For some patients, surgery to cut and release the abdominal wall muscles may be necessary to fully repair complex ventral hernias. But select patients may benefit from a technique that employs injections of botulinum toxin A (Botox) to relax the abdominal muscles before surgery, enabling the surgeon to repair these large hernias less invasively.

Eric G. Sheu, MD, PhD, section chief of Bariatric and Foregut Surgery and a member of the Complex Hernia Center at Brigham and Women’s Hospital, has performed several of these procedures. They have allowed complex hernia repairs to be performed via a minimally invasive, robotic approach and have been well-tolerated by patients.

“There’s been a movement in hernia repair to really close the muscle tears completely, which we know provides the best outcomes for patients,” Dr. Sheu says. “By giving Botox injections before surgery to relax the lateral abdominal wall muscles, we’re able to create the laxity that allows us to restore a patient’s abdominal wall anatomy and core function.”

A New Option for Repairing Mid-sized Hernias

For smaller ventral hernia repairs, the muscles can usually be brought together with no additional procedures. For very large repairs, meanwhile, more complex surgery to release the muscles may still be needed.

“The Botox technique seems to work best when you’re in that middle zone, where the muscles are a bit too contracted laterally to come together, but where a more invasive procedure may not be needed,” Dr. Sheu says. “For medium-sized hernias, particularly in patients who have had a recurrence, this can be a very good option.”

This approach is still relatively uncommon, but several studies have found that Botox injections result in changes to the abdominal wall that make hernia repair surgery less complicated and more effective.

“As far as recovery from this procedure goes, it still may be more difficult than what you would have for a simple hernia, but not having to do the surgical release certainly makes it easier for patients,” Dr. Sheu says. “These procedures can often be done on an outpatient basis or require only a one-night hospital stay, compared with these more complex surgeries that usually require at least a couple of nights in the hospital.”

A Partnership Between Surgery and Radiology

This procedure requires a partnership between surgery and radiology. It includes imaging to determine which patients are most likely to benefit from the procedure as well as the involvement of an interventional radiologist who performs the Botox injections under the guidance of either ultrasound or CT.

Patients receive the injections two or more weeks before surgery to allow their muscles to relax fully. They receive a total of six injections, three on each side of the abdomen.

Daniel I. Glazer, MD, medical director of CT and director of Cross-Sectional Interventional Radiology at the Brigham, collaborates with Dr. Sheu on these procedures to ensure optimal placement of the Botox injections.

“As interventional radiologists, we’re well-positioned to do this type of procedure. We understand the anatomy and have the ability to accurately place the needles where they need to go,” Dr. Glazer says. “This collaboration allows us to work on a fairly innovative technique and help patients avoid more complex, invasive surgeries. It’s better for the patients both in terms of having a successful procedure and reducing morbidity.”

Innovative Care for Patients With Complex Hernias

This procedure is just one of the many novel approaches being offered to patients through the Brigham’s Comprehensive Hernia Center. The center includes board-certified general and gastrointestinal surgeons who have expertise in diagnosing and treating all types of hernias, including those that are very large, very complex, or recurrent. Experts in the center are skilled in the full range of hernia surgeries, including open, minimally invasive, and robotic surgical techniques.

The team also includes board-certified plastic and reconstructive surgeons who excel in complex abdominal wall reconstruction when direct closure is impossible and experts in wound healing who can help optimize cosmetic outcomes.

In addition to performing hernia repair surgeries, the center helps patients address any factors that could prevent a successful surgery and recovery. These include guidance in smoking cessation, a diabetes management program, and help with weight loss to reduce the chances of developing another hernia.

“We created this center to ensure that patients get all the medical and surgical care needed to have the best outcomes for their hernia repair,” Dr. Sheu says.

Total knee replacement (TKR) for the treatment of advanced knee osteoarthritis is an efficacious and cost-effective treatment, even for people with extreme obesity (defined as having a body mass index, or BMI, of 40 or higher). This finding from experts at Brigham and Women’s Hospital was published recently in the Annals of Internal Medicine.

“Total knee replacement is one of the best medical advancements of the 20th century, reducing pain and helping people gain functional status and become more active in their day-to-day lives,” said corresponding author Elena Losina, PhD, co-director of the Brigham’s Orthopaedic and Arthritis Center for Outcomes Research and a founding director of the Policy and Innovation eValuation in Orthopaedic Treatments Center.

