Other Articles

Using DNA to Predict Scoliosis
Six million people (estimate from the National Scoliosis Foundation) have scoliosis in one form or another. The primary age for onset of idiopathic scoliosis is 10-15 years old. Finally, there is a test which can reliably predict scoliosis. Fewer X-rays. Lower cost. Better outcomes.

New Capital, New Science for Cartilage Repair
$36 million invested in the last couple of months. TiGenix has more than that in the bank to fund market penetration. Then a new paper last week finds molecular cause of OA. Cartilage repair momentum is building.

Should I Become a Physician-Employee?
Large healthcare institutions are increasingly purchasing orthopedic practices. What does this mean for patient referrals? How beneficial can it be for orthopedists? The upside is more stability, among other things…and one of the downsides is loss of freedom.

Outrageous Whistleblower Lawsuit Challenged
Spine surgeons sued by whistleblowers in Boston are fighting back. Their lawyer is outraged and says the claimants are just shopping an old and settled case to another judge. Is this the proverbial lipstick on a pig? Find out.

Medical Education Under the Microscope – Is It Up to Today’s Challenges?
Where is the line drawn between what medical schools, residencies, and professors should provide to students and what doctors-in-training should reach for themselves? Here are the results of interviews with three senior surgeons, who opine on things such as attitudes, how people learn, and the possible effects on the field.

The Underlying Meaning of Zimmer’s Purchase of Abbott Spine
From the price paid to the timing, this transaction held an underlying meaning for the entire spinal implant industry. Zimmer, the $4.2 billion (revenue) diversified orthopedic company is now #5 in spine. More to come?

Resurging Lumbar and Cervical Total Disc Replacement Markets! New PearlDiver Estimates
Rumors of the TDA market’s demise were premature. Increasingly positive long term patient data is at the core of a resurging lumbar and cervical TDR market. Senior analyst Matt Menze tackles the TDA market and interviews one of the fathers of TDR, Dr. Scott Blumenthal from the Texas Back Institute. Where is this market actually heading? We think to the $2 billion range by 2015. All details here.

Six Days in June – Biomet and Zimmer Battle for Distributors in Kentucky
Documents filed recently in a Kentucky lawsuit pull the curtain back on an epic battle between Biomet and Zimmer. For six fevered days in June 2007, Biomet CEO Jeff Binder and founder Dane Miller went into the trenches to save one of their own. For all the details, read on.

Multicenter Clinical Trials: Do They Get the Respect They Deserve?
They’re not fast or sexy, but they are critical…large trials, that is. With multiple sites and principal investigators who donate their time, large trials are more complex—and normally yield more actionable data—than smaller, quicker studies. But large trials don’t always get the respect they deserve. And, says at least one physician-researcher, this could affect the future of the field.

Patent Wars: Medtronic Attacks NuVasive
MSD’s lawsuit came amid a period of declining spinal implant market share – from a peak of 60% in late 1998 (just prior to being acquired by Medtronic) to, we estimate, 36% currently – and a growing sense that MSD’s reign as the king of spine was coming to a close. What’s really behind Medtronic’s attack on its former senior exec? Read on.

Spine Gainsharing Through the Looking Glass
The feds have issued their first opinion allowing a spine gainsharing proposal. In Alice in Wonderland style, Through-the-Looking-Glass logic, they said the proposal was improper but would not impose sanctions. Who is the author of such a plan and what’s her secret? Read here.

PearlDiver Data Raises New Questions About Synovial Injections
Synovial injections for painful knees have been approved for use since 1997. If the goal is to improve the quality of life for the patient, is that being accomplished? The latest numbers from the PearlDiver Patient Records Database cast doubt.

Plantar Fascia: The Annual 3 Million Patient Market
“Plantar Fascial Fibromatosis (ICD-9-D-728.71) is right up there in frequency with pain in the shoulder joint, degeneration of lumbar intervertebral discs, pain in the lower leg joint, and carpal tunnel syndrome. As usual, PearlDiver has this market mapped out.

Orthopedic Incubators: Where Little Ideas Grow Up
Business incubation, also known as acceleration, can be a wild ride. Thus it’s best to approach it armed with the solid advice of experienced professionals. Who should take this ride? What can venture financiers bring to the table? These questions and more are answered by two seasoned VC professionals.

Just Say No to CMS Potential Coverage Decision List
Unless you want to be on the receiving end of a non-coverage letter, just say no to CMS’ proposed list of potential National Coverage Decisions. You’ve got until September 28 to make your case. Read what a leading industry consultant and analyst have to say.

Staking a BIG Claim
Alphatec, the company whose IPO collapse served as an object lesson for all medical device companies, has nearly completed its turnaround. The key? New management and new technology. Exhibit A: OsseoFix™—with it Alphatec stakes a claim to the next big spinal implant market.

