Week 4: Katelyn

This week was the fourth week of immersion and I have continued to experience a variety of opportunities this week.

For research this week, I began to segment the patient scans. The primary goal of this segmentation is to isolate the patient's distal femur from the CT scans. Along with my research mentor (Dr. Quevedo), we developed a protocol for this segmentation to ensure consistency throughout the patient cohort. Once the distal femur is segmented, the greyscale values from the segment is exported as a txt file to be used for the BMD analysis.

During the clinic this week, I saw a wide array of patients including bone health work-ups, pain follow-ups, post-ops, and others. Of all these cases, the one that stood out to me was a multifocal osteonecrosis patient. While I have seen patients with osteonecrosis before during my time shadowing, I had yet to see a patient with multifocal osteonecrosis. This type of osteonecrosis has multiple spots and is not confined to one bone. Interestingly, due to its widespread nature, it is often complex to treat. For this particular patient, the onset of this osteonecrosis was long term usage of steroids for treatment of lupus. This steroid induced osteonecrosis is not uncommon and interestingly is also associated with onset of osteoporosis. This patient had edema and pain in the lateral distal femur due to one of these osteonecrotic spots. While the multiple spots cannot all receive treatment, this lateral distal femur can be treated through a core decompression procedure as an attempt to stimulate bone growth. In addition to this treatment, taking an OP medicine (bisphosphonates) can work to minimize the progression of the disease. The primary goal of this treatment is to prevent collapse since the spot interfaces with the articular cartilage surface. Collapse of this area would likely result in rapid progression of OA and likely would require a TKA.

In the OR this week, I saw a total hip arthroplasty (THA) and hip cephalomedullary nail (CMN) procedures. At this point, I have seen multiple THA procedures last week, so it was interesting to see what parts of the procedure change with patient variability and what stays consistent. The hip CMN procedures are used to internally fix a hip fracture. The fixation consists of four main components: an intramedullary rod and three screws. This procedure is minimally invasive and only requires three small incisions lateral to the hip. The approach used for this procedure is intertrochanteric, which is where the intramedullary rod is inserted through. Following the rod insertion, a primary screw is inserted through the femoral neck and a secondary screw is used to apply compression to the fracture to ensure union. Finally, a screw is inserted perpendicular to the femoral shaft to secure the rod distally.

I also got to sit in on a discussion of surgical approaches for intra articular fractures. I found this conversation particularly interesting because it resulted in a discussion of usage of dual fixation (plate and nail/screw) vs a nail/screw. The argument was on the basis of the stress and potential failure of these various fixation types. Such conversations are fascinating to sit in on as orthopedic surgeons have a better understanding of the role of mechanics than most surgeons do as a result of the load transmission through the skeletal system. 

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