Week 6

I started off the week joining Jacob and Dr. Schneider for what was supposed to be an amputation, but ended up being a couple of angioplasties that had taken priority. They were done under x-ray guidance, so everyone in the room had to wear lead. I thought it was really cool how they closed the insertion point with a collagen plug, but then they had to apply pressure for 20 minutes in order for it to be stable which didn't seem very efficient.

There were a couple of really interesting cases in clinic this week. One man from China came in with x-rays (real, physical films!) that showed what looked like cystic growths all around his knee. He had essentially no range of motion and couldn't walk at all. On the x-rays the growths looked like cysts, but he also had an MRI that showed that the growths were bony. Dr. Bostrom took the images to radiology to get second opinions, but the radiologists weren't sure what they were either. They were able to determine that the growths were not malignant. Since the bone closest to his knee joint is so compromised, when he has his knee replaced he will need rods into his femur and tibia in order to allow the implant to fix to normal bone. On a side note, he didn't speak English so there was also a translator present. It was an interesting dynamic to see, trying to make sure nothing was lost in translation in either direction.

Dr. Bostrom's patients are generally older people who have been having joint pain for a while. On Friday, however, we saw a 19 year old girl with osteonecrosis in both hips. She was diagnosed with TTP (thrombotic thrombocytopenic purpura), a blood coagulation disorder, the previous year. She was treated with steroids for several months to get the TTP under control. The osteonecrosis could have been caused by the TTP (blood clots leading to avascular necrosis), the steroids, or a combination of the two. The osteonecrosis had caused collapse on her left hip, but not her right. Once the bone has deteriorated enough to no longer support the cartilage above it, the cartilage is disrupted and the femoral head reaches a collapsed state. Eventually she will need her hip replaced, but in the meantime she will be taking bisphosphonates to stabilize the deterioration of her right hip and maybe buy time before her left hip needs replacing. It was really hard hearing her mother repeatedly ask about all the treatment options out there, even though none of them really work once the hip has collapsed. I could tell neither one of them was quite prepared for the news that the daughter would need a hip replacement so young, but Dr. Bostrom was really patient and explained why the other options wouldn't work and could even cause more damage.

On Thursday there were several interesting revision surgeries. One patient had severe osteolysis from polyethylene wear. There was a hole in the acetabulum, and a very large hole in the femur. The hole in the acetabulum was packed with bone graft, but the hole in the femur was packed with a substance resembling caulk. It was a calcium phosphate and calcium sulfate mixture injected directly into the defect. Eventually the calcium sulfate starts to dissolve, leaving a scaffold of calcium phosphate, which then attracts bony ingrowth and eventually seals the defect with new bone. I thought it was really cool how something so seemingly simple could repair such a huge problem.