“The challenge is that knee osteoarthritis disproportionally affects people who have extreme obesity,” she added. “Many surgeons are hesitant to offer the procedure because of their concerns about complications in this patient population.”

The goal of the study was to help inform physicians, policymakers and patients about the long-term clinical benefits and value of the procedure.

OAPol Computer Model Aids in Analysis

To perform their analysis, investigators used a computer simulation called the Osteoarthritis Policy (OAPol) Model, which was developed by a multicenter team that Dr. Losina leads. The OAPol model has been continuously funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases since 2006.

“The goal of this type of research is to capture all the long- and short-term benefits and the detriments of a specific medical procedure over a timeframe that is meaningful,” Dr. Losina said. “Because a total knee replacement lasts decades in most cases, a computer simulation is a good way to help evaluate this procedure over its long-lasting timeline.”

The analysis looked at the benefits, risks and costs of TKR surgery. The primary benefit noted was pain reduction. The potential risks involved postsurgical complications, including pulmonary embolism, pneumonia, deep vein thrombosis and infection. Investigators also looked at the cost of the procedure and the dollar value of the quality-adjusted life years (QALY) gained. This measure accounts for factors like workdays lost due to pain or other complications of illness.

The analysis found favorable cost-effective ratios of $35,200 per QALY for patients aged 65 and under and $54,100 per QALY for those over age 65. Most patients with extreme obesity develop advanced knee osteoarthritis earlier in their lives and consider surgery earlier compared to patients with similar stages of knee osteoarthriris who don’t have extreme obesity. That is why the researchers conducted analysis for different age groups.

In addition, CMS is the most likely payer for those over age 65, while those younger than 65 are more likely to be covered by commercial insurances. The analysis provided valuable data for both types of payers.

“There are plenty of interventions that cost a lot but provide little benefit. Our study showed that despite being costly, this procedure provides a very good value,” Dr. Losina said. “As a society, it’s important to promote good value care and reduce wastage of health care resources.”

Weighing Benefits and Risks of TKR

Dr. Losina explained that although the rates of surgical and postsurgical complications are higher in people with obesity, because overall complication rates are so low, even a two- or three-fold increase means this operation is still very safe overall.

“But it’s still important to recognize the challenges,” she noted. “Patients with BMIs over 50 may be so heavy that equipment in some operating rooms may not be suitable. Especially in nonacademic settings, if surgeons don’t feel comfortable operating on these patients, they may want to refer these more challenging cases to an academic medical center. Ideally it would be helpful for these patients to try to lose weight, but it may be difficult to achieve without rigorous, structured weight-reduction programs.”

Richard Iorio, MD, chief of the Adult Reconstruction and Total Joint Arthroplasty Service and Vice Chairman for Clinical Effectiveness at the Brigham, said that he “applauds Dr. Losina and her team for their pioneering work concerning the cost-effectiveness of TKA in those with extreme obesity.”

He explained that several patient demographic factors and medical comorbidities may lead to increased episode-of-care costs. When combined, they can lead to complication rates that are orders of magnitude higher. Most of these factors are nonmodifiable, but others can be optimized before surgery, he noted.

“It is unfortunate that hospitals and surgeons are judged by short-term complication rates instead of a 20- to 30-year horizon for determining success or failure,” Dr. Iorio said. “If episode-of-care length is changed to reflect the true survivorship of the operation, we may be able to ultimately prevent problems with access to care for high-risk patients.”

As Dr. Losina concluded, it’s all about improving patients’ lives. “Orthopaedic surgeons want nothing but the best for their patients,” she said. “We hope this study will help to facilitate the availability of this procedure in those who need it.”

Treating patients with traumatic spinal cord injuries has significant challenges, in large part because of the potentially severe and life-altering effects these injuries can have. Despite recent progress in finding the best way to treat spinal cord damage, many patients are left with profound disabilities. Additional research, both in the lab and the clinic, is vital.

At Brigham and Women’s Hospital, physicians and scientists are making advances on several fronts. From the time patients with these injuries are brought into the Emergency Department, experts in trauma and critical care medicine collaborate with spine surgeons, neurologists and other specialists to address the most immediate complications and do everything possible to ensure the best long-term outcomes.

