Bronx-Lebanon Hospital Center brings together advanced technologies, experienced orthopaedic surgeons and wraparound care to make minimally invasive surgery (MIS) of the knee, hip and spine safer and more accurate, fostering the best possible outcomes as well as speedy and comfortable recoveries for patients.
Leading-edge technology and techniques are key features of the program, but the comprehensive care and professional judgment provided by the surgeons are equally important. Whether a patient has a congenital condition, an injury or a degenerative joint problem, careful selection and preparation before surgery as well as an emphasis on aftercare promote positive outcomes.
“We continuously focus on patient satisfaction in terms of optimizing care, education and engagement,” says Morteza Meftah, MD, Chief, Adult Reconstruction Surgery and Clinical Research, Department of Orthopaedics at Bronx-Lebanon. “With MIS techniques, multimodal pain management and rapid-recovery protocols, we have improved joint replacement outcomes. We also have a dedicated team that thrives on providing a high-quality patient experience.” That team includes fellowship-trained surgeons, who leverage the capabilities of state-of-the-art imaging and operative suites to further enhance outcomes.
Dr. Meftah reviews the radiographic findings of advanced osteoarthritis with a patient, discussing the SwiftPath methods, expectations and outcomes of outpatient total hip replacement.
An Innovative Spine MIS Program
Ashley Simela, DO, Attending Surgeon, Department of Orthopaedics at Bronx-Lebanon, and Clinical Instructor of Orthopaedics, returned to the Bronx two years ago following a fellowship at Cedars-Sinai Medical Center in Los Angeles. He sought the opportunity to recreate the prestigious spine surgery program at Cedars-Sinai, which has a strong focus on MIS.
Ira Kirschenbaum, MD, Chairman, Orthopaedics, “was extremely supportive,” Dr. Simela says. “He helped me move forward with this most important service.”
Dr. Simela and his colleagues now perform an array of procedures for back pain, including cervical/lumbar discectomy, fusion and disc replacement. Approximately 90 percent of the time, he uses a minimally invasive approach, relying on advanced visualization and monitoring technologies such as fluoroscopic imaging and neurological monitoring. Often, a complex procedure is performed in a two-staged approach, anterior and then posterior, with a vascular access surgeon assisting with the abdominal approach. Dr. Simela also performs 360-degree lumbar fusion minimally invasively, one of the few surgeons in the region to offer this option.
Ashley Simela, DO, Attending Surgeon, Department of Orthopaedics at Bronx-Lebanon Hospital Center, and Clinical Instructor of Orthopaedics, reviews spine anatomy and fusion technique with a patient.
Dr. Simela conducts a patient consultation to discuss minimally invasive spine surgery.
For disc replacement surgery, he orchestrates several teams to perform the complex procedure.
“We connect the patient to the neurological monitoring system, placing leads that monitor brain, motor and vascular function,” he says. “With this system, we can assess the spinal cord intraoperatively. After the monitoring is set up and the patient is positioned, we use the imaging unit to determine the bony landmarks, which we rely on to tell us the exact location of the spine and discs. Once we’ve estimated the landmarks with respect to the cervical/lumbar spine, we proceed with surgery.”
The first incision, Dr. Simela says, serves as a probe to tell him where he is docked in relation to the imaging unit. By matching his position relative to the patient’s body (through the imaging), he can accurately map the surgery.
“The neuromonitoring team then ensures the spine is still in a normal position,” he says. “We make an additional incision, deeper into the muscles, then go through the submuscular plane and retract the fascia. Using small instruments, I carefully take down the sympathetic chain, moving it slightly aside. Then I bring in a microscope and, using that, we perform dissection and discectomy.”
After removing the damaged disc, Dr. Simela prepares the implant. He has already sized it, so once the site is prepared, he assembles the two-piece replacement for implantation.
“I then perform the final prep work,” he says. “I ensure the ends of the bones are smooth, the disc is excised completely and there is no excessive bleeding.”
Everyone carefully monitors the patient, prioritizing communication. A shift in the status observed by one team may prompt a request to another. For example, in response to a change in the patient’s neurovascular status, the anesthesiologist may be asked to raise the blood pressure slightly.
“After the insertion, I return to the microscope and check the positioning of the disc,” Dr. Simela says. “I then close the incisions.”
The entire procedure takes 2 to 2 1/2 hours. Patients typically stay in the hospital less than 24 hours. As soon as they return to the orthopaedic floor, patients are encouraged to walk. Pain is minimal, and they are easily able to return home the morning after surgery.
Valued for reducing hospital stays and pain levels, MIS is particularly appropriate for patients in the Bronx, Dr. Simela says, because of its high levels of obesity and associated comorbidities.
“Many of my patients would have been turned away by nine out of 10 surgeons,” he says. “But to me, an obese patient is an ideal candidate for MIS because of the obstacles to healing that these patients face after open surgery. Once we help them get ready for surgery, they do better with MIS.”
Surgeons at Bronx-Lebanon also perform procedures to correct spinal deformities, some from degenerative conditions, some from unaddressed congenital problems.