Today’s medical students might consider this surgeon’s early career moves to be either zany or zen. “I took my first job out of residency without knowing the salary,” smiles Dr. Paul Tornetta, Professor and Vice Chairman in the Department of Orthopaedic Surgery at Boston University School of Medicine. “During those days the medical culture was such that we trusted we would have enough money to live on.” But Dr. Tornetta, also Director of Orthopaedic Trauma for the Boston Medical Center, must have done something right.

Raised in suburban New York by parents who were accomplished and supportive, Paul Tornetta credits his mother in particular for being the parental force behind his dreams. And his savvy mother knew how to sell him on success. “Although neither of my parents finished college, my dad worked in publishing and my mom was in real estate and consulting. My mother always set the expectation that higher education was not an ‘if’ thing, but a ‘when’ thing. It was sort of like sales people do when they say, ‘Well, which of these jackets do you want?’”

On the operating table as a child, Paul Tornetta would hold that experience close to him and develop a strong curiosity about the power of medicine. “I had heart surgery at the age of four. I think it was the explanations given to me by the doctors and my mom that made me curious about medicine. Having surgery made the medical world more real to me. And it would soon become evident that my skill set, i.e., math and science, would work better in medical school than, say, in an English Ph.D. program.”

A double major in math and chemistry at Franklin & Marshall College, Paul Tornetta would get early exposure to trauma. "I was an EMT in college and thus saw numerous accidents and learned about hospital acute care. When I entered medical school at SUNY Downstate Medical Center in 1983, I thought I would become a pediatrician because I liked children and had fun when interacting with them. I didn’t know much about the field, however. In my first year I did a pediatric rotation and saw a 4-year-old girl who had experienced a horrible accident and was now a quadriplegic. It was then that I realized that pediatrics was too heartbreaking for me. In orthopedics at least I’m dealing with patients who can understand what’s going on—not so in pediatrics.”

Once in his third year of residency, Dr. Tornetta would find his way to orthopedics. “I became fascinated by skeletal injuries and the dramatic changes I saw between when someone was injured and then only a short time later when they were much improved. During this time my mom had avascular necrosis of the hip. While doing literature searches on this topic my interest in orthopedics only deepened. Also, I came to see that while medical doctors are interested in disease and want to help patients, they don’t see the types of improvements that surgeons see.”

Doctors sometimes see miracles in their work. As far as Dr. Tornetta was concerned, he experienced the supernatural early on. “No one had told me that I had to do well in medical school to get a residency. I met with the Chair of Orthopedics at State University of New York Health Science Center at Brooklyn (‘Downstate’), who looked at my transcripts and said, ‘You might want to pick another field.’ As you can imagine, I sunk in my chair. Thankfully, I did well in my clinical rotation in the department. But still, it was a miracle that I got into the program.”

Continues Dr. Tornetta, “During my residency I worked more hours than ever and read all the time. It was essentially a resident-run program as there was not a lot of oversight. This was ideal for those of us who were self starters, because we could excel. If you had needed mentorship, however, you would have had a hard time. The Chair, Stanley Gordon, was helpful to me, however. He was a very fair and kind man who exemplified the ethics of orthopedics and held, for instance, that the practice environment is not as important as the patients. As I approached my fourth year I became interested in trauma, in part because we did a lot of this work, and also because I was fascinated with injury.”

Captivated with trauma work, Dr. Tornetta would again see fate guide his career. “Unlike when I exited medical school, coming out of residency I was well prepared for the next step. I had published my own research but wasn’t well positioned to get a top trauma fellowship because the politics of the day weren’t on my side. I had my eye on three programs and was very well qualified, having published my own work and having scored very highly on the Orthopaedic In-Training Exam. At the time Dr. Andy Burgess was running the R. Adams Cowley Shock Trauma Center at the University of Maryland, a program that interested me greatly. A representative of the program phoned me and said, ‘Look, you’re fourth out of three people. The third person wants to look at another program before he decides. If he doesn’t take it the spot is yours.’ My mindset was that I didn’t feel I needed any old fellowship so if I didn’t get this one I would just move ahead with my career without one. As chance would have it, the third person took the spot at Maryland. Fortuitously, a faculty member of mine took a pelvic course at which Joel Matta was speaking. Joel made it known that he had a fellowship spot available and my faculty member recommended me and alerted me to the potential opportunity. I applied and was granted an interview. When I arrived the receptionist said, ‘You’re the guy from Maryland.’ Puzzled, I said, ‘No, I’m from Brooklyn.’ ‘That’s weird,’ she said, ‘because Andy Burgess called about you.’ It seems that Andy felt bad that I didn’t get the spot in Maryland and must have talked to Joel Matta and supported my application. It was a purely altruistic gesture on his part because I would have never known.”

