Dr. Daniel C. Allison

Last week, the world sustained a tremendous loss. Legendary film producer Don Phillips passed away at the age of 80. My uncle Don was my mentor, my guide, my motivator, and my consiglieri. He was dubbed “The Man with the Golden Eye,” having discovered such great actors as Sean Penn, Matthew McConaughey, Viggo Mortenson, Rory Cochrane, and countless others. He was known for plucking people out of relative obscurity (in often random situations) and making them film stars. But he didn’t just find people; he nurtured, supported, guided, and developed them. And his influence was not limited to the film industry. Since I was 4 years old, he guided me as well. He loved doctors and medicine, and motivated and encouraged me through the toughest times of medical school, residency, and beyond. He cared far more about others’ success than his own. He showed you how to see the bounty and interest in even the most mundane. He made you reject mediocrity and strive for greatness. He knew how to open doors, and then give you the ability and the courage to walk through them. I am so grateful for having had him in my life, and hope everyone else has someone like him in theirs as well. The world needs more people like him. Don, I miss you.

Last week, the world sustained a tremendous loss. Legendary film producer Don Phillips passed away at the age of 80. My uncle Don was my mentor, my guide, my motivator, and my consiglieri. He was known as “The Man with the Golden Eye,” having discovered such greats as Sean Penn, Matthew McConaughey, Viggo Mortenson, Rory Cochrane, and countless others. He was known for plucking people out of relative obscurity (in often random situations) and making them film stars. But he didn’t just find people; he nurtured, supported, guided, and developed them. And his influence was not limited to the film industry. Since I was 4 years old, he guided me as well. He loved doctors and medicine, and motivated and encouraged me through the toughest times of medical school, residency, and beyond. He cared far more about others’ success than his own. He showed you how to see the bounty and interest in even the most mundane. He made you reject mediocrity and strive for greatness. He knew how to open doors, and then give you the ability and the courage to walk through them. I am so grateful for having had him in my life, and hope everyone else has someone like him in theirs as well. The world needs more people like him. Don, I miss you.

Here’s the follow up:

A solitary destructive bone lesion in the setting of localized primary carcinoma does not always mean metastatic bone disease. Without a known history or clear staging evidence of metastatic bone disease, the wisest choice is to perform core needle biopsy prior to surgery to rule out primary sarcoma.

We placed the patient in skeletal traction and performed core needle biopsy, which confirmed metastatic carcinoma, c/w breast primary.

We proceeded with surgery according to our COVID-19/SARS CoV-2 protocol (see last post).

We opened the fracture site through a lateral subvastus approach and performed extended curettage of all visible tumor. The fracture was reduced anatomically and provisionally fixed with a lateral large fragment plate. Then passed a retrograde 12 mm carbon fiber nail, fixed with two distal interlocking bolts through the plate (+ one distal to the plate) and two interlocks proximally (one a recon screw through the nail proximally to protect the femoral neck).

No blood transfusion or further medical intervention was needed. Patient started walking with full weight-bearing on POD #1 was discharged home with home health on POD #3. Our plan is to resume systemic therapy per medical oncology in 2 weeks and initiate external beam radiation to the right femur in 6 weeks

During the COVID-19/SARS CoV-2 surge in Los Angeles, the only surgeries performed at our hospital are oncologic and emergent cases. This case qualifies:

55-year-old African-American female presents with a displaced right femur transverse fracture through a destructive bone lesion.

She has a history of recurrent, localized breast adenocarcinoma, and complete staging shows a lesion only in the right distal femur.

Are there any other tests that you need before definitively treating this problem? What’s your plan? Straight to nail?

Answer to these questions and much more coming soon ..

Here’s the rest:

The history of a relatively low energy mechanism in the setting of a bone lesion on imaging suggests pathologic fracture

The imaging findings alone are diagnostic of fibrous dysplasia (FD) and no biopsy is necessary

Upon bone grafting FD, new bone simply turns into FD bone again. Therefore, if we fill bone defects, we do so with hardware

FD Pearls:
Radiographic: ground glass, long lesion in a long bone
Histologic: immature woven bone with osteoblastic ri***ng forming “Chinese letters” (? politically incorrect) or “alphabet soup” surrounded by fibrous cells/stroma
Genetic: GNAS1 gene mutation - constitutive activation of adenylate cyclase - inc. intracellular cAMP

Polyostotic FD syndromes:
McCune Albright: irreg café au lait spots, endocrine anomalies
Mazabraud’s: IM myxomas, atypical malignancies

Some evidence indicates increased mortality in orthopedic surgical patients in the COVID-19 era. Studies by Mi et al and Catellani et al indicate that COVID+ fracture patients, esp femur fx, have significantly increased mortality from pulmonary compromise. However, this risk should prompt early intervention, not delay.

