Kevin L. Kirk, DO is a board-certified orthopedic surgeon specializing in disorders of the foot, ankle and lower leg. Although he treats all general orthopedic conditions, he has a special interest in foot and ankle joint replacement, arthroscopy, reconstruction and trauma surgery.
Dr. Kirk received his Doctor of Osteopathic Medicine from the Philadelphia College of Osteopathic Medicine in 1999. He completed an internship in General Surgery and subsequent Orthopedic Surgery Residency at Walter Reed Army Medical Center in Washington, DC. He then went on to complete a fellowship in Foot and Ankle Surgery at Johns Hopkins University/Union Memorial Hospital in Baltimore, MD.
After completing fellowship, he was appointed the Chief, Foot and Ankle Surgery at Brooke Army Medical Center. In 2010, he became the Chief, Orthopedic Surgery Service at San Antonio Military Medical Center serving in that position until his retirement from the Army in 2013. He has recently relocated his practice from the University Orthopedic Associates in New Jersey where he was an orthopedic consultant to the athletic programs at Rutgers/Princeton and Rider Universities.
Dr. Kirk is a highly experienced orthopedic surgeon and a veteran of two deployments with forward surgical teams to Afghanistan in 2005 and 2011. He remains active in the orthopedic academic community. He has served on the faculty of the Uniformed Service University of Health Sciences, Baylor College of Medicine and Rutgers/ Robert Wood Johnson Medical School.
TOA: How did practicing orthopaedics in the military setting different from practicing in the civilian arena?
- Camaraderie versus competition. In the military, we are all one team working towards the goal of providing the best care for our soldiers/ beneficiaries, particularly in the deployed environment. The differences that you have between different specialties, anesthesiology and general surgery, evaporate in that environment since you realize your sole purpose is to save lives and limbs, so the coordination of care is much better with less conflict. (I still stay in touch with a lot of the guys that I served with, but I have never been able to replicate the collective sense of working for something greater than yourself in my six years of private practice).
Whereas in the civilian side there is always competition to gain patients within and between groups/surgeons, so often there is conflict such as, “why is the sports guy doing trauma?” or “foot and ankle cases?” when it should go to the most qualified surgeon. In the military, especially at the medical centers, there was specialized care, such as sports/foot and ankle / trauma/hand, etc., so that the most qualified surgeon will perform the surgery. In an effort to fill ORs, some civilian surgeons will push the limits of their skill set rather than refer to a more appropriate surgeon. (I know that that is not very politically correct, but it is honest.)
- Too many patients and not enough time versus too much time and not enough patients. Due to the number of beneficiaries and limited/inefficient resources in the military system, there are often long wait times for surgery or exams such as MRIs. Not that the quality is inferior, but without financial incentive, there is no need to work harder, so it leads to further delays. In the civilian side, it is a hustle to get as many patients as you can.
- Injury severity. Particularly with the recent conflicts in Iraq/Afghanistan, the use of improvised explosive devices (IEDs) injuries can be quite devastating, such as extensive soft tissue and bone loss coupled with contralateral limb loss. In fact, especially with open tibia fractures, there is an inverse pyramid of the severity with military open tibia fractures being primarily the worst (Grade III) and most prevalent when compared to civilian open tibia fractures being less severe (Grade I) and being the most prevalent.
Due to the high energy mechanism of injury coupled with the “up-armored vehicles” later in the conflicts led to severely comminuted fractures of the foot and ankle. Oftentimes in civilian practice, you will have more isolated severe fractures, such as calcaneus or pilon fractures, whereas in the military the fractures would be in combination (for example comminuted calcaneus, talus and tibia fractures coupled with spine injuries and possible closed head injuries). The severity of these fractures often led to posttraumatic arthritis in active young patients.
The onset of arthritis at such a young age caused an interesting dilemma. In most patients with arthritis of the foot or ankle, total ankle arthroplasty or fusions are usually a good option; however, these patients are often much older and less active. In the military population of active young patients with the same severity of post-traumatic arthritis, fusions are usually the only option. The decreased mobility of the ankle or foot after fusion often led to the inability to run which many of the soldiers equated to their full recovery, i.e., “being healed.” Since they were not able to run, and having seen their buddies with amputations being able to run, caused a high number of delayed amputations, approximately 15 percent.
TOA: Foot and ankle is one of your specialties. What are some of the most exciting advances in foot and ankle that you have witnessed over the past few years?
- IDEO brace see above
- Total ankle arthroplasty- The improvement in the quality and design of the implants has steadily improved over the last several years, which has allowed for more patients to benefit from the technology. I have seen an increasing request by my patients for this procedure to allow for maintenance of ankle motion rather than the restricted motion of a fusion. With the improved designs, the implant survival rate has steadily improved (still not as good as TKA/THA) to where most patients can expect the implant to survive 10 years or greater. In appropriately selected patients, the implant can last their lifetime. As more of TAR being performed, it has also led to advances in revision procedures that are now able to be performed instead of resorting to a fusion procedure.
