The American Academy of Orthopaedic Surgeons - 74th Annual Meeting was held in San Diego, February 14-18, 2007. The following is a briefing of some of the articles presented at the conference.
Gene Therapy and Tissue Engineering: Tomorrow is Today
San Diego, CA
Gene therapy and tissue engineering conjure up thoughts of futuristic science fiction. But this biotechnology is developing rapidly and could be at your nearby orthopaedic surgeon’s surgical suite before you know it, according to Regis O’Keefe, MD, Ph.D., Professor of Orthopaedics with the University of Rochester Medical Center in New York State and spokesperson for the American Academy of Orthopaedic Surgeons and “Gene therapy using stem cells is a lot closer to clinical use in orthopaedics than most people think,” said Dr. O’Keefe. “These tissue engineered products could be on the market in five to ten years.”
“Gene Therapy and Tissue Engineering” will be presented at a media briefing to be held at the 74th Annual Meeting of the American Academy of Orthopaedic Surgeons at the San Diego Convention Center on February 14, 2007 at 9:30 a.m. in Room 23C. Regis O’Keefe, MD, Ph.D., will be joined by Johnny Huard, Ph.D. and Steven A. Goldstein, Ph.D., Research Professor, Henry Ruppenthal Family Professor of Orthopaedic Surgery and Bioengineering, Professor of Orthopaedic Surgery at The University of Michigan Medical School., Ann Arbor, MI.
The goal of tissue engineering is to create living tissue to replace or repair diseased tissue. Tissue engineered products for orthopaedics, may facilitate repair or serve as a “functional replacement”. There are countless applications in orthopaedics –replacement for bone, cartilage, muscle and ligament loss and to increase or promote bone formation in spinal fusions and with some fractures. Biological approaches are being used to improve muscle healing for sports injuries including menisci and ligament injuries.
Researchers have found that muscle stem cells are more plentiful than bone marrow stem cells, for example. “Muscle cells have emerged as promising vehicles for gene therapy and tissue engineering in the musculoskeletal system,” said Johnny Huard, Ph.D., Associate Professor in the Departments of Orthopaedic Surgery, Molecular Genetics and Biochemistry, Bioengineering, and Pathology at the University of Pittsburgh School of Medicine, and is also the Director of the Stem Cell Research Center at Children's Hospital of Pittsburgh. One study showed that 95% of muscle stem cells were incorporated into the bone.
O’Keefe points out that the #1 reason that people go to the doctor is for issues with the musculoskeletal system. In a society where many “baby boomers” expect to stay active longer with a high quality of life, physical fitness has become a priority. “A person cannot be fit from a cardiovascular and pulmonary standpoint without having a musculoskeletal system that is healthy and can support increased activity,” added Dr. O’Keefe. “There is a tremendous opportunity to use tissue engineering for osteoporosis, osteoarthritis and bone repair to help keep that musculoskeletal system in good condition.”
Allowing Children to Grow while Treating Chest and Spine Deformities
San Diego, CA
Orthopaedic surgeons are optimistic about recent improvements in operative treatment of very young children suffering from scoliosis severe enough to consider surgery, even for those under the age of five years. For decades, spinal fusion surgery has been the prescription for severe scoliosis. The significant drawback of early fusion is that growth of the spine stops and this, in turn, interferes with the development of the lungs and chest cavity.
“Scoliosis surgeons are exploring opportunities to treat a child’s chest and spine to allow continued growth,” reports B. Stephens Richards, MD, moderator of a media briefing on scoliosis treatment advances on Friday, February 16 at the Academy’s 74th Annual Meeting. “Although the majority of scoliosis surgical patients present in early adolescence when spinal growth is no longer an issue, there are some very young children with severe deformities who need surgery but also need to maintain growth potential of the spine.”
Fusion involves inserting a series of rods, hooks and screws to straighten the spine. Side effects, in addition to cessation of growth, may include increased stress on the unfused segments which could lead to the need for more surgery as an adult.
Several surgical options give today’s very young patients brighter prospects than earlier generations. One technique includes the use of “growing” rods attached to the spine that are increased in length at least twice per year to guide straighter growth. Another technique expands the chest cavity in children with missing or fused ribs, thus providing an opportunity for better lung development. A third evolving procedure uses staples in the convex side of a spinal curvature which allows growth to potentially straighten the spine.
