Orthoplastic Surgery: Function Follows Form

Banner: Orthoplastic Surgery: Function Follows Form

A multidisciplinary approach combines orthopedic and plastic surgery expertise to improve functional outcomes

By Cale Li, MD
 

Key Takeaways: 

  • Collaboration: Orthoplastics is a developing surgical trend in which orthopedic and plastic surgeons work together to achieve better aesthetic and functional outcomes in orthopedic procedures, particularly for conditions like sarcoma or bone cancer.
  • Combined Approach: Orthopedic surgeons and plastic surgeons work together in the O.R. during complex cases. This could involve procedures like tumor removal followed by correction of muscle and bone defects caused by the resection.
  • Improved Outcomes: Data shows that incorporating plastic surgeons into the surgical team for complex cases leads to lower rates of wound complications and better functional outcomes. 
  • Benefits and Challenges: Collaborative orthoplastics reduces stress for surgeons, creates the potential for more aggressive surgical approaches, improves wound complication rates, and patient satisfaction. However, no formal training programs currently exist for orthoplastics.

“Form follows function” is very well and good when designing stationary structures, but for the human body, proper movement cannot happen without proper form. Orthoplastics, a developing trend in surgery, understands how better aesthetic outcomes in orthopedic procedures can lead to better functional outcomes.

‘Orthoplastics’ means the orthopedic surgeon and the plastic surgeon work together when treating a condition, such as sarcoma or bone cancer. During a sarcoma or bone tumor removal, for example, the orthopedic surgeon might operate first and remove the tumor, followed by their plastic surgery colleague who might then correct the muscle and bone defects caused by the resection, and close the wound.

“I discuss orthoplastic surgery as a formalized combined approach between orthopedic surgery and plastic surgery to tackle a wide variety of problems,” said plastic surgeon Jarrod Bogue, MD. “We focus on collaboration to solve complex problems that involve each of our disciplines in order to best help our patients.”

While there is overlap between plastic and orthopedic surgery, traditionally they have been separate subspecialties.

Collaboration Leads to Better Outcomes

“We used to do a lot of this stuff ourselves, but quite frankly, the data would suggest that the outcomes weren’t as good as they could be. They've gotten better. And part of that getting better was incorporating plastic surgeons into the team,” said Wakenda Tyler, MD, orthopedic surgeon and musculoskeletal oncologist. 

Collaboration between surgical subspecialties has precedence: breast surgery and plastic surgery have been treating breast cancers together, with better outcomes. The idea of orthoplastic surgery has been around since the 1990s, but has gained significant traction over the last decade or two. 

“If you look at data over the last ten to 15 years, they've shown that when you have a plastic surgeon in the operating room for complex cases — and this is kind of across the board for surgical things, but particularly in the oncologic world that I live in — there is a lower rate of wound complications and functional outcomes are better. So essentially, there’s data to support having your plastic surgeon colleagues in the operating room,” said Dr. Tyler.

“Better communication between specialties and a coordinated surgical plan translate into better outcomes and more durable solutions for patients,” said Dr. Bogue. “I saw orthoplastic surgery firsthand during my residency at NewYork-Presbyterian Hospital and fellowship at Memorial Sloan Kettering Cancer Center. I was always drawn to this due to the fact that it allows physicians from different specialties to collaborate. We can learn more from one another than we can alone, and this, in turn, allows our patients to return to optimal form and function.”

The logistics of planning operating room time with a colleague can be tricky, but for Dr. Tyler, the advantages are worthwhile.

“When I first started out in practice, which is now going on 13, 14 years, I was very much, I wouldn't say silo-ed, but I would try to do a lot on my own. I was a little bit of a maverick—unafraid to take on the case and then do coverage and all these other things yourself.

“But then you’ve got to deal with the consequences of it not going as well as you expected it to, and a lot of times it doesn't. You may think you're really good at something, but you're not always as good as you think you are. And your [plastic surgery] colleague, who's really the expert because that's all they do, is much better than you. That's the reality. And so I think when I arrived at Columbia, I had the approach of bringing more people into my OR than I previously have.

“Which means that you've got to compromise: okay, I really wanted my OR day to be on Wednesday, but the person I really like to work with, who's a plastic surgeon, needs to operate on Thursdays. Am I willing to alter my schedule to make it happen because I need this person? Then the answer usually is, yes, you'll make it happen, and you alter your schedule.

Orthoplastics Provides Benefits to the Patient and the Surgeon

“The advantages are big. First of all, it takes stress off you, the surgeon. We do these cases where we've operated for 12 hours, and then you've got to do a complex closure after 12 hours of taking a tumor out, having somebody there to tap you out, and say, ‘Okay, go to the bathroom, get a granola bar, I'm going to get this closed.’ That's a big, big plus.”

Another benefit of having a plastic surgery colleague in the operating room: the possibility of taking a more aggressive surgical approach if needed, such as in cases of cancer.

“As the orthopedic surgeon, I can be more aggressive in my approach to resecting a tumor, because I know that my plastic surgeon is going to come in and take care of the aesthetics. That's the nice thing about it. I can be a little more aggressive, and that aggressiveness may result in better outcomes,” said Dr. Tyler.

“So if I'm doing a soft tissue section of the thigh where I'm taking out a large portion of the patient's muscle, tendons, ligament, and skin…I’ve got this big defect now, and that's a great example of where the plastic surgeon can come in and fill in the defect so that there’s no longer exposed bone, nerves, or vessels like there normally would be,” she continued. “I also think the wound complication rate is much better in these situations.”

“I lead an investigative research team,” said Dr. Bogue. “We have recently completed investigating an orthoplastic approach and have found in a systematic review that we are very often able to salvage limbs and restore function.”

Communication between plastic and orthopedic surgery is important not only at the operating table but also during the planning before and after the procedure.

“We discuss each combined case ahead of time to determine what the goals of each discipline are going into surgery. This conversation elucidates the framework for how we are going to carry out this tailored approach to each individual patient," said Dr. Bogue.

“We regularly see patients together in the clinic and attend meetings, like tumor boards, to further discuss the broad goals of individual patient care. In a way, it really is personalized medicine: there is not a one size fits all approach.”

For Dr. Tyler, collaboration has become ingrained in the way she practices and she can’t see herself going back to the old way of doing things, alone.

Success Means There’s No Going Back

“Pretty much everything I do, almost 85 percent, 80 percent of the sarcomas I take out now, I'm probably including a plastic surgeon in my reconstructive process. Patients meet the plastic surgeon before the surgery even happens. We coordinate it this way so that patients know going into the surgery that the plan was always to have a plastic surgeon,” said Dr. Tyler.

“Most patients are happy to hear that plastic surgeons are closing their wounds, not orthopedic surgeons. Usually, they are very happy about that.”

For now, the discipline of orthoplastic surgery is more of a self-motivated one. There are no formal orthoplastic training programs, as of yet.

“Right now, it’s very much just us kind of putting it together. I think if you want to do orthoplastic surgery, you’re probably going to train in plastic surgery, and then you’re going to figure out a way to incorporate yourself into an orthopedics department,” said Dr. Tyler.

“There’s no fellowship, no specific training. I think someday there will be. It’s a great idea. Having crossover learning between subspecialties is really important in medicine.”

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