By Angelique Gammon
It’s quiet in the operating room, with only minimal exchanges between orthopedic surgeon J.P. Bramhall, M.D. and the anesthesiologist monitoring the 13-year-old undergoing labrum repair. Today’s surgery is remarkable only because it’s unusual to have such a significant tear in the ring of cartilage that surrounds the socket of the shoulder joint in a patient so young.
Most of the eyes in the OR are glued to the screen that provides a magnified view of Bramhall manipulating one of the tools of his trade – a series of probes and power tools inserted into the patient’s shoulder joint through a long narrow tube called an arthroscope. To the layman watching, the view on the screen looks like a rotary snow shaver skimming over ice as Bramhall moves with speed and precision to first detach the torn segment of the labrum and then smooth the surface so it can be reattached with three, 2.9mm anchors. With another tool he drills three holes in the socket bone. Bramhall fits a single anchor with suture, which looks very much like drywall anchors you might have laying around the house, onto the end of the tool, and guides them down the tube. With tiny grunts of effort, Bramhall in turn makes three “excellent” stabs placing each anchor in the bone. Change tools. A lesson in dexterity as Bramhall manipulates pincer-like extensions to tie perfect surgical knots in the sutures. It looks like tying square knots in fishing line with needle-nose pliers until you remember you’re watching this highly magnified process on a high-definition computer screen; in reality it’s happening inside a 13-year-old girl’s shoulder joint.
Around 16 minutes after the start of surgery, Bramhall steps away from the operating table as the nurse and anesthetist prepare the patient for the move to post-op. Before walking back to his office next door, Bramhall will stop in the Physician’s Center lobby waiting area to reassure the patient’s mother that everything went well. They discuss pain management and expected recovery over the next few days.
The mother’s words and smile convey both gratitude and relief.
A Place on the Team
As an orthopedic surgeon, Dr. J.P. Bramhall has spent his 26-year career in sports medicine helping patients get back in the game. Some of those patients will hear the roar of 100,000-plus fans when the Aggies charge onto Kyle Field in September. Others just want to get back in the game of life.
It’s been a full-circle path for Bramhall to his leading the team of physicians in charge of keeping Aggie athletes healthy and in top performance shape. A four-year baseball letterman for the Aggies from 1978-81 for Coach Tom Chandler, Bramhall went on to graduate from Texas A&M College of Medicine in 1985. He has been a team physician and orthopedic surgeon for the Aggies since he returned to Bryan/College Station to begin private practice in 1991. This season marks his 15th year as director of Sports Medicine for the Texas A&M Department of Athletics.
Like the athletes he cares for, Bramhall is competing at the top, where he says his role as team doctor has “exploded” over the past 26 years. “It used to be a couple of days a week with a couple of docs,” says Bramhall. “Now, there is ‘next day’ urgency on injuries,” says Bramhall, for parents, coaches, and athletes, especially with the NCAA rule of five years to complete four years of eligibility. “The recovery clock starts immediately.”
The fact Bramhall played college ball adds a dimension of trust with both players and coaches who look to him to keep careers and seasons on track, especially after an injury. “Our coaches are very supporting and trusting with safety of the athletes. There is a trust relationship; our experience goes a long way.
“A large part of the job is educating athletes about surgical recovery. They want ‘lightswitch’ treatment,” says Bramhall. “It’s tough to communicate the challenges of post-surgical recovery. These are Division I athletes — it’s survival of the fittest. They’ve had big success; it’s psychologically demanding.”
Bramhall gets it. Thirty-five years after he last suited up for the Aggies he says, “I still want to play.”
If it can’t be inside a baseball stadium, his patients are happy he’s still in the game with his partners at Central Texas Sports Medicine in Bryan. The six CTSM physicians combine their responsibility for maintaining the health of Aggie athletes with a private practice that cares for anyone who has suffered the slings and arrows of life: weekend warriors, high school athletes, aging jocks and those just aging.
With the start of the fall seasons, everyone’s schedule ramps up: Sunday afternoon post-game injury clinic and daily after-practice clinic for Texas A&M athletes. If Fridays include travel for the Aggies, the docs pack, too.