Scoliosis is a condition of side-to-side spinal curves, and affects about two percent of the population. Bracing is the standard treatment for less severe patients, generally in adolescence, with scoliotic curves between 25 and 40 degrees.
No More Ugly Orthopaedic Shoes!
San Diego, CA
Remember the kid in your class who had to wear those ugly orthopaedic shoes? Worse yet, perhaps you were that child. Those days are long gone as is the understanding of what flatfoot is and how to fix it. It was once thought that the bony architecture of the foot could be changed with shoes or positioning a bar between the shoes to hold the feet in the “correct” position. Research has shown that assumption is not true. Great strides have been made in understanding and treating flatfoot.
People with flat feet lack the proper “arch” in the foot. If a child or adult is not experiencing any pain, having difficulty walking or wearing shoes, treatment may not be required.
If the foot becomes painful and/or it becomes difficult to wear shoes, some type of treatment is appropriate. Patients may even experience back, hip, or knee pain related to their flatfeet. According to Steven L. Haddad, MD, an orthopaedic surgeon with the Illinois Bone and Joint Institute, Ltd. and a spokesperson for the American Academy of Orthopaedic Surgeons, conservative treatment works for a large percentage of those with flatfeet. “Many patients do very well in an athletic-type shoe with an orthotic.” Conservative treatment is used almost exclusively with children, though some children with severe flatfeet require surgical reconstruction to improve their quality of life.
Haddad cautions that not all adult patients with flatfoot experience foot pain. “Sometimes a patient presents with lower back pain, or pain in the hip, leg, knee or ankle.” It is the lack of an arch in the foot that causes the foot to roll inward. This pronation causes the person’s gait to change, which can then produce problems elsewhere in the body or locally within the foot itself. Pain refractory to conservative care (i.e. orthotics, physical therapy, and medication) is the indication for surgical reconstruction of a flatfoot. If you are experiencing these symptoms, it is important to seek the advice of an orthopaedic surgeon.
Acquired flatfoot (those who are not born with a flatfoot) may be the consequence of a traumatic injury to the ankle, according to Dr. Haddad. “Adults can rupture or injury their posterior tibial tendon, which if the primary tendon supporting the arch. This can be the result of sports that require “pivoting” – like soccer or football, and are often mistaken for a severe ankle sprain. This type of trauma can lead to a flatfoot deformity in up to 25% of all acquired flatfoot patients.”
Haddad admits that this type of injury is hard to prevent. If there is a congenital abnormality, a fracture or dislocation, torn or stretched tendons, or degenerative or systemic conditions, surgery maybe indicated for persistent pain and/or significant deformity from acquired flatfoot.
The treatment of rotator cuff disease
San Diego, CA
The treatment of rotator cuff disease has gone “arthroscopic”. For years, the treatment of torn and ruptured rotator cuffs required “open surgeries” -- large incisions so the surgeon could visualize the area to be repaired. Then came the use of arthroscope – revolutionizing rotator cuff surgeries. The orthopaedic surgeon could use two small incisions. The device, with a small camera on the end, was inserted through one of the incisions. This allowed the surgeon to get a clear view of the injured area, magnified on a screen. Gone was the pain from an open surgery, longer hospitalization and recovery time.
All is not well though, according to Jon “JP” Warner, MD, director of The Harvard Shoulder Service, based at the Massachusetts General Hospital and the Brigham and Women's Hospital and spokesperson for the American Academy of Orthopaedic Surgeons. “There is an ‘elephant in the room’ that no one wants to talk about. A large portion of my practice is fixing failed surgeries. I am increasingly concerned that the demand, from patients, for arthroscopic surgery is driving this trend. Not all cases are suited for this type of surgery. There is an epidemic of rotator cuff problems with ‘baby boomers’. They want arthroscopic surgery on an outpatient basis so they can get back to work the next day. As surgeons, we want to meet our patients’ requests. It’s a challenging situation.”
