New dimensions of orthopædics

Before arriving at Yale School of Medicine (YSM), Lisa Lattanza, MD, chair and Ensign Professor of Orthopaedics & Rehabilitation, was already known internationally for performing the world’s first elbow transplant in 2016. Earlier this year, she performed the first fully in-house 3D surgical procedure. With these achievements, she follows in the footsteps of, among others, YSM’s Kristap Keggi, MD, who pioneered the anterior approach to total hip replacement, and YSM’s Michael Baumgaertner, MD, whose identification of the optimal placement of screws for hip fracture repairs has become the international standard.

For more on the latest developments in her department and her vision for the future, Yale Medicine Magazine spoke with Lattanza about the convergence of personalized medicine, engineering, and 3D technology to resolve even the most complex cases.

You recently performed the first entirely in-house 3D surgical procedure. Can you explain what differentiates Yale’s approach?

There are few academic centers across the country that have the capability of doing all the work in-house, meaning that you plan the operation virtually with an engineer. Then, based on that plan, bone models, guides, jigs [printed pieces that indicate where holes and cuts need to be made]—all the things that are needed in surgery to be able to execute that procedure exactly the way you planned it on the computer—are printed in-house.

Prior to this, we had been using an outside company to do the same types of cases. But the exciting thing about having it within the department is there’s so much more we can do. For example, there was a case that David Frumberg, one of our pediatric orthopædists, wanted to do, but the commercial companies wouldn’t do it because it required making a cut through the knee joint to correct the deformity. But because we were able to plan that, we could do the surgery.

We don’t have as many restrictions on what we’re able to do because we’re the surgeons and we’re the engineers, and we know what the technology can do—and that it’s safe. It gives us more control, and it also helps with cost containment. It’s much less expensive for us to do this [work] than to purchase these services from an outside vendor, which then makes it accessible to patients. It’s an equalizer for access to this type of technology because many insurance companies won’t pay for it due to the expense. Because we can do this in-house for about two-thirds of the cost, we can offer it to patients who wouldn’t normally be able to access it.

Was developing a 3D surgery program one of your goals when you joined Yale in 2019?

I started doing 3D personalized surgery in 2012 at UCSF [UC San Francisco] and was an early adopter of this approach. I’ve done more than 500 cases using this technology—more than anyone in the United States and probably more than all but one other person worldwide. I know the power of what it can do. A lot of the cases we do now wouldn’t have had a solution prior to the ability to do 3D planning. When I came to Yale, I wanted to make sure that I could continue to do these cases here because some centers don’t allow it due to the expense.

But the other part was that I really wanted our department to be at the forefront of the use of 3D personalized surgery for complex deformity correction, congenital problems, post-traumatic problems, difficult arthroplasty cases, and tumor cases. I wanted to put Yale on the map for this. When I got here, I started a 3D task force with some like-minded colleagues in the department. When we got to the point where we had done all that we could do without an engineer on board, we recruited Alyssa Glennon, who was a lead engineer at Materialise, one of the biggest companies in this arena in the United States. She collaborated with us to establish our 3D Collaborative for Medical Innovation (3DC), where all of this happens within the department.

Obviously, this approach isn’t applicable to every surgical procedure. How do you decide when to use it?

Many surgeries are very straightforward. But sometimes you have a complex deformity of a bone or joint, or a congenital malformation where the anatomy is difficult to understand in 2D on an X-ray, or even with a CT or an MRI scan. 3D technology comes into play when you think there’s a way to correct this condition with an osteotomy [cutting of the bone].

There are other places, too. For example, we’re developing a destination program for avascular necrosis [AVN] of the hip with Daniel Wiznia, one of our orthopædic surgeons, and we’re printing guides so that he can go right to where the AVN is seen on a CT scan and core out just that area. In the past, we’d look at the X-ray or the CT scan and hope to get in that same spot; now we can target it very precisely. As we learn what the technology can do, we’ll continue to expand its uses.

Hopefully over time, someone with two years of experience will be able to do something just as well as someone with 10 years of experience, because they’re using the same kinds of techniques and guides. It makes surgery shorter, decreases blood loss, and we can more accurately correct the deformity. All of these things have been shown with various types of research, [including] some that’s happened here at Yale.

3D approaches are bringing personalized medicine to a new level. How is Yale leading efforts to train surgeons in this rapidly developing area?