Elbows, Knees & Shoulders
Three months ago on a Wednesday morning in May, summer vacation was still merely a promise. Spring football had just ended, but Bramhall’s schedule was still full: morning clinic hours at CTSM, surgery after lunch, and athlete clinic at the training room outside Olsen Field starting at 4 p.m.
On this day, Bramhall will see 24 patients before he walks next door to the Physician’s Center where he will repair a torn labrum on a 13-year-old patient. His morning clinic patients are diverse and yet the same. Bramhall works on knees, elbows, and shoulders. Over the next three hours, his patients will include athletes from Tulane, Oklahoma State, and Stephen F. Austin universities. He will assess an Aggie tennis player whose knee has locked up in practice two weeks before the NCAAs and a Stephen F. Austin soccer player worried she may have reinjured the knee Bramhall has already put back together once. He also will see a police officer wrestling with whether to have surgery for a torn knee cartilage, a home builder with a torn triceps, and an accountant who has put off knee surgery until after tax season.
Injuries, it seems, have seasons, too. Or at least injury repairs have seasons. “Ranchers can’t have shoulder surgery in the winter; they have to throw hay,” says Bramhall. “Accountants wait until May.”
Whatever the path that brings them to Bramhall, the pathos is the same: something hurts; they are hoping Bramhall can fix it. A majority of patients seem to have a connection to Bramhall. Some have a family member or teammate who has been his patient. Another exclaims, “You just did surgery on my favorite prof!” Others have sought him out because of his success with high-level surgeries not performed by all orthopedic surgeons.
It’s 8:49 a.m. when Bramhall walks into the exam room of his first patient, a two-week follow-up after knee surgery.
“Any problems?” Bramhall inquires.
“Just pain,” replies the patient.
Bramhall nods. It’s the first, but far from the last, time he will hear this complaint today. After all, it’s a sports medicine practice, and he is a surgeon.
Bramhall reassures his patient that when rehab is complete, the pain should go away completely, and he outlines a safe return to activity over the next four weeks “adding more and more” exercise as strength returns. Bramhall pauses, and then adds, “Don’t pound it.”
The patient exclaims, “Did you hear that? He said I could run a marathon!”
Deadpan, Bramhall replies, “I did not say that.”
And so it goes. In each room, the patient outlines the complaint, and depending on the injury, Bramhall talks the patient through a series of diagnostic “drills:”
“Push out. Push. Go straight up and hold. Push up. You’re not going to like this … push up.”
After his years in practice, you sense Bramhall can tell what it is each patient needs to hear:
“Four weeks in a sling is non-negotiable.”
“You’re not going to like me very much for three months.”
“You’ll make progress for four weeks, then plateau, but you will make progress again after six weeks if you do the rehab.
To a high-school ACL repair he has just released from crutches: “Don’t be a typical high school kid. Stay in rehab; see me in two weeks.”
Today is a first visit for an 18-year-old Tulane pitching recruit who has torn a ligament in his elbow. He and his parents are upbeat during the exam, but everyone understands that a lifetime of hopes and dreams has been sidelined by this injury. They are looking to Bramhall to restore that hope.
After the “drills,” Bramhall opens a drawer saying, “Let me get an elbow,” as he pulls out an anatomical model. He talks them through how he proposes to graft a new tendon in place of the torn ulnar collateral ligament in the medial elbow, a procedure generally known as Tommy John surgery, named for the professional pitcher who came back to win more games after his surgical repair than he won before his injury.
Bramhall walks them through both the procedure and the rehab, explaining that the new tendon is a “triple strength fix” compared to the ligament that is torn. There are risks. Recovery takes effectively a year: after surgery, the player will be able to hit at three months; play another position at six months; and return to the mound — carefully — at nine months.
Bramhall suggests using the pitcher’s Palmaris Longis for the graft, a thin superficial flexor of the forearm that is an evolutionary leftover; it’s functionally more active in non-human primates. Not everyone in the population has a PL, in which case a segment of the patient’s hamstring is used for the graft.
