Dr. Craig Levitz is a surgeon at South Nassau Hospital in New York, where he is also the co-chief of sports medicine. He has published over twenty scientific articles, focusing primarily on advancements in knee and shoulder surgery. Dr. Levitz has operated on over 100 professional athletes, providing medical care to the Cincinnati Reds, the Toronto Blue Jays, and the Tampa Bay Devil Rays. In addition to his surgical practice, he has held prestigious research fellowships, served on corporate advisory boards, and worked as a consultant to the medical industry.
Knee1: Dr. Levitz, your recent contributions to knee care include the use of new fixation systems. Could you describe a fixation system for us in layman’s terms?
Dr Levitz: When ligaments are reconstructed, or cartilage is reconstructed, we need to make it adhere to the body; to be fixed to where it came from. Glue would be the simplest fixation system, but unfortunately we have no glue for the human body. In the past, we used metal or synthetic substances to fix tissues throughout knee joints. Now we’re doing more biocompatible things, because, for example, if you put a metal screw in, it can come back out and irritate the patient. In ACL (anterior cruciate ligament) surgery, these newer fixation systems allow for small graft harvests, quicker recovery, and the use of bioabsorbable implants.
Knee1: You mention that these new fixation systems use biocompatible materials. What kinds of materials are biocompatible?
Dr. Levitz: Well, we use something called PLA (polylactic acid). We also encoat it with hydroxy-apatite, the main calcium crystal in bone and a plastic polymer which the body can absorb.
Knee1: Can you tell us more about the role you’ve played in the development of this technology?
Dr. Levitz: The technology itself was developed by industry, but because of the volume of surgery I do, I’ve been part of the early rollout. I get access to the technology before the majority of the medical community does, and I provide feedback to the company. This kind of feedback is part of the regular process for introducing new procedures. Just because things are approved doesn’t mean they represent the best option. Once things are available, we still want to evaluate them to make sure they’re the best possible option, and the only way to do that is to be constantly updating the procedures.
Knee1: On the subject of updating procedures, you’re also pioneering several new cartilage transplantation techniques, such as meniscal transplants. The development of meniscal technology has been limited in the past by the number of available grafts. Is this still the case?
Dr. Levitz: Actually, our biggest problems have been insurance issues: someone has to purchase the transplant, because insurance companies don’t want to pay for it, and the transplants generally run about $5,000. If there was a cheaper graft available, we’d do a lot more of these operations. In the last month I’ve seen three patients who needed the transplant and couldn’t pay for it, because they couldn’t be approved by their insurance agencies. So the biggest obstacle is getting hospitals to approve it as a necessary procedure.
We have a limited number of resources, and unfortunately a lot of decisions are made on an economic basis. We have a lot of technologies to offer patients that are often limited in their applicability by their expense, and although we try to work through this problem, it’s frustrating as a physician. We all think we have health insurance for everything, but that’s not true. I’m seeing that insurance is covering less and less.
Insurance companies’ decisions really aren’t based on medical factors. For example, the hospital doesn’t get paid anything extra for a minimally invasive operation, although it’s a much more difficult procedure and it saves the insurance company thousands and thousands of dollars.
Knee1: You also have an interest in finance and medical economics. Are these the kinds of issues that the field of medical economics addresses?
Dr. Levitz: Medical economics is essentially the study of practicing medicine in a limited-resource environment. It’s a very broad field, which covers issues from insurance coverage to the patient-care relationship to the malpractice crisis that is currently limiting patient access.
Knee1: Several of the procedures that you’ve pioneered, Carticel in particular, are recommended primarily for younger patients. [For our readers: Carticel is a procedure by which millions of cells are grown in a laboratory from the patient’s own tissue, and then implanted into the patient’s knee. For more information, see www.carticel.com.] What kinds of procedures do you predict will develop for orthopaedic patients who are not as young and healthy?
Dr. Levitz: Well, in that population you have to replace a portion of the knee. I do believe that researchers are now working on the next generation of Carticel, in which they’ll be able to grow the cells on a patch, and implant the patch. The procedure itself currently has limitations that prevent us from using it on a widespread basis, but as they make improvements, I think it will be available to more patients.
Knee1: After medical school, you were selected for a fellowship with Dr. James R. Andrews, one of the world’s preeminent sports physicians and orthopaedic surgeons. What was that experience like?
Dr. Levitz: I spent a year under Dr. Andrews; he was a mentor for me. As a fellow, I was not only with him in surgery, but I also covered the sports teams with him. That really was a unique experience, because of his unique style of teaching and mentoring. He has a passion for his work, as well as tremendous skill, and he teaches fellows how to develop that same passion. He has a tremendous work ethic, and he leads by example.
After you finish that fellowship, you’ve seen and done just about everything, so nothing can take you by surprise. I think that’s why you see a tremendous amount of Andrews’ fellows being so successful once they get out of the fellowship: more than just not being scared or surprised by new things, they’re constantly looking for ways to make improvements.
Knee1: It appears that you’ve done a fair amount of training other surgeons yourself. Is teaching a major part of your work?
Dr. Levitz: As a matter of fact, I just got off a plane from Baltimore, where I was doing exactly that. I spent a lot of time demonstrating these new procedures through cadaver workshops and training other surgeons. I think it’s important. Through my fellowship and my work as a consultant, I’ve been fortunate enough to be on the cutting edge, but not everybody has been that fortunate. There are thousands of surgeons who would be able to do these procedures, if they could be exposed to them without having to go back and get another fellowship.
Currently, I don’t have a fellowship program because at this point I don’t want to give up that much patient involvement: I like to be involved from beginning to end. But maybe later in my career I’ll take that step.
Knee: What future trends do you expect to see in the field of orthopaedic care?
Dr. Levitz: Minimally invasive surgery is the most important trend in orthopaedic care today. Our newest cause for excitement is minimally invasive partial and total knee replacement. This approach radically reduces both postoperative pain and the length of the patient’s hospital stay, and eliminates rehab. The biggest factor in the development of minimally invasive surgery was getting physicians to believe that we could accomplish things through smaller incisions, with less violation of the soft tissue. This acceptance has definitely taken place. We then pushed industry to develop smaller and smaller instruments.
A standard knee incision runs eight to nine inches, whereas the minimally invasive incision runs about three to four inches, so it’s fifty percent smaller. More importantly, in the past we used to cut into the quadriceps muscle, and now we don’t cut through that at all, and that really improves the recovery time. We don’t violate the muscle or tendon at all. And we can replace the whole knee through this type of procedure. It used to be that patients were in the hospital for a week, then went up to rehab for two weeks. Now, they spend three days and go home, and the only thing that’s different is the approach to the knee. Probably the biggest change in my practice recently has been how much better my patients have been doing because of this minimally invasive approach.