“The Brigham has an experienced and efficient ED system, and when a patient comes in with a traumatic spine injury, the first thing we look at is ABC — airway, breathing and circulation,” said Yi Lu, MD, PhD, director of neurological trauma and co-director of the Brigham’s Adult Spinal Deformity and Scoliosis Program. “At the same time, there have been quite a few studies showing that if the spinal cord can be decompressed and stabilized within the first 24 hours, the outcomes are much better.”

Dr. Lu added that even though some of these surgeries are quite complex, the team at the Brigham always strives to bring these patients in to the operating room as quickly as possible to maximize their likelihood of a functional recovery.

Exploring New Interventions to Repair Nerve Damage

Beyond surgery, a number of medical interventions are being explored to improve patient outcomes, including drugs, cell-based therapies and biomaterials and neural scaffolds. Dr. Lu and other Brigham investigators are studying many of these approaches in the lab in cell and animal models.

Corticosteroids were once considered promising for reducing long-term damage, but research revealed these drugs tend to do more harm than good. Similarly, other therapeutic agents, including GM-1 ganglioside and rho kinase inhibitors, have had clinical trials discontinued after failing to show benefit.

Other medical interventions, however, have shown promise and continue to be studied. These include riluzole, a sodium channel inhibitor currently approved to treat ALS, the antibiotic minocycline and granulocyte colony-stimulating factor, all of which are being tested in later-stage clinical trials.

Stem cell-based therapies are also considered a promising avenue for repairing damaged nerve connections. However, more research is needed to determine the best subtype of stem cells and how to use them. Likewise, the use of neuro-spinal scaffolds are being studied as a way to promote neuronal growth. A clinical trial looking at this approach is underway at the Brigham.

In addition to these medical treatments, research is looking at technological interventions such as neuromodulation and brain-computer interfaces. “Spinal cord stimulators combined with extensive physical therapy have shown improvements in functional outcomes,” Dr. Lu said. “Brain-machine interfaces that bypass the injury site may also help patients’ functional outcomes.”

A Team-Based Approach to Care

Dr. Lu said that the Brigham’s expertise extends far beyond treatment of the injury itself. “Many of these patients require extensive and meticulous care in the intensive care unit,” he said. “From head to toe, every single system in the body can be affected by spinal cord injury.”

He credits the Brigham’s nursing team with making sure patients’ needs are addressed. This includes tackling not only blood pressure and breathing problems that can occur as a direct result of injury, but also preventing and treating other longer-term issues that can arise in patients who are paralyzed, such as aspiration pneumonia, bed sores and urinary tract problems like retention.

Dr. Lu noted that physical therapists, including those at Spaulding Rehabilitation Hospital, where the majority of the Brigham’s spinal cord injury patients go after being discharged, also play a vital role. Spaulding Rehabilitation Hospital is a Harvard Medical School-affiliated hospital that’s part of the Mass General Brigham healthcare system (formerly known as Partners HealthCare).

“Physical therapy is a very important part of recovery, if not the most important part,” he said. “Close interaction between our team and the physicians and therapists at Spaulding ensure our patients are well taken care of and have the best recovery possible. We, and our patients, are fortunate to have this relationship.”

New Spine Center: A Multidisciplinary, Integrated Care Model

Brigham and Women’s Spine Center is a new service line committed to high-quality care that is carried throughout each patient experience by a team of renowned experts in spine conditions including Harvard Medical School-appointed neurosurgeons, orthopaedic surgeons, pain medicine specialists, physical medicine and rehabilitation specialists, advanced practitioners and other clinical staff.

Our team of specialists offer a range of personalized treatment options to help patients regain function, such as:

• Rehabilitation solutions, including physical therapy or occupational therapy
• Minimally invasive interventional treatments, including injections or medications
• Surgical treatments including spinal decompression, spinal fusion or spinal reconstruction

Our multidisciplinary team advocates for each patient’s best interest and customizes care recommendations to meet individual goals.

Mechanical problems with the knee, which patients may describe as locking, grinding or clicking, have traditionally been associated with meniscal tears. But a new study from investigators at Brigham and Women’s Hospital has found that these symptoms are more often driven by cartilage damage rather than meniscal pathology.