- Cartiva- implant arthroplasty- Arthritis of the big toe can be quite disabling. Prior to the Cartiva implant most patients would require fusion of the toe joint if they had extensive arthritis. This allows for the motion to be maintained and good long term results with improved pain. Most of the published literature demonstrates a greater than 90 percent improvement with follow-up greater than five years.
TOA: You have taken a particular interest in osteoporosis.
Kevin Kirk: This may take a while … I attended the American Orthopaedic Association Meeting in Boston while I was a resident and walked into an Own the Bone Symposium. I really did not know much about osteoporosis and why orthopedic surgeons would be interested in this topic. I did not think much more about it during my time in the military since most patients were younger and injuries were mainly due to war trauma.
After my retirement from the Army in 2013, I took a job at Rutgers/University Orthopedic Associates in New Jersey where they had a robust osteoporosis screening and secondary fracture prevention program. I started to rekindle my interest in the Own the Bone program/osteoporosis and secondary fracture prevention.
From my deployment experiences, you returned changed and want to serve your patients better and have better treatment of diseases. I felt that this would be my way to make a lasting impact on my community and hospital system. So when I returned to join The San Antonio Orthopaedic Group in 2014, there were only a few surgeons ordering Dexa scans or referring for osteoporosis care. I saw the opportunity to develop a program within our group and within the Baptist Healthcare System. At the time I started to take general orthopaedic call as well and really saw the impact of osteoporosis and geriatric fractures.
According to the National Osteoporosis Foundation, an estimated 10 million adults in the US have osteoporosis and over 43 million have low bone mass. Osteoporosis is a silent disease often resulting in fractures from ground level falls so a patient doesn’t know that they have a problem until they fracture. Over 1 million fractures occur annually, which is a much higher annual incidence than new strokes, heart attacks or breast cancer combined. Once a patient fractures, there is a 30 percent mortality rate within the first year, and 50 percent typically do not return to their prior level of ambulation/function.
As orthopaedic surgeons, we would typically treat the fracture and never treat the underlying cause. Thereby the patient would be at a 40 percent risk of another fracture within the year following if the osteoporosis is left untreated. As orthopaedic surgeons we are the “tip of the spear” when it comes to identifying fractures related to poor bone quality. It is with those facts, I petitioned our TSAOG Executive Committee to start a secondary fracture prevention program.
I currently supervise the nurse practitioner for our Bone Health Institute, and her volume has steadily increased since starting the program. In addition, I have become the physician champion for the Own the Bone/ Secondary Fracture Prevention program at Mission Trail Baptist Hospital on the southside of San Antonio. We are currently in the process of seeking Joint Commission credentialing as a certified Osteoporosis/ Fragility Fracture program. My hope is that we can serve a model for the other programs within our system and duplicate the program at other facilities within the Baptist System.
TOA: Why do you think it is important for orthopaedic surgeons to engage in the public policy process with organizations like TOA and AAOS?
Kevin Kirk: If you are not at the table you are on the table: Physicians and surgeons are reluctant leaders. I think that it is critical that surgeons to remain active in organized medicine to assist policymakers with decisions that affect our patients and their care. We are the frontline of healthcare and truly understand the needs of our patients and the impact policy decisions can have on the delivery of that care. Therefore, we need to be at the table.
Mil Med. 2010 Dec;175(12):1027-9.
Prevalence of late amputations during the current conflicts in Afghanistan and Iraq.
Stinner DJ1, Burns TC, Kirk KL, Scoville CR, Ficke JR, Hsu JR; Late Amputation Study Team.
After identifying this as a problem, since this rate was three times greater than civilian trauma patients, our group set out to find a solution. The solution was the Intrepid Dynamic Exoskeleton Orthosis (IDEO). This innovative orthosis allowed patients with fused ankle to return to running and helped decrease the late amputation rate.
Comparative effect of orthosis design on functional performance.
Patzkowski JC, Blanck RV, Owens JG, Wilken JM, Kirk KL, Wenke JC, Hsu JR; Skeletal Trauma Research Consortium.
J Bone Joint Surg Am. 2012 Mar 21;94(6):507-15.
Management of posttraumatic osteoarthritis with an integrated orthotic and rehabilitation initiative.
Patzkowski JC, Owens JG, Blanck RV, Kirk KL, Hsu JR; Skeletal Trauma Research Consortium.
J Am Acad Orthop Surg. 2012;20 Suppl 1:S48-53
Can an integrated orthotic and rehabilitation program decrease pain and improve function after lower extremity trauma?
Bedigrew KM, Patzkowski JC, Wilken JM, Owens JG, Blanck RV, Stinner DJ, Kirk KL, Hsu JR; Skeletal Trauma Research Consortium (STReC).
Clin Orthop Relat Res. 2014 Oct;472(10):3017-25
Fortunately the success of the IDEO has translated to the civilian side and now is commercially available through Hangar Prosthetics as the Exosym brace. In fact, I have been able to get this type of brace for Workers’ Compensation patients with good results. It is actually a part of the ODG for Worker’s Comp. Well, that is all I have to say about that!