Week 2 - Ellen Brooks/Dr. Marx

Week 2 of immersion and I am starting to feel like I am getting familiar with the clinical and OR space as well as starting to get settled in the lab. 

I shadowed Dr. Marx through clinical visits both last Friday and this Monday. Both days there were primarily ACL injuries as well as a few rotator cuff injuries, dislocated patellas, and patients with osteoarthritis. 

In addition to the care and time that Dr. Marx and his team puts into treating physical symptoms, this week opened my eyes to the psychological component as well. Each patient is seen for maybe a maximum of 15 minutes, but despite the short time, each patient receives the same care, support, and listening ear from the clinical team. Most intriguing in this realm was a patient that came in very displeased with their recovery from an ACL repair. The recovery was on track with clinical expectations, but the patient was not experiencing the degree of pain reduction and function that they had hoped for 6 months after surgery. Dr. Marx sat down with the patient, listened to their concerns, and explained, three things: 1. from his perspective the recovery was on track, 2. that he didn't want the patient's suffering to be dismissed and that he understood that this was an unpleasant and difficult process, and 3. that the pain will go away and normal functionality will return. This is a side of medicine that is very rarely seen in the engineering and laboratory realm and was very intriguing to me!

This past weekend, I attended the virtual OSTR Retreat. It was very interesting to hear about some of the research being done in orthopedics in Ithaca and New York City. It was also amazing to see how many people are a part of orthopedics research at Cornell. 

On Sunday, I attended an MRI course with Dr. Prince. I did not expect to be taught how to operate the equipment and look at images. This was a very interesting experience. As a person who has had a number of MRI's, I was fascinated by the behind the scenes work and how injury was determined on the images. 

This week in the OR, I watched two total knee replacements and four ACL surgeries. ACL reconstructions can be done in many different ways using a variety of graft options. The primary types, and some risks and benefits, are as follows:

1. ACL graft from a cadaver - This type is currently very rarely used, and never performed by Dr. Marx as it has a high re-tear rate. 

2. Hamstring graft - In this type of graft, two of the four hamstring tendons are harvested from a patient and folded over to create extra strength. This graft as a small risk of re-tear but is the easiest to recover from, making this the most common graft used by Dr. Marx. 

3. Patellar tendon graft - This graft takes a piece of the patella, a section of the patellar tendon, and a piece of tibia for the graft. This graft type is stronger than a hamstring and has a lower re-rupture rate. However, the recovery time is longer as the patient needs additional time to heal from the graft harvest. Dr. Marx typically uses this graft for high risk patients, those returning to competitive sport, and for patients who have already re-torn an ACL.

4. Quad tendon graft - This is the newest type of graft and is rarely used by Dr. Marx as there is some evidence suggesting higher re-tear rate and longer recovery time than a patellar tendon or hamstring tendon graft. However, additional data may show this to be a good option for additional surgeries. 

In addition any of these graft types, an additional graft from the IT band can be taken and used to further stabilize the repaired ACL in high risk patients. Dr. Marx and his team are currently working on a study determining the effectiveness of this additional graft. 

In addition to clinical observation this week, I also observed a Return to Play assessment at HSS Physical Therapy for a patient 6 months out from ACL surgery. Many orthopedic and sports medicine doctors at HSS recommend this assessment to determine how recovered a patient is from surgery and injury. This assessment is super cool. The PT first tests the strength and flexibility of each side, looking for any asymmetries. Next, the patient performs a series of movements (jumping, lunging, squatting, etc.) that are recorded by a camera and computer program that analyzes the position of each joint through the movement. This seems like a very sophisticated and data driven manner to determine if a patient is recovered enough to return to sport without risk of reinjury. 

Finally, this week, I started work on a genomics project with Dr. Singh and Dr. Chen. This project is looking at what genetic pathways are upregulated and downregulated with loading of articular cartilage and will be used to inform future models. I have analyzed the data and found that 11 pathways are significantly altered following loading. Over the next several weeks, I will sort through literature to determine the relevance of each of these pathways. 










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