Findings from the study were published recently in the Journal of Bone and Joint Surgery.

“We’ve always thought that if a patient comes in and says their knee is catching or locking, it must be due to meniscal pathology,” said senior author Elizabeth G. Matzkin, MD, surgical director for women’s musculoskeletal health and chief of women’s sports medicine in the Brigham’s Department of Orthopaedic Surgery. “This research suggests that’s often not the case.”

Prospective Data Aid in Analysis

For the study, the investigators prospectively gathered data on 565 patients who were scheduled to undergo knee arthroscopy between 2012 and 2019. Patient-reported knee symptoms (PRKS) were collected before surgery using the Knee Injury and Osteoarthritis Score Questionnaire.

When the patients later underwent surgery, the investigators were able to examine the specific pathological conditions in the knee. They found that tri-compartmental cartilage damage was associated with significantly worse PRKS. Surprisingly, they didn’t observe an association between meniscal pathology and preoperative PRKS. Most patients with a degenerative meniscal tear, however, had concomitant cartilage pathology.

“These findings question traditional teaching and force us to dig deeper to understand where these symptoms are coming from,” Dr. Matzkin said. “Patients with these mechanical symptoms have always been grouped together, but perhaps they shouldn’t be.”

Linking Surgical Outcomes to Pathology

Dr. Matzkin’s team is now completing the second part of this study, which looks at one- and two-year outcomes after arthroscopy. The study aims to determine how patients do postoperatively, whether they had meniscal pathology, cartilage damage or both. Early findings suggest that outcomes are good regardless of the underlying causes of the symptoms that led the patients to seek out surgery.

Meniscal pathology and cartilage pathology often go hand in hand, especially in people with osteoarthritis, Dr. Matzkin noted. “We know that we’re helping patients with these surgeries,” she concluded. “But this study will help us further investigate how we are helping them.”

Shoulder instability is a relatively common concern in athletes, especially among those who play contact sports such as football, basketball and rugby. This condition has a number of treatment options, including physical therapy and various surgical procedures, but much remains unclear about how to determine the best course for each patient.

One initiative that aims to address these questions is the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group. The group’s shoulder instability study is co-led by Carolyn M. Hettrich, MD, MPH, chief of the shoulder service in the Department of Orthopaedic Surgery at Brigham and Women’s Hospital.

“This study is aimed at looking at predictors of outcomes for patients who undergo surgery for shoulder instability,” Dr. Hettrich said. “It is through understanding what leads to both excellent and poor outcomes that we can improve patient care.”

So far, more than 1,800 patients have been enrolled in the study, and 16 papers using data from the project already have been published. The investigators will continue to follow study participants for up to a decade after their surgeries to determine long-term outcomes, including the predictors of arthritis.

MOON Shoulder Group Studies

The MOON Shoulder Group is the largest prospective cohort of patients with shoulder problems in the world. Dr. Hettrich launched the group’s shoulder instability study with Brian Wolf, MD, in 2012, when she was at the University of Iowa. The study now includes 26 surgeons from across the country. In addition to studying shoulder instability, the larger group also has studies looking at rotator cuff tears and shoulder arthroplasty.

“These efforts have already produced important findings,” Dr. Hettrich said. “We have published research looking at differences in age, gender and race among patients. We’ve also looked at return-to-play in athletes.”

As part of the study, data are being collected on all patients at the time of surgery and at several points of follow-up: six months, two years, six years and 10 years. All surgeries for shoulder instability, both open and arthroscopic, are included in the study.

“Based on what we’ve already learned, we know that we should consider surgery for shoulder instability much earlier in certain groups of patients,” Dr. Hettrich said. “This is in part because subsequent dislocations can predispose people toward having more loss of cartilage and bone, which can increase the risk of repeat dislocation and poor outcomes.”

Using Data to Optimize Patient Outcomes

One recent study from Dr. Hettrich, presented at the virtual meeting of the American Shoulder and Elbow Surgeons in October, looked at the predictors of bone loss at the time of surgery. The prospective, multicenter study, which included 895 patients, found that an increased number of preoperative shoulder dislocations was the strongest modifiable predictor of glenoid and humeral bone loss, which is known to result in worse outcomes. It was one of only eight studies selected for presentation at the meeting. A poster featuring details of this same study was also awarded as the top poster in the category of Shoulder and Elbow by the American Orthopaedic Association and will be featured at this year’s Annual Leadership Meetings.