Highlights of Our COVID-19 surgical protocol:

All OR equipment in room before patient arrival
Common equipment fixtures wrapped in plastic
Patient transfers direct
Initially entry only through the front door
The OR team wears PAPR or N95 + face shield
Doors are not opened within 15 minutes of intubation unless emergency
Hand sanitization in OR with Avagard scrub
Sterile surgical gowns over non-sterile PPE gowns with double-glove / shoe cover
After case, sterile PPE and shoe covers are discarded, maintaining non-sterile underlying PPE
Exit through the back door into transition station, where residual PPE is shed
OR staff then uses shower kit for thorough body scrub in locker room
OR room undergoes terminal clean

We chose piriformis entry carbon fiber nail with recon locking proximally and one static interlock distally, after open reduction through a lateral subvastus approach + “miss-a-nail” 3.5 mm interfragmentary compression screws

28 year-old male recovering from recent non-Hodgkin’s lymphoma (in remission) presents with acute onset of left thigh pain and inability to ambulate after a fall from his motorcycle at very low speed. No antecedent pain. No other past medical / surgical history. No family history of syndromes or bone / soft tissue tumors.

His airway is patent, he breathes normally, and he is hemodynamically stable. Exam demonstrates left thigh swelling and pain and the limb shortened / externally rotated. The remainder of his secondary survey is normal. He has no skin lesions, masses, or other abnormalities.

X-rays demonstrate a spiral subtrochanteric femur fracture and an associated femoral lesion that spans from the fracture to the distal femur. MRI confirms an intramedullary / cortical lesion in this area, with a cystic component.

btw … he’s COVID-19 / SARS CoV-2 positive (again, asymptomatic with no respiratory or systemic compromise)

How would you classify this fracture? How would you treat it? Do we need to biopsy the lesion prior to proceeding with treatment? What syndromes are associated with this lesion and how could they apply to this patient’s history? What is the significance of the femoral lesion and how does it impact our treatment? What role does his COVID-19 positivity play?

These questions and more answered at the next post ..

Here’s the Trauma Call Follow Up:

Case 1: 86 year old female household ambulator with right femoral neck fracture after a ground-level fall – cemented hemiarthroplasty through anterior approach. Immediate ambulation as tolerated with fall precautions only

Case 2: 27 year old RHD male S/P assault with left open olecranon fracture – immediate I&D and ORIF using pre-contoured olecranon compression plate and ulnar-sided 90 degree mini-frag recon neutralization plate

Case 3: 75 year old female with severe osteoporosis and highly unstable right ankle fracture dislocation – 90 degree lateral and posterior fibular anti-glide plates; posterior distal tibial buttress plate; medial malleolar recon neutralization plate.

Case 4: 24 year old female with low energy closed left tib-fib fracture + left foot Lis Franc injury – closed reduction and intramedullary nail fixation of tibia; ORIF of Lis Franc complex with dorsal bridge plates

Case 5: 23 year old female with right ankle open dislocation + right great toe proximal phalange open fracture – immediate I&D and open reduction with ATFL, CFL, and anterior capsule repair; I&D and ORPP of great toe proximal phalange

Hats off to our trauma residents for their hard and good work - so far so good .. already looking forward to the next call

A routine day in the life on Orthopedic Trauma Call at a metropolitan Level I Trauma Center:

Case 1: 86 year old female household ambulator with right femoral neck fracture after a ground-level fall

Case 2: 27 year old RHD male S/P assault with left open olecranon fracture

Case 3: 75 year old female with severe osteoporosis and highly unstable right ankle fracture dislocation

Case 4: 24 year old female with low energy closed left tib-fib fracture + left foot Lis Franc injury

Case 5: 23 year old female with right ankle open dislocation + right great toe proximal phalange open fracture

How do you manage each case? .. remember your basic trauma and orthopedic principles

Here’s the follow up:

The management of gunshots to bone depends mainly upon the energy dispersed (KE = ½ mass x velocity squared). The higher the velocity, the exponentially higher the kinetic energy and subsequent tissue damage

Tissue injury occurs not just from the bullet itself, but also from the associated surrounding cavitation and distributed shock wave, which can cause massive soft tissue / bone destruction. A bullet retained in the body indicates that 100% of the bullet’s kinetic energy has been transferred to the patient.

Most projectiles are made of lead, though brass (copper+zinc) is also commonly used.