We started the Master of Science in Personalized Medicine & Applied Engineering program in 2022 with Daniel Wiznia and Steven Tommasini, one of our research scientists. Having worked together since 2012, Alyssa Glennon and I noticed that neither surgeons nor engineers are trained how to do this. It’s all learned on the fly. The bottleneck is getting engineers trained well enough that they can help plan a case with a surgeon. You also have to train surgeons to do it because you still have to understand the anatomy and what you’re trying to correct. You need to know how it would’ve been done in the old way—if there was an old way.

In the master’s program, we train engineers, computer scientists, medical students, physicians, and dentists, bringing together imaging, engineering, and anatomy. They graduate being able to not only understand how to do these cases, but also how to run the software that allows us to be able to plan and print what we need, in addition to many other skills. We’re also changing things constantly to keep up with what we are doing with AR [augmented reality], VR [virtual reality], AI, and 3D printing of cellular components, bone, and cartilage. The program will grow as the technology grows, and it goes hand in hand with the 3DC, which creates 3D patient-specific models and tools. As far as we know, it is the only one of its kind in the world.

In what other areas has Yale expertise advanced the field of orthopædics?

We have a number of specialized programs that allow us to treat complex cases. The hip preservation program is a multidisciplinary program that uses hip arthroscopy, and if necessary, complex osteotomies around the hip—primarily for hip dysplasias, but also for hip problems from trauma. It’s really about finding the right operation for the right patient, whether that be an arthroscopic approach or redirecting the hip, which might allow for better weight bearing on the native joint, all the way to joint replacement if none of the procedures short of hip arthroplasty will solve the problem.

Under the direction of David Frumberg, we have a limb-lengthening program, and he’s also very adept with the use of techniques for bone transport [to fill bone defects]. For patients who have a bad defect in a long bone from trauma or infection, the techniques Dave [Frumberg] uses allow for healing of those bones in ways that we didn’t previously have. The limb lengthening that he does is specialized treatment for children with congenital problems, as well as for adults who have a post-traumatic limb discrepancy.

We have a new foot and ankle surgeon, Arianna Gianakos, who specializes in minimally invasive approaches to ankle pathology. She’s doing a type of in-office arthroscopy with nanotechnology that allows her to both diagnose and treat problems around the foot and ankle, sometimes right there in the office. We have a program for multi-ligament knee instability and knee dislocations. We are one of only a few sites in the country doing research in this area, and Michael Medvecky, a YSM orthopædic surgeon who specializes in athletic injuries, has written most of the sentinel articles on how to fix these knees to get the best result possible.

Orthopædic medicine has traditionally suffered from a lack of diversity. What are some of the initiatives that you’ve undertaken to include women and other underrepresented groups in orthopædics?

I co-founded a nonprofit organization called the Perry Initiative in 2009 with Jenni Buckley, who’s an engineer. It started off as a one-day program for female high school students, exposing them to the careers of orthopædic surgery and engineering [through a hands-on curriculum]. We now have about 17,000 young women who’ve been through this program. In 2012, we started a similar program for women in medical school. If you look at all medical students, 1% of women match into orthopædic surgery. If you look at the women who have gone through our program, 23% match into orthopædic surgery.

When I came to Yale, we also took a comprehensive look at how we select residents and decided to take a different tactic. We set out to make it a less biased process and use criteria that were part of our new culture and value set. We did away with board scores, and we don’t look at school of origin as part of the criteria. Instead, we look at grit and resilience, leadership qualities, work ethic, and what we refer to as distance traveled—meaning ability to overcome obstacles in your life. We now have the most diverse class of residents in the history of Yale and one of the most diverse orthopædic residency cohorts anywhere in the country. We are at almost 40% women and those underrepresented in medicine. We’ve taken a similar approach to recruiting faculty. We have a diverse search committee that knows that inclusive excellence is part of our culture and values. We actively seek out diverse candidates for open positions.

Other than 3D surgical procedures, what’s next on the horizon for orthopædics?

We’d love to be able to grow bone and cartilage in the lab in 3D. Can you imagine if we didn’t have to do joint replacements anymore because we could now grow cartilage? Eventually, printing in plastic will be a thing of the past because we’ll be using augmented reality in the operating room to do the same thing.