Dr. Hettrich said her group plans to submit the study for publication. They will also be publishing an online calculator for predictors of bone loss that orthopaedic surgeons and their patients can use when making treatment decisions.

“The Brigham is one of the lead sites for the shoulder instability study,” Dr. Hettrich concluded. “We’re on the forefront of looking at what allows patients to do well and what may cause them to do poorly, and then applying this information to the care of our patients so that we can optimize their outcomes.”

There are many challenges to treating autoimmune diseases such as rheumatoid arthritis and lupus. Brigham and Women’s Hospital has recently undertaken a number of new initiatives to address some of these challenges and improve patient care.

“One of the biggest problems we see is lack of access, especially for more specialized rheumatology services,” said Susan Ritter, MD, PhD, associate medical director of the Brigham and Women’s Arthritis Center. “This is a larger issue in other parts of the country, where there are not enough providers to meet the needs of the population. However, it’s a problem even in Boston. We have a large number of providers, but there is so much demand.”

One project that the Brigham has undertaken to address this concern involves optimizing best practices for recurring functions in patient care. Through a pilot program, members of the rheumatology team—including physicians, nurses and medical assistants—took a closer look at common questions and requests from patients and identified ways to establish and enhance processes for meeting these needs.

“We focused on ways to improve best practices for 20 of the most common things that we do on a regular basis,” Dr. Ritter said. “For example: What do we do when a patient calls and has a question about medication? How do we optimize referrals for lab tests? We’ve created documentation to streamline all of these frequently occurring processes.”

Meeting Demands Through Education and Prioritization

Continuing medical education programs for primary care providers that focus on rheumatic diseases, offered through Harvard Medical School, are another important way the Brigham is meeting increasing demands in patient care. Patients stand to benefit significantly when primary care providers are educated on the initial steps needed for evaluation and management of these diseases as well as on the signs and symptoms that should prompt more urgent referrals to rheumatology specialists.

In diseases for which it’s vital for patients to see a specialist right away, the team at the Brigham has put systems in place to ensure those with more urgent needs are prioritized. “One example of this is giant cell arteritis, where it’s important that we get a biopsy within two weeks,” Dr. Ritter explained. “We’ve created a button right in our computer system that flags these patients in our system. It allows us to fast-track their care.”

Another recurring challenge is getting buy-in from insurance companies to approve some of the newer small molecule and biologic therapies. This is a particular concern in the treatment of rheumatoid arthritis because a number of medications are now available, but these drugs are expensive. When patients can benefit, however, it’s important that they start taking these medications as soon as possible to prevent the permanent damage to joints that can result from unresolved inflammation.

“When patients check in for their appointments, we give them iPads and they’re asked a series of questions about their medications and symptoms,” Dr. Ritter said. “We can use that data to show over time how well somebody is responding to a particular therapy. These data allow us to identify when the therapy isn’t working, so we know that we should try something different. All of this goes right into our electronic medical records and is also available within the clinic documentation.”

Dr. Ritter noted that this system has the added benefit of helping patients become more active in their own care by allowing them to see trends in their data. “We will be moving toward doing this for other rheumatic diseases,” she said. “It helps us to better care for our patients and to justify to the insurance companies the therapies that they need.”

High Volume Leads to Specialized Expertise

Because of the high volume of patients seen at the Brigham, individual rheumatologists can develop special areas of expertise in conditions that are not commonly seen at other centers. One emerging specialization is in immune-related adverse events caused by checkpoint inhibitors for cancer.

“We have several doctors who are specifically interested in seeing these patients,” Dr. Ritter said. “We work with the oncologists at the Dana-Farber Cancer Institute to make sure patients are seen quickly.” The goal of this collaboration is to optimize cancer care while managing the many immune-related adverse events from these drugs.

Another example of a team approach is in the treatment of Raynaud’s disease. A specialized clinic allows patients to see experts in rheumatology and cardiovascular disease on the same day. In addition, it enables physicians to collaborate and communicate with each other on treatment methods.

