Today, he’s an orthopedic surgeon with Novant Health Orthopedics & Sports Medicine in Lexington and Thomasville, North Carolina. Looking back, he can’t help but see all the similarities between his dad’s work and his.
“A worn-out joint replacement in a car and in the body are pretty similar,” he said. “The instrumentation and the tools are pretty similar – drills, saws, screwdrivers. Some of the instruments I use now are even made by the same manufacturers that make tools for cars.”
An orthopedic operating room can even sound like an auto repair shop. Power tools – loud ones – are being used in both places.
In both a body shop and an orthopedic OR, things are getting repaired. The work is, paradoxically, noisy and messy – but also precise and delicate.
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Pierce takes on straightforward cases, but he’s also a special breed of orthopedic surgeon who’s built a subspecialty in the field of revision surgery. “Revision surgery is different than primary total knee replacement,” according to the American Academy of Orthopedic Surgeons (AAOS). “It is a longer, more complex procedure that requires extensive planning and specialized implants and tools to achieve a good result.”
In the most complex revision surgeries, “all three components — femoral, tibial and patellar — need to be removed or replaced and the bone around the knee needs to be rebuilt with augments (metal pieces that substitute for missing bone) or bone graft,” according to the AAOS.
Started as a teacher of kids facing challenges
It was when Pierce joined his hometown volunteer rescue squad, made up of EMTs and paramedics, in high school that he discovered he “loved being able to provide comfort to people who’d been injured.” He said being a high school member of the squad wasn’t all that unusual in Midlothian and that it was this experience that led him to know orthopedics was his calling.
But he didn’t go straight to medical school after college. He taught seventh and 12th grades as a member of Teach For America for two years before entering med school.
He taught at a charter school in Houston where students were from underserved neighborhoods. “About a third didn’t have any English speakers at home,” Pierce said. “Many of them – when they came to middle school as sixth graders – didn’t speak any English themselves. What goes on during the school day is one thing, but then there’s a whole other aspect that happens at home. These kids were seeing their parents deported and having to live with extended family. It’s a very difficult situation for them.”
Just as Pierce sees similarities in auto mechanics and orthopedic surgery, he seems them in teaching and medicine, too.
“You realize that, in order to make someone successful, you need a unified partnership,” he said. “It takes more than school. You need to help with the social aspects of students’ lives, as well. It’s something you also see in medicine. No matter how well things go in the OR, I’m no help on the outside once the patient gets home. People need to be set up for success at home whether they’re young students or adults who’ve had orthopedic surgery.”
What no patient wants to consider – revision surgery
Ever the teacher, Pierce makes sure patients know what to expect and have the information they need for a smooth recovery. That’s a key part of the job. Because Pierce specializes in revision surgery, he’s often operating on people whose first surgeries didn’t heal properly – or failed years later.
It’s not that surgeons are doing anything wrong to warrant those revisions. It’s purely a numbers game, Pierce said. “There are nearly a million knee replacements in this country every year – and that number is growing. (There were nearly 2.4 million hip and knee replacements in 2021.) Since 2% of those can be expected to become infected, we’re talking about 20,000 every year. With that much volume, there are a lot of infections that can occur.”
Infection is often a possibility after surgery. But there are other potential problems down the road in joint replacement. “After two years, the most common cause of revision surgery is loosening,” Pierce said. “And once they become loose, they don’t become unloose. They continue to get looser and cause bone loss, which can be painful.”
Why might implants become loose? Doctors aren’t sure. Pierce said doctors once thought that more active patients and younger patients were putting more stress on the implant, but recent studies don’t support that.
Then there are patients who are doing well but have further trauma such as a car accident that may cause an implant to loosen.
Another reason is something called osteolysis, or bone degeneration. There’s a type of osteolysis that can occur as a complication of joint replacement surgery. Occasionally, polyethylene or another material in a joint implant can wear down, leading to debris accumulating in the surrounding joint tissue.
Many patients are reluctant to have joint replacement surgery – and Pierce doesn’t blame them. But patients who need a revision are generally quicker to jump to surgery because they know what to expect. “When we talk infection or loosening, we’re talking about conditions that are not going to get better,” he said. “Those patients are more apt to want to pursue surgery.”
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Bring on the tough casesDr. Paul Lichstein, another orthopedic surgeon who specializes in revision surgery (but at Novant Health Orthopedics & Sports Medicine in Salisbury), recruited Pierce. When tasked with recruiting another revision surgeon, he contacted the program director from the fellowship he’d done at Harvard Medical School, who immediately recommended Pierce, who was a current fellow at the time.
“When we met, I thought: He’s exactly what we’re looking for,” Lichstein said. For one thing, Pierce was ready to return to small-town life. He enjoys practicing medicine in Lexington and Thomasville, where he’s one of the few surgeons fellowship trained in arthroplasty, the surgical procedure that restores joint function. “Folks are on a first-name basis here,” he said. “That’s not something you get at a larger hospital.”
Lichstein, too, is right where he wants to be. “I grew up in a small town and like the feeling of a small town,” he said. “They don’t need more of what I do in Boston or San Francisco or another big city. They need more of what I do here and in other small towns.”
In talking about Pierce and the subspecialty they share, Lichstein said, “There are people who derive satisfaction and pride from taking on tough challenges. It takes a certain mentality, a certain personality. We deal with a lot of adversity – revision surgeries can be difficult, and the outcomes may not always be excellent. Dan was … ready for that.”
Lichstein has never met another orthopedic surgeon who once worked as a mechanic – but he does see the similarities. “It’s a very dexterous thing we do,” Lichstein said. “There’s also a very important concept of 3-D interpretation. You have to be able to think about things in three dimensions. There are similarities with both carpentry and with mechanics, but there’s a certain artistry to what we do, too.”
‘Not just a single episode of care’
While they both like a challenge, neither doctor is a glutton for punishment. “It’s not like I enjoy a beatdown,” Lichstein said. “I just like doing really hard things. The gratification that comes from those successes is unlike anything else. Dr. Pierce and I are kindred spirits in that way.”
Their love of revision surgery goes deeper than the thrill of the challenge. “Dan and I both appreciate the incredible relationships we can develop with our patients,” Lichstein said. “It’s not just a single episode of care. We develop lifelong relationships with some patients. You become friends, partners in seeking a solution. Revision patients require a great deal of thought, planning and interdisciplinary care. We might involve infectious disease colleagues, oncology, internal medicine, hematology. Orthopedics isn’t isolating. It’s a field that allows you to make connections with patients and other clinicians.”
“There’s nothing more gratifying than finding a solution to a really bad problem after a patient’s long, hard climb,” Lichstein added. “The most rewarding endeavors are the ones that are the most challenging.”