Week 1: Katelyn

This week marked the beginning of our immersion experience. So far, I have had the opportunity to start my research and to shadow my clinician, Dr. Hansen, at his clinic. These appointments were very interesting to observe largely due to the variety of patients that Dr. Hansen has, which include orthopedic oncology, metabolic bone diseases, and trauma cases. 

On Tuesday, Dr. Hansen holds appointments with current patients which includes post-ops and follow-ups. I was particularly fascinated by the process of these appointments and Dr. Hansen's ability to quickly analyze the patient's situation. This Tuesday, there were a total of 35 patients including: post-ops for hip and knee replacements; pain follow-ups; osteonecrosis; hip, sacrum, and humerus fractures; osteoporosis treatment follow-ups; osteosarcoma and benign bone tumors; Paget's disease; and repeat stress fractures. Typically, the flow of seeing these patients included a quick review of their file and any scans followed by speaking one-on-one with them. One particular aspect I was intrigued by was the differential treatment plans for patients with similar cases. As a bit of context, low bone density (osteopenia) is defined as a T-score between -2.0 and -2.5 whereas osteoporosis is defined as a T-score below -2.5 or an osteopenic score with a low energy fracture (fragility fracture). For osteopenic scores, Dr. Hansen prescribes an antiresorptive treatment for the patient. The primary goal with treatment is to prevent additional bone resorption with a secondary goal of improving T-scores if possible. However, there are two main types: Prolia, a RANKL inhibitor that requires an injection every 6months for 3years, and Reclast, a bisphosphonate that requires an IV infusion every year for 3years. I noticed that Dr. Hansen prescribes Prolia for individuals that are more mobile and less resistant to treatment whereas Reclast is prescribed for individuals with less mobility and more resistant to treatment. Additionally, Prolia is not an ideal treatment for individuals with a history of stroke and cardiovascular issues. Interestingly, the Prolia has been shown to have a potential for bone resorption rebound once treatment is stopped so upon stopping Prolia, the patients get switched over to Reclast (one or two infusions depending on T-scores) to prevent the rebound. I also found it interesting that the Prolia has been shown to more consistently improve T-scores than Reclast.  

On Wednesday, Dr. Hansen sees new patients. This Wednesday, he saw a total of 9 patients. A majority of these patients are referrals which tend to be slightly more complex and often idiopathic. One interesting thing I learned was about compressive side vs. tension side femoral head fractures. Typically, tension side femoral head fractures require surgical intervention with insertion of 3 screws through the femoral neck to prevent fracture propagation through the neck. The compressive side femoral head fractures on the other hand are often treated more conservatively as they have a lower risk of fracture propagation through the femoral neck and a higher likelihood of healing without surgical intervention. Though in cases where pain is persistent and scans indicate no improvement, then surgical intervention is needed. Another fascinating piece of information I learned was about osteonecrosis and bone infarct. While both describe bone death, osteonecrosis is used to describe death at the subchondral bone whereas bone infarct is used to describe death in the marrow and cellular bone. 

This week I also started my research project which will utilize opportunistic CT scans to evaluate BMD within the distal femur compartments. Before I can start the 3D reconstruction, I have to screen the cases for eligibility. A primary criterion for the study is exclusion of individuals with contralateral metal (i.e. implants) as this may cause scan artifacts. 

Overall this week was a very exciting start to the immersion experience. It was very informative to see the current treatment options for bone pathologies that are discussed within a lab setting. For instance, I wasn't fully aware of the rationale for selecting between the different antiresorptive treatment options.  Next week I have the opportunity to shadow during OR and clinic as well as continue my research progress. I am much looking forward to continuing to learn more.