Low velocity (2000 fps [M-16/AR-15, AK-47]) gunshots to bone should be treated as Type III open fractures. Any gunshot to bone associated with hollow viscus injury should be debrided.

Despite what the movies tell us, not all bullets have to be removed. However, those in an intra-articular location / an area that could lead to systemic lead absorption (plumbism [word of the week]) should be removed and the area lavaged.

This bullet seems to be about as close to the joint as possibly without being in it. The fx lines indicate some communication between projectile and joint fluid. The concern for lead absorption and possible joint incongruity push us to intervene.

We started the case with non-invasive needle arthroscopy technology. Using just a 16-guage needle with an indwelling 18-guage camera, we were able to get a direct, hi-def view of the medial tibial plateau, which demonstrated a distinct convexity in the exact region of the bullet. With the same needle, we performed joint lavage. Then using a novel technique I learned from an post, we extracted the projectile with minimal soft tissue dissection and bone loss. We filled the residual defect with injectable bone graft substitute.

Within a few days, the patient is back to walking without pain and without assistive devices.

For more interesting cases, check our our Instagram .md

NATIONAL PA WEEK: Oct 6-12, 2020

From their hands-on assistance in the OR to their clinical decision-making to their patient connection/interaction to their overall diligence and hard work, the Physician Assistant (PA) is an essential part of the modern high-level surgical team.

We would like to celebrate national PA week by honoring our very own Renee Herman PA-C. Renee has proven to be a tremendous addition since she signed on 3 years ago. Beloved by patients, fellow clinicians, and ancillary staff members alike, her diligence, conscientiousness, clinical acumen, and surgical skill are a great asset to our patients, the hospital, and the team.

Congratulations Renee! Our surgical service and our patients thank you for your outstanding work and dedication – we are so glad to have you as part of the team!

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“My favorite part about working with residents is watching these smart, motivated individuals blossom from green neophytes into talented, capable surgeons and clinicians destined to make a profoundly positive impact on patient’s lives and our profession.” - Dr. Allison

Faculty Spotlight: Dr. Daniel C. Allison (.md) is a fellowship trained orthopaedic oncologist and reconstructive surgeon. He serves as the Assistant Director of Orthopaedic Oncology and is also a member of the Arthroplasty and Trauma Services. 
  
Dr. Allison received his medical degree with Honor from Baylor College of Medicine and then completed orthopaedic residency at USC + Los Angeles County Medical Center, where he also pursued additional fellowship training in musculoskeletal oncology and pelvic reconstruction. 
  
Dr. Allison also serves a Commander in the United States Navy Reserves. He deployed to Mosul, Iraq as an orthopaedic trauma surgeon at a Role II (mobile surgical hospital) in a forward operative base as part of the effort to defeat ISIS. He also recently served in New York at Harlem Public Hospital as an orthopaedic trauma surgeon as part of the military effort to fight the COVID-19 outbreak.  
  
His clinical and research interests include limb salvage surgery, pediatric arthroplasty, orthopaedic complications, and complex long bone / large joint / pelvic reconstruction. 
  
Dr. Allison is an inventor/designer for numerous orthopaedic implants and devices including: an anterior THA table-less retractor system, a primary THA femoral stem, a revision THA femoral stem, a revision total knee replacement, and a trans-tibial amputee osteointegration implant. 
  
We work with Dr. Allison at Cedars-Sinai on his busy orthopaedic oncology/reconstructive service and while on trauma call, and we also work with him at Children’s Hospital of Los Angeles, where he serves as co-director of orthopedic oncology and director of pediatric arthroplasty. 

Want to learn more? Visit csorthoresidency.org

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Thanks to everyone who joined our orthopaedic oncology Q&A. In case you missed it, here is a brief recap:

Residents on the oncology service primarily work with Dr. Earl Brien and Dr. Daniel Chris Allison (.md). The service consists of a PGY-4 and a visiting PGY-3 from Community Memorial Hospital in Ventura, CA. The rotation is divided into two 6-week mentorship-model experiences with Dr. Brien and Dr. Allison.

Cases on the service are varied and complex, spanning the full gamut of musculoskeletal oncology and incorporating principles from trauma and reconstruction. We work closely with our colleagues in internal medicine, hematology/oncology, radiology, radiation oncology, vascular surgery, and supportive care to provide for our patients.

Residents typically spend 2 days in clinic and 2-3 days in the operating room. Teaching conferences include: tumor board and small-setting resident lectures with Dr. Brien.

Want to learn more? Visit csorthoresidency.org