Week 2: Manav Surti

 This week was filled with much opportunity, including my first OR experience! 

On Monday, I once again shadowed Dr. Gomoll in the clinic. There were many cases and I was once again able to practice looking at the knee MRIs alongside Dr. Gomoll, as he advised patients. I also learned some new terms like BFR (blood flow restriction), in which the physical therapist sequesters blood out of the knee area using a tourniquet. This seemed counterintuitive but this actually serves to stimulate muscle growth for patients that are undergoing atrophy from favoring one leg due to a knee injury in the other. I also learned that Dr. Gomoll doesn't like to treat all mensical tears; horizontal meniscal tears are fine to live with if they do not cause pain, since they hardly interfere with normal mechanics. A quote that stood out to me that Dr. Gomoll told a patient was, "you need to be miserable enough for long enough to embrace surgery." He told this to a patient that was unsure whether their case required surgery or not. Ofc the decision is up to the patient, Dr. Gomoll can only recommend what to do. But for confused patients the gist of this idea is that they will know they should undergo surgery when the pain and recovery period from surgery seems miniscule compared to the pain they feel on a regular basis. 

On Tuesday, I joined Justin and Pooja in seeing two craniotomies. This involved being in the room during both the neurosurgery, performed by neurosurgeon Dr. Philip Stieg, as well as the closing up portion, performed by plastic surgeon Dr. Jason Spector. The first case had undergone a previous procedure, but the doctors found that the bone cement that was introduced into the brain was causing infection, and had to be removed. The second case involved a patient that had a congenital birth defect and had a shunt implanted to relieve pressure. The hardware had some complication and the patient was experiencing scabbing in brain areas where scabbing is harmful. Dr. Spector was able to use his proprietary material, Dermasphere, to treat wound growth back into the affected areas. This was really interesting, as I attended a talk moderated by my PI, Dr. Larry Bonassar, where he hosted Dr. Spector who talked about his product for an hour. This product is especially interesting to my research interests involving mechanobiology, as the hydrogel product relies on biomechanical interfaces and the fact that cells are drawn toward mechanical interfaces in the process of durotaxis. For a mechanobiological and biomechanical product to make it to the clinic gives me much hope for the future of the interface (no pun intended) between biology and mechanics. 

On Wednesday, I joined Dr. Gomoll in his OR, in which he had cases from 8am til 5pm. This was an action packed day, full of so many different types of procedures. The first case was removal of some stabilizing tibial screws. This was my first knee surgery that I saw, and it was a very visually conducive surgery since it was arthroscopic. This meant that Dr. Gomoll just makes 2 small holes in the joint space and inserts an arthroscope to visualize the interior of the joint space. Using this visual information, he can insert various tools into the joint space and shave away parts of frayed meniscus, probe various cartilage defects, and remove hardware or loose bodies. This is also super easy to see since the arthroscopic screen is very high in the room, and easy to see from anywhere in the room. The next cases involved repair of the medial patellofemoral ligament (MPFL) using a donor semitendinosous (hamstring tendon) allograft. This graft is meant to reconstruct the MPFL, or ligament that connects the patella to the femur, on the medial side. This is done by attaching two suture points on the patella, with a screw that wraps the rest of the ligament around it, on the femur. It was really interesting to see that a ligament could be repaired using a muscle tissue. It was also very cool to be able to see the suturing of the graft prior to implantation; it seemed that each end of the graft received about 10-15 suture points, which makes sense because it has to stabilize such a mobile joint without failure. Finally, I was able to see the surgery I was most interested in; an osteochondral allograft (OCA). OCAs involve taking healthy, cadaveric, articular cartilage and replacing degraded patient cartilage. During this procedure, Dr. Gomoll reams a 12mm diameter plug on the defective patient site. After this, the donor allograft is brought into the room, and the proper patient matched site is also reamed and drilled out from the donor tissue. After the 12mm healthy plug is taken from the allograft, Dr. Gomoll hammers the healthy plug into the patient's 12mm hole, essentially taking out the degraded cartilage and putting in healthy cartilage (Fig 1). This is a great surgery when the cartilage damage is concentrated in one region, and a total or partial knee replacement is not needed. This was also a great opportunity for me to take the donor cartilage after the fact, since it would just be thrown out after. For my research project I would like to test the metabolic activity of the cells within the donor articular cartilage after removal of a plug, in direct relation to my thesis project which examines metabolic activity in bovine articular cartilage. 

Fig 1. Healthy, donor articular cartilage allograft that was implanted to replace a patient's degraded articular cartilage. This tissue can easily be given to me for research purposes after the surgeon is done using it, as these tissues come from registered organ donors who consented to having their tissue used for surgical or research purposes. 

On Thursday, I met with Dr. Tony Chen in the HSS biomechanics laboratory space, to discuss my research project. I realized very quickly that it would be very difficult to recapitulate the drilling of a healthy articular cartilage plug that Dr. Gomoll conducts in the OR. After Dr. Gomoll is done drilling their one needed plug, he moves on to the next surgery. My whole research project banks on the fact that I am able to extract my own cartilage plug in a similar, surgical manner, and when I saw Dr. Gomoll would not be able to drill another plug for my research purposes, I became worried that I would not be able to extract my own plugs for experimentation. My meeting with Dr. Chen was very, monumentally helpful; Dr. Chen has all of the tools required for plug extraction. Thus, I will be continuing work with Dr. Chen and his postdoc Vince, in order to stain the articular cartilage plugs for their mitochondrial activity after we extract the plug. 

I am excited for week 3 and the potential to obtain more donor samples! 

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