This controversy and other issues related to rotator cuff disease will be discussed by an international panel in a media briefing, “Topics in Rotator Cuff Disease”, at the Academy’s Annual Meeting to be held at the San Diego Convention Center on February 16, 2007 at 3:45 p.m. in Room 23C of the convention center. Dr. Warner believes that assembling an international group allows orthopaedic surgeons in this country to learn from their colleagues who have other types of health care systems and often less bureaucracy. Unlike the United States, information can be disseminated much more rapidly. “The Europeans, in particular, bring ‘heat and light’ to this discussion.”
Damage Control Orthopaedics: Patient Stabilization, Early Mobilization
San Diego, CA
Severe orthopaedic trauma care has advanced beyond the Golden Hour - the first 60 minutes after injury – with new techniques to allow some delay while more critical injuries are treated.
Nirmal C. Tejwani, MD, moderator of a symposium on this subject at the 74th Annual Meeting of the American Academy of Orthopaedic Surgeons, comments that, “Damage control orthopaedics allows delaying the definitive orthopaedic treatment to a time when the patient’s overall condition is stabilized. External fixators can be used quickly to temporarily stabilize fractures. This approach allows time for patients to improve and for soft tissues around the fracture to partially heal.”
The changing face of trauma includes new ways of treating trauma in the elderly, the obese and among those patients who suffer high-energy fractures.
The energy of an injury is related to mass times velocity squared; high energy injuries involve a large mass, such as motor vehicles or high velocity like high speed crashes and gunshots. Minimally invasive techniques for use in trauma patients has lessened the large exposures previously needed. Locking plate and screws allows more secure fracture fixation and early mobilization in the elderly. This is a crucial improvement because the elderly often are unable to keep weight off a broken leg or use crutches. Early mobilization prevents problems associated with prolonged bed rest, helping to prevent pressure sores, pulmonary problems and blood clots (DVT).
Recovering from trauma takes time. Dr. Tejwani advises, “The biggest misconception about fractures is the length of recovery time. Fractures generally take 12 weeks to heal and most patients are unable to resume normal activities or sports participation for three to six months.”
Women’s Sports Injuries: It’s Not Just the Hormones
San Diego, CA
The long-held belief that women have more sports injuries than men because of the difference in hormones is just not true. Hormones certainly play a role according to orthopaedic surgeon Kimberly J. Templeton, MD, spokesperson for the American Academy of Orthopaedic Surgeons and Associate Professor with the University of Kansas Medical Center, Department of Orthopedics. “There is definitely input from the hormones but there are other musculoskeletal differences between men and women.”
Dr. Templeton points out how men land differently than women after taking that basketball shot. “Men flex their hips and knees when they land. Women tend to land with their hips and knees straight – causing increased tension on the ACL. That’s one of the reasons why women have more ACL (“anterior cruciate ligament’) injuries than do men.” Templeton points out that these types of injuries can be “career enders” to young female athletes and may lead to an increased risk of degenerative arthritis later in life, so it is critically important for girls to understand what they need to do to stay healthy. There are very specific neuromuscular training programs that have been shown to reduce the incidence of serious knee injuries. Templeton advises parents to work with their daughter’s coaches – particularly ones who understand the differences in training for girls vs. boys.
Neuromuscular training programs are now being introduced in the schools so young female athletes can learn the right way to land, among other things, and protect themselves from serious injury. According to a study conducted by Timothy E. Hewett, Ph.D., comprehensive neuromuscular training is effective in improving measures of both performance and lower extremity biomechanics in adolescent female athletes.
Dr. Templeton also underscores the importance of girls understanding bone health. There is a common misconception that a woman protects herself from osteoporosis only by engaging in weight bearing exercise. Dr. Templeton encourages her patients to participate in weight-bearing exercise and to lift weights but cautions that exercise must be balanced with enough calories and nutrition. She emphasizes that, “Engaging in weight bearing exercise without adequate calories and nutrition doesn’t do anything for systemic bone mass.”
Without a balanced diet with enough calories, including adequate amounts of Vitamin D and calcium, girls and women run an increased risk of injury. Templeton also helps her patients learn the right way to lift weights for to gain maximum benefit and to minimize injuries.
Technology Helps Surgeons Get Near-Perfect Knee Implant Alignment
San Diego, CA
Using image-guided technology, orthopaedic surgeons are able to align knee implants with near pinpoint accuracy. For patients undergoing total knee arthroplasty, close to perfect alignment should translate into longer durability of joint replacements, according to a renowned panel of orthopaedic surgeons who discussed advancements in computer-assisted total knee replacement (TKR) surgery at the 74th Annual Meeting of the American Academy of Orthopaedic Surgeons.