The Brigham also has experts with an interest in working with people who have lupus. “As part of our Lupus Center, we provide additional information to patients in the form of regular newsletters as well as other services,” Dr. Ritter said. “The health care system can be a challenge for people with lupus, many of whom come from disadvantaged backgrounds. We want to help them get the care they need.”

The Division of Rheumatology, Inflammation and Immunity at Brigham and Women’s Hospital was well-represented among the presenters, moderators and award recipients at the American College of Rheumatology’s (ACR’s) annual meeting, held in November in Atlanta.

The division had 117 accepted research abstracts, 39 oral presentations, 78 posters and 24 invited presenters and moderators.

“This is a meeting where rheumatologists and scientists from all over the globe come together to share ideas and make connections,” said Daniel Solomon, MD, MPH, chief of the Section of Clinical Sciences in the Division of Rheumatology, Inflammation and Immunity. “For a single institution to contribute such a considerable proportion of research at a single meeting is noteworthy.”

Experts from the Brigham presented significant research in disease areas such as lupus, vasculitis, psoriatic arthritis and ankylosing spondylitis, according to Dr. Solomon. Another important topic at the meeting was immunophenotyping for patients with rheumatic diseases. This effort aims to guide treatment decision-making and eventually develop more personalized therapies for different subsets of patients based on the subtypes of immune cells driving their disease.

A Number of Honors

Recently, two members of the division have taken on major leadership roles within the ACR. Ellen M. Gravallese, MD, who became chief of the Brigham’s Division of Rheumatology, Inflammation and Immunity in November, officially took up the mantle as the 83rd president of the ACR. Her term will run from November 2019 to November 2020. Meanwhile, Dr. Solomon was named editor-in-chief of Arthritis & Rheumatology, the major journal in American rheumatology.

At this year’s ACR annual meeting, members of the division were presented with several awards and appointed to leadership positions during the annual meeting, including:

Sarah Kim Chen, MD, MPH, received a Distinguished Fellow Award. Dr. Chen’s research focuses on the use of prescription opioids among patients with rheumatic diseases compared to people with other diseases, including hypertension.

Jonathan Scott Coblyn, MD, and Simon M. Helfgott, MD, were appointed ACR Masters. This prestigious designation honors members who have made outstanding contributions to the field of rheumatology through scholarly achievement and/or service to their patients, students and profession. Dr. Coblyn, whose research focuses primarily on rheumatoid arthritis, is director of clinical rheumatology and director of the Center for Arthritis and Joint Diseases. Dr. Helfgott’s research focuses on the medical treatment of rheumatoid arthritis and other inflammatory disorders.

Candace H. Feldman, MD, MPH, ScD, received the Mary Betty Stevens, MD, Young Investigator Prize for her research on systemic lupus erythematosus (SLE). Dr. Feldman is a clinician and epidemiologist who studies health care disparities, particularly in people with SLE. Read about her work here.

Maura Daly Iversen, MPH, DPT, ScD, received a Lifetime Achievement Award from the Association of Rheumatology Professionals, a division of the ACR. Dr. Iversen is a behavioral scientist and epidemiologist whose research focuses on clinical and translational trials of exercise to manage arthritis symptoms and reduce cardiovascular risk.

Katherine P. Liao, MD, MPH, received the Henry Kunkel Young Investigator Award, which recognizes physician-scientists aged 45 or younger who have made outstanding contributions to basic or clinical research in the field of rheumatology. Her lab is developing bioinformatics methods to study rheumatoid arthritis and the clinical and genetic factors that lead to outcomes such as cardiovascular disease and severe joint damage.

Beyond the awards given out at the ACR meeting, Sonali Parekh Desai, MD, MPH, also of the Division of Rheumatology, Inflammation and Immunity, was given the Donabedian Award in Quality and Safety from the American Public Health Association on November 5. Dr. Desai, medical director for ambulatory patient safety at the Brigham, is leading work to reduce diagnostic errors through an ambulatory safety net program focused on missed and delayed diagnosis of cancer.

“The Division of Rheumatology, Inflammation and Immunity continues to be one of the top-ranked programs in the United States,” Dr. Solomon said. “The members of the division demonstrate outstanding leadership throughout all aspects of the field, including clinical care, research, publishing and teaching.”