Innovating infection away from orthopedic surgery

“When you’re dealing with delicate surgeries, especially knee replacements, it’s comforting to have a doctor who cares deeply and communicates clearly," says Crall. “I know many people who have relied on Dr. Glassman for treatment, and there’s a reason he is the head of a department with so many accolades. Even back in high school, peers relied on his judgment.”

Orthopedics inspires a future surgeon

A native of Bexley, Ohio, Andrew Glassman always knew he wanted to become a doctor. At school, he excelled at math and science. At home, he spent long hours taking things apart and putting them back together. From working on cars to woodworking, he was always most fulfilled when discovering how something worked.

He earned a degree in biology at Northwestern University before continuing to a master’s program in biology with a focus on neuroscience at the University of Michigan. Given his passion for working with his hands, he anticipated a fruitful career in neurosurgery. Then, as a medical student at the Medical College of Ohio (now the University of Toledo College of Medicine and Life Sciences), he faced an unexpected reality.

“From a research perspective, I found neuroscience incredibly fascinating, but from a clinical perspective, it felt quite depressing,” he remembers. “There were so many patients with tumors, traumatic brain injuries and other conditions I couldn’t heal.”

When he discovered orthopedic surgery during his internship at the Los Angeles County-USC Medical Center, something clicked. By leveraging his natural inclination toward structural design and engineering, he could dramatically change someone’s quality of life.

 

“I found orthopedic surgery to be a very happy subspeciality. It’s incredibly rewarding to help someone return to an active life,” Glassman says.

Innovating new joint replacement options

It was the early 1980s, and one of the primary challenges in Dr. Glassman’s field was the issue of implants coming loose. Inspired to contribute to a solution, he became an Adult Reconstruction Fellow at the Anderson Orthopaedic Research Institute, a renowned practice based in Arlington, Virginia. There, he practiced under Charles Anderson Engh, MD, a pioneer in developing new total joint replacement technology.

In 1977, Dr. Engh had conducted clinical trials leading to U.S. Food and Drug Administration (FDA) approval of the first cementless total hip implant approved for biologic fixation, a technique that promotes direct bone ingrowth into the implant instead of relying on bone cement. “Cement fixation can deteriorate with time, but the bond between bone and implant strengthens as time goes on,” Dr. Glassman explains.

After a year-long fellowship, Dr. Glassman accepted an offer from his mentor to join the practice as a partner, and one year turned into 16. Together, he and Dr. Engh drove innovation forward in their field, demonstrating how to design implants in a way that makes biologic fixation more predictable and improves implant longevity.

In 2001, Dr. Glassman moved home to Columbus to marry his childhood sweetheart. By then, he was a well-known clinician and researcher in his field. In 2013, he was appointed as the chair of the Department of Orthopaedics in The Ohio State University College of Medicine.

“I had never tossed my hat in the ring for this kind of position,” he remembers. “I associated administrative leadership with bureaucracy. In my mind, that was far removed from patient care and innovation, which is what truly interests and excites me.”

Despite his initial hesitation, he soon learned that by growing and strengthening his department, he could advance patient care and innovation faster than he could have imagined.

Building a team to fight orthopedic surgery infection

In most aspects, total joint replacement has come a long way since Dr. Glassman was a resident physician. But despite continual progress toward better-crafted, longer lasting joint implants, approximately 1 to 2% of all joint replacements will become infected within 10 years of surgery.

“In my field, infection is the last frontier. The germs are smarter than we are. Even though it’s not a surgeon’s fault, it is psychologically devastating to care for a patient who develops an infection,” Dr. Glassman says.

Many infections are related to patient risk factors such as uncontrolled diabetes, chronic dental infection and smoking. Once an infection develops, a surgeon might wash out the area and put the patient on an antibiotic. More often than not this course of treatment fails, requiring removal of the infected implant and replacing it with a temporary spacer infused with antibiotics. After another six to 12 weeks, the patient undergoes a second surgery to receive a new implant. Their journey to healing is far longer and more traumatic than they ever could have anticipated.

To improve outcomes for these patients, Dr. Glassman has assembled a multidisciplinary team committed to preventing and treating infection.

From a clinical perspective, he identified a gap in training among physicians. Because an infected joint is relatively rare, many orthopedic surgeons don’t feel adequately trained to manage it. In 2015, Dr. Glassman spearheaded the creation of a specialty care team, the Musculoskeletal (MSK) Infection Group, to manage infection cases. Operating within East Hospital at the Ohio State Wexner Medical Center, the MSK Infection Group consists of more than 30 specialists, including total joint replacement surgeons, plastic surgeons, infectious disease specialists, radiologists, nurse practitioners and more.

Today, physicians throughout the region can refer their patients for immediate intake under the supervision of the MSK Infection Group. Currently, the group handles more than 400 cases a year.

“We’re working to build a true regional center of excellence with a higher success rate than what we see elsewhere. Referring physicians send patients our way, reducing failed attempts to manage the problem of infection,” Dr. Glassman says.

From the perspective of Christopher Kaeding, MD, the Judson Wilson Professor in the Department of Orthopaedics, who specializes in Sports Medicine surgery, initiatives like the creation of the MSK Infection Group have “put Ohio State Orthopaedics on the map.”

“I’ve worked under many chairs, and Andy has been the most successful at building our department,” he says. “We have doubled in size under his leadership.”

Moving orthopedic research forward

Dr. Glassman has also supported research to prevent orthopedic infection from happening in the first place.

One research direction involves discovering new chemical and mechanical ways to disrupt biofilm, the bacteria-laden slime that develops on infected implants and requires their removal. Simply washing the implant doesn’t remove the biofilm, and antibiotics can’t penetrate it either.

The Ohio State Wexner Medical Center is one of several centers participating in a study that examines the use of a peptide antibiotic to attack the biofilm and cure an infection without necessitating the removal of an implant. “If we could avoid the massive trauma involved in taking out an existing implant, that would be a game changer for our patients,” Dr. Glassman says.

Another study involves removing an implant and replacing it with a metallic tubular “sprinkler system” instead of a spacer. Attached to a tube that exits the body, the system allows for continuous irrigation of the hip or knee with antibiotic solutions. Preliminary results indicate that this solution substantially reduces the time between the removal of an infected implant and the implantation of a new one.

A third area of research, still in the initial stages, explores the use of viral particles to destroy bacterial infections in joint replacements.

Next Frontiers

For every 99 people like Colby Crall, whose joint replacement surgeries went off without a hitch, there is one patient who is suffering from an unexpected infection.

“Some people rest on their laurels at the prime of their careers,” reflects Julia Bishop, MD, an orthopedic shoulder surgeon at Ohio State. “One thing that has always impressed me about Dr. Glassman is that he never stops learning and problem-solving. He never stops looking for ways to become more innovative on behalf of his patients.”

“By continually expanding our department’s footprint in central Ohio and beyond, we are changing the narrative for patients experiencing an infection,” Dr. Glassman says. “And by changing the narrative, we can change lives.”