“Many international patients, such as those from the African diaspora, have congenital conditions that in the United States we would remedy in children,” Dr. Simela says, “and we can treat these problems as well.”
High-tech Procedures for Hip Replacement
Minimally invasive techniques have made significant inroads in hip and knee replacement as well. Dr. Meftah uses MIS for both procedures. In hip replacement, MIS can be challenging due to the large structures involved. However, it provides patients with wide-ranging benefits, including smaller incisions, shorter recovery times and less pain.
Drs. Meftah and Simela discuss their clinical research studies.
“MIS is a relatively new approach to hip and knee replacement,” Dr. Meftah says. “Our goal is to avoid extensive damage to soft tissue in order to improve postoperative pain and recovery times. The incision is also smaller than in traditional methods. My fellowships at the Hospital for Special Surgery and Houston Methodist were essential to my learning these methods and implementing them at Bronx-Lebanon.”
Dr. Meftah uses Intellijoint, a computer navigation system, to assist in implant positioning. With Intellijoint, sensors provide real-time data to the surgeon about how the leg and joint are aligned, including acetabular positioning, leg length and offset.
“This simple, friendly, computer-assisted system improves the accuracy of implant positioning,” Dr. Meftah says. “For example, during hip replacement, it ensures the implants are in perfect position, the hip joint center is optimized and there is no leg-length discrepancy, which minimizes dislocation.”
After hip replacement surgery, patients typically stay in the hospital for a day, Dr. Meftah says. Pain-control and postoperative protocols play a crucial role, as does ensuring that patients know what to expect beforehand.
“We have started a Joint Camp that educates patients and their family members about the details of their joint replacement surgery,” Dr. Meftah says. “This is essential to improving their patient experience throughout the joint replacement. Using a detailed questionnaire in this class helps us identify patients who qualify for short-stay or outpatient surgery. According to a recent study we conducted, many patients do better and are happier that they do not have to stay in the hospital.”
Knee Surgery, Updated
Knee replacements also benefit from the union of patient-focused protocols and advanced approaches, although these procedures, too, can pose significant challenges as more clinicians turn to MIS.
Suhas Abel, MD (left), graduating class of 2017 in Adult Reconstruction Fellowship, receiving his certificate from Dr. Meftah (right), Director of the program at Bronx-Lebanon Hospital Center
“With MIS, the field of view and amount of exposure are less than in traditional methods, making it more difficult to operate,” Dr. Meftah says. “The patella is not everted, and the amount of soft-tissue dissection is less. Surgeons must therefore possess a high level of technical skill to achieve the same outcomes with MIS techniques.”
In addition to continuously honing his surgical skills, Dr. Meftah is dedicated to enhancing the patient experience after knee surgery. To do so, he draws on a detailed database Bronx-Lebanon uses to assess postsurgical outcomes.
“One of the key research areas I am interested in is improving recovery and reducing pain after knee replacement,” Dr. Meftah says. “In fact, I am now performing a clinical trial using a long-acting pain medication around the soft tissue of the knee during knee replacement surgery. This medication, called Exparel, is achieving excellent results. We noticed a marked reduction in pain and significant improvement in range of motion after total knee replacement.”
“With recent advancements in joint replacement, such as minimally invasive surgical techniques, improvements in pain control and better postoperative recovery protocols, most patients do not need to stay in the hospital more than a day.”
— Morteza Meftah, MD, Chief, Adult Reconstruction Surgery and Clinical Research, Department of Orthopaedics at Bronx-Lebanon Hospital Center
Expanding Access to MIS
Just as Dr. Meftah is involved with clinical research to optimize results from knee and hip replacements, Dr. Simela is participating in studies regarding spine surgery. He and his colleagues are involved in three institutional review board-approved research studies: two examining differences in MIS outcomes among patients with slightly increased obesity, diabetes or hypertension, and the other examining the outcomes of orthopaedic procedures in patient populations with a high prevalence of infectious disease, including hepatitis C, HIV and tuberculosis.
The Joint and Spine SwiftPath team at Bronx-Lebanon, from left: Dr. Meftah, Dr. Simela, Ana Minaya, MA, Madelyn Tzili, MA, Ivelize Fernandez, Surgical Coordinator
Dr. Simela notes that in the past and even today, patients with these comorbidities would be disqualified from surgery.
“Here those conditions are not automatic disqualifiers,” he says. “We have the cultural competencies and high standard of care needed to help these patients. We use techniques to avoid needle-stick and blood-borne contamination. From a research standpoint, we are investigating whether patients will continue to thrive after surgery and experience the enhanced quality of life following the procedure that warrants offering MIS.”
“Send your patients who might benefit from orthopaedic surgery to us, and let us evaluate them,” says Dr. Simela.
Dr. Meftah agrees.
“The mean age of our society is increasing, as is the number of patients who need joint replacement,” he says. “Our program educates patients prior to surgery and involves them more in their own care. In addition to advances in technology, I believe those types of improvements in quality of care are the future of innovation in orthopaedics.”
To learn more, visit bronxcare.org.