Approximately 300,000 knee replacement surgeries are performed each year in the United States. Standard knee replacements require the use of an intramedullary (IM) rod, which is inserted up the length of the femur to determine proper knee implant alignment. No IM rod is necessary for the computer-assisted approach, reducing the risk of fat embolization, a complication that can cause acute respiratory distress. The quality and accuracy of the image guidance may enable surgeons to use smaller incisions while achieving the same successful outcomes.
“Computer assisted total knee arthroplasty surgery is making rapid progress,” said Dr. Daniel J. Berry, professor and chairman of Orthopedics at the Mayo Clinic in Rochester, Minnesota. “Contemporary methods of computer-assisted surgery now have been proven to provide a high level of accuracy in experienced hands. Current efforts are focused on making the process simpler, more efficient, and more cost effective. As these methods evolve, it seems likely some form of computer assistance will eventually become a routine part of total knee arthroplasty,” Dr. Berry said.
Computer-assisted TKR involves extra time and additional difficulty because it still is in its infancy. As the power of the technology and techniques become more established, it will become a more common procedure and an option for more surgeons and patients.
Training Technique Offers New Hope for Female Athletes
San Diego, CA
In the past 30 years, there has been an explosion in the number of girls and women participating in all types of sports. There has been a 10-fold increase in high school and 5-fold increase in collegiate sports. With this massive upsurge comes a disturbing trend – a much higher incidence of injuries for female athletes when compared to boys and men playing at the same level of sports.
Studies have shown that girls and women have a four to six times higher incidence of ACL (“anterior cruciate ligament”) injuries than their male counterparts. This can have a devastating impact on the female athlete including being sidelined for the season, loss of scholarships, a decrease in scholastic performance and a 100 times greater chance of being diagnosed with osteoarthritis. Some put the total cost of health care upwards of $625 million.
“Pivoting” and “cutting” sports – such as basketball and soccer -- put female athletes at greater risk of ACL injuries. Many theories have been forwarded for this disparity. They have ranged from hormonal differences between females and males to women landing with more inward collapse of the knees – putting undue stress on the ACL.
Various solutions have been proposed including plyometrics (high-intensity jump training) and technique training. According to Timothy E. Hewett, Ph.D., director of the Cincinnati Children’s Hospital Sports Medicine Biodynamics Center and spokesperson for the American Academy of Orthopaedic Surgeons, “Both strength and balance training are potentially effective but only as an adjunct to these other types of training.”
Hewett found that the reason for these serious injuries was how well the female athlete “controlled” her landing. Dr. Hewett conducted a meta-analysis of six studies on “neuromuscular training” to prevent ACL injuries. He found that all the studies advocated use of this method.
In a six-week pre-season neuromuscular training intervention program performed three times a week (60 to 90 minute sessions), the rate of non-contact ACL injuries decreased 72%. All of the studies supported combining different types of neuromuscular training to prevent injuries and enhance performance.
Another important component of neuromuscular training is having a coach or trainer analyze an athlete’s movements and provide feedback on proper position of the body and her technique. This type of feedback helps the athlete “feel” the proper positions and moves she should be making. In the Hewett study, they asked a trainer to work with the athlete so she could develop an awareness of her movements and make modifications when indicated. A strong neuromuscular program is multi-faceted. Hewett recommends using several different programs. “Off-season and pre-season conditioning programs are critical to preventing these types of injuries. A program needs to combine high intensity jumping exercises and movement, resistance, speed and balance training as well as core strengthening.”
With more than 29,000 members, the American Academy of Orthopaedic Surgeons is the premier not-for-profit organization that provides education programs for orthopaedic surgeons and allied health professionals, champions the interests of patients and advances the highest quality of musculoskeletal health. Orthopaedic surgeons and the Academy are the authoritative sources of information for patients and the general public on musculoskeletal conditions, treatments and related issues. An advocate for improved care, the Academy is participating in the Bone and Joint Decade - the global initiative in the years 2002-20011 - to raise awareness of musculoskeletal health, stimulate research and improve people's quality of life.