor who treated her at the time told her that, “if ankle replacement surgery were perfected, I’d be the perfect candidate,” Cohen recalled.

In the meantime, she went on, “I just went on for years having problems, to the point where I was having trouble walking. I even went into a wheelchair for a while. I didn’t know what to do.”

Finally, she was referred to Steinlauf, who took on her case and to whom she returns for annual check-ups. “The ankle is fantastic — I wish the other one was like that,” Cohen said, referring to the arthritis in her left leg. “My right ankle is better than my left now. I have good motion — everything. My doctor’s amazed with me.”

Another common trouble spot for arthritis sufferers is the big toe. For years, the standard treatment for loss of cartilage in the joint that connects the toe to the foot was to fuse the two bones, which was “never a great solution,” said Dr. Thomas San Giovanni, of Doctors Hospital’s Center for Orthopedics and Sports Medicine in Coral Gables. Other procedures used in the past, he said, were not “truly respectful of the true anatomy of that joint, and to its motions and stresses.”

To fix that problem, San Giovanni, a foot and ankle specialist, designed an implantable prosthetic joint that is expected to return the “great toe,” as he calls it, to full function in patients who had become arthritic there. The first operations to install the new joints are scheduled for June.

“This will be the first anatomically designed, total-joint replacement for the big toe,” said San Giovanni, the orthopedic surgeon for the Miami City Ballet, who also is a surgical consultant to the Florida Panthers, the Tampa Bay Buccaneers and Florida International University. “This is an innovative solution that makes anatomical sense. I’m pretty positive that this is going to be a game changer.”

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