Bramhall demonstrates: hold up your hand with the palm facing you and touch your thumb and pinky finger together. If you see a visible tendon in the center of your wrist, congratulations, you have PL should you need a tendon graft sometime in the future. The pitcher’s PL is “robust.”
Bramhall leaves the family to discuss possible surgery dates with his nurse, Kristi Crowson, R.N. Walking into the next exam room, Bramhall opens with, “What do you want to do about your knee?”
“I want to fix it,” says the accountant, noting that tax season is finally over. Her next deadline involves wanting to know when she will be able to return to water sports. “Three months,” says Bramhall, asking Kristi to step in and schedule the surgery.
The pitcher and his parents are ready to leave, having scheduled the Tommy John surgery for the end of the month. The dad asks if Bramhall performed the same surgery on Bramhall’s son, a former All American pitcher for Rice who went on to play in the pros. Bramhall shakes his head; “I should have.”
Bramhall’s son Bobby had the surgery twice, using both his hamstrings in the process, before he was released after two years from a Triple A club. Pathos.
For the rest of the morning, Bramhall moves between exam rooms and a two-sided island that bisects the clinic space.This is one of two, nine-room “pods” in the new offices of the CTSM practice. One pod houses orthopedic sports medicine; Bramhall shares the space with orthopedic surgeons Rick Seabolt, M.D., and Barry Solcher, M.D. In the second pod, primary care sports medicine doctors Laura Marsh, D.O.; James Distefano, D.O.; and Kory Gill, D.O., provide a variety of sub-specialties including health evaluations, musculoskeletal injuries, and concussion management. All six of the CTSM physicians are team physicians for Texas A&M Athletics.
Walking around the facility Bramhall helped design he points out ways the layout is meant to enhance patient care and experience including onsite MRIs, x-rays and a new lab for blood workups. The physical therapy office is double the size of his former office, but they have already outgrown the space. “I was pacing off the parking lot behind PT yesterday for an expansion,” says Bramhall.
One of the things Bramhall describes as most exciting about sports medicine is the advent of biologics, non-surgical therapies, including Platelet-Rich Plasma therapy and stem cell injections. With PRP therapy, platelets from the patient’s own blood are spun off to create a concentration that has been shown to promote healing when injected into injured tendons, ligaments, muscles and joints. Stem cells injections can promote healing using stem cells derived from full-term placentas and has shown some short-term benefit, says Bramhall, though the long-term benefits aren’t yet clear.
Soon it’s time for Bramhall to make the 45-second walk across the parking lot to the Physician’s Center for the one surgical case he has scheduled for the day. He will return to his office after surgery for paperwork that he fill outs while snacking on trail mix until it’s time to head to his next round of patients, this time at Texas A&M’s training room.
It’s a light spring day; fewer than a dozen athletes line the hall outside the training room. The clinic process starts over, but instead of parents or spouses, these athletes have trainers in tow, there to take note of any training changes recommended or follow-up care. A volleyball player hits the exam table with an exultant, “I’ve been waiting all semester for these babies!” as Bramhall prepares hyaluronic acid injections for both knees, a fluid that helps lubricate joints and can relieve pain. The next patient is less sanguine, leaving nail marks in her trainer’s fingers as Bramhall injects her shoulder joint. One athlete gets to toss his sling; the next is a pre-op visit for a knee scope the following day. The visits are quick; the athletes, and their doctor, know the drill. Everyone here is motivated to stay at the top of their game.
On A Personal Note
In 1995, at the request of the Texas A&M Large Animal Hospital, Bramhall successfully performed arthroscopic knee surgery on 275-pound African lion. In May 2013, Bramhall was inducted into the Texas High School Football Hall of Fame in recognition for his 22 years of work with high school coaches and trainers and Central Texas Sports Medicine’s Saturday morning clinics following Friday night football games. Bramhall and his wife Belle are active in the Bryan/College Station community. They have two children; Bobby is currently attending law school at the University of Tennessee, and Kaci works in the Houston area as an account executive for Bauerfeind USA.