Five months of pelvic and acetabular surgery later, Dr. Tornetta returned to New York with a job waiting in the wings. “My residency Chair had offered me the job of running the SUNY Downstate trauma center from the orthopedics side. This was the job I took without a contract or without any knowledge of what my salary would be. It was 1993 and a time when up-and-coming orthopedists just went for what we wanted and trusted that things would work out. I was actually more interested in having control over my research projects and which implants I used. I felt confident that I understood the work environment, so there was no learning curve. I presented papers, ran trials, and began to make an academic name for myself outside of my institution. Not part of any ortho clique, I was like an undrafted free agent. This liberty gave me the opportunity to be involved with a variety of different projects. One of my early supporters was Dr. Jim Goulet, who introduced himself to me after I presented a paper and was encouraging of my work. Then there was the famous Dr. Roy Sanders, whom I met during my fourth year of residency. He gave a positive review of one of my papers and later gave me the opportunity to do some committee work for the Orthopaedic Trauma Association (OTA). Roy is tough, but fair, and has been one of my best friends over the years. I think there is a natural kinship as he, too, came up through the ranks without mentorship. Dr. Fred Berens was another early supporter. When I first attended orthopedic events he approached me when I didn’t know anyone and made me feel welcome.”

In 1998 a phone call would pull Dr. Tornetta from Brooklyn and land him in Boston, the nerve center of the medical world. “Back in my third year of medical school I met Dr. Tom Einhorn, who, it turned out, would keep track of my career over the years. The Chair of Orthopaedic Surgery at Boston University, Dr. Einhorn reached out to me, saying that the significant trauma volume at the university was not being sufficiently managed. It was a perfect time for a change of environment so I went to Boston to meet with him. Key for me, and more important than compensation, was that I needed guarantees regarding direct patient care, control of the operating rooms and the implants we use, and support for my research.”

Having negotiated his future, Dr. Tornetta was then set to leave his mark on a medical center with deep roots. “Boston Medical Center, a combination of Boston University and Boston City Hospital, is an appropriately busy place to run clinical trials. If a center is too big it is unwieldy—our 2,500 trauma admits per year is just right. Boston University had its beginnings as an entity that was dedicated to caring for the injured patient. Boston City Hospital used to be the trauma center of Boston and was big on indigent care. Even today, everyone at the hospital has indigent care as part of their mission. And the administration understands how important various resources are as opposed to, say, an administration that sees getting an angiographer in the middle of the night as a waste of resources. This means we have people in all subspecialties who are flexible and dedicated, and who cooperate well among one another. This is an area that’s not well compensated, so you know people have to be dedicated in order to do this work.”

But most times, Dr. Tornetta, like his colleagues, doesn’t hear from patients or learn of their successes. When he does, it’s an “aha” moment. “The most rewarding patients are those who exceed my own expectations of what I can accomplish. I’m thinking of a patient with a terrible pelvic ring injury. After I operated on him, he went on to compete in team triathlons. One day he brought in a medal he had won. Then there was the lady who had chronic pelvic instability and had to have a huge pelvic surgery and go into a wheelchair temporarily. Recently while I was strolling around the grocery store, she tapped me on the back and said, ‘I get up and thank you every day because I’m not in pain.’ These success stories are what it’s all about.”

Dr. Tornetta, like all orthopedists, is able to help these patients because of the elaborate and thorough work done in medical centers around the world. And when multiple centers join forces, the healing power is multiplied. “We just completed the SPRINT (Study to Prospectively evaluate Reamed Intramedullary Nails in Tibial fractures) trial, the largest randomized trial in orthopedic trauma history. It involved three continents, over 200 surgeons, 29 clinical sites, and more than 1,300 patients. The participants were randomized between two groups: those who got reamed tibial nails and those who got nonreamed tibial nails. Our primary finding was that the two techniques were not different. The outcome data we had at the one-year mark showed that even for isolated closed tibia fractures, only 80% of patients would be back at work. And overall, the outcome on patient activity levels was lower than we thought it would be.”

Dr. Tornetta has also had some nonclinical epiphanies as part of his research activities. “I am very struck by how the politics of orthopedic research can hinder the field. Generally speaking, there is a tendency for senior surgeons to dissuade junior surgeons from participating in large trials. For example, let’s say you are a junior-level surgeon in an academic center. Your boss wants you to publish and you want to get promoted. The most expedient thing to do is a retrospective analysis of your work with a report on the outcomes, complication rates, and techniques. That takes about ten hours…and you can get a resident to help out. Boom. You are first author on a peer-reviewed publication. Contrast that with the SPRINT trial with its multiple sites and 24 principal investigators. And the surgeons who contribute patients only have their names at the bottom. Yet they have put in hundreds of hours and work without financial compensation. The only personal glory for them is in knowing that they have made some contribution to further the field.”

His most memorable moments at work are with people. The same is true of home. “My wife and I often head to our beach house where her family visits us. She is also a busy doctor, so this is an excellent escape (although I work a good amount of the time there). Also fun for me are my regular workouts, photography, and listening to music. Missing from my life now, unfortunately, is my mother, who passed away a couple of years ago. She truly made anything I’ve accomplished possible as she was so supportive and loving.”

Dr. Paul Tornetta…whose best mentor was his mom.