Future of major orthopedic surgery remains bright, thanks to research

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Rheumawire

Mar 11, 2004

Future of major orthopedic surgery remains bright, thanks to research

San Francisco, CA - Thanks to groundbreaking orthopedic research, the

future of many orthopedic procedures looks extraordinarily bright, say

experts from the Orthopaedic Research Society (ORS) [1]. They were

speaking at a press conference on the last day of the ORS annual

meeting, which always overlaps with the first day of the American

Association of Orthopaedic Surgeons meeting, and marking the 50th

anniversary of the foundation of the ORS.

" Without the orthopedic research that has been conducted over the past

50 years, treatments that are now considered usual would have otherwise

been unavailable, and patients' quality of life would not be what it is

today, " says Dr D Boden (Emory Orthopedics and Spine Center

Atlanta, GA).

Spine fusion

In the past, patients would be told that there was nothing that could be

done for this problem, or they may have undergone a lumbar spine fusion

to unite the 2 bones together and eliminate motion in the painful

segment of the spine. This surgery could take up to 5 hours, required a

large incision on the abdomen and stomach, a long hospital stay spanning

2 weeks or more, and as much as a 25% chance that the bone graft would

not heal.

Today, minimally invasively techniques allow for smaller incisions, less

blood loss, and faster recovery time, Boden says. " There have been the

development and refinement of metal plates, screws, rods, and cages as

well as the discovery of bone morphogenetic proteins that has allowed

for the commercial production of pure recombinant proteins and can

replace the need for bone-graft harvest, decrease pain after surgery,

and improve the chances of bone healing to more than 97% on the first

try, " he says.

Fifty years from now, Boden predicts that disc replacement will be an

alternative to spinal fusion. Moreover, gene therapy will be able to

prevent or reverse disc degeneration and genetic research will help

discover genetic sources of back pain, he says.

Anterior cruciate ligament reconstruction

There are 150 000 to 200 000 anterior cruciate ligament (ACL)

reconstructive procedures performed yearly in the US, says Dr Jo A

Hannafin (Institute for Sports Medicine Research New York, NY).

Fifty years ago, she says, the function of the ACL was poorly understood

and reconstruction was not available, so athletes were urged not to go

back to their sports.

But " we have come a long way in the past 25 years using arthroscopy and

minimally invasive graft harvest techniques, a number of graft choices

including patellar and hamstrings, and numerous techniques for

graft-bone fixation, " she says.

However, the future lies in prevention, Hannafin says. " There will be

widespread implementation of ACL injury-prevention programs in early

childhood, " she says. Within the next 10 years, there will be prevention

programs in high schools and colleges as well as large-scale studies

examining the effectiveness of these programs, she predicts.

For those who have sustained an ACL injury, " there will be better ways

to repair it, either with gene therapy, tissue engineering of a ligament

replacement graft, or improved biologic incorporation and healing of a

donor graft. "

Ewing's sarcoma

While rare, this bone cancer is malignant and aggressive, says Dr Steve

Goldstein (University of Michigan, Ann Arbor). Fifty years ago, a

Ewing's sarcoma patient would likely undergo amputation or possibly

radiation to the thigh, only to die within months when the cancer spread

to the lungs.

Fortunately the prognosis is now much less grim, he says. Now, doctors

can detect the cancer much earlier and give chemotherapy to reduce the

size of the tumor and its potential to spread, leading to an increase in

survival from 5% to 80%, Goldstein says.

Other key advances include " limb-sparing procedures such as the use of

large allografts and devices, metal and ceramic, to reconstruct the

limb, so individuals can have some quality of life, " he says.

On the horizon is " the use of genomic and proleomic markers that

identify the existence of cancer cells earlier in their development as

well as cell-specific therapies that seek out and kill cancer cells, " he

says.

Osteoporosis

Fifty years ago, " we could not diagnose osteoporosis, but we can now

diagnose it with dual x-ray energy absorptiometry, " says Dr Puzas

(University of Rochester School of Medicine, MN).

We also could not treat it 50 years ago, he says. " But today we have

lifestyle and nutritional [therapies] related to calcium and vitamin D,

as well as the identification of antiresorptive agents to stop bone

erosion, including the bisphosphonates; estrogen and its analogs;

calcitonin; and another medication that deals with osteoporosis from the

bone formation side by stimulating new bone formation (the recombinant

parathyroid hormone product teriparatide [Forteo®, Lilly]). "

" In a few years, there will be new antiresorptive agents with no side

effects and novel stimulators of bone formation to rescue the lady who

has lost so much bone she is at a very high risk of fracture, " he

predicts.

In addition, " estrogen will be off the table except in very specific

cases, " he predicts.

Total hip replacement

" Fifty years ago, there were few viable options for patients with

end-stage arthritis of the hip beside resection arthroplasty arthrodesis

(fusion) or partial replacement of the joint, " says Dr Stuart Goodman

(Stanford University, CA).

He points out that total hip replacements were first performed by

England's Sir Charnley during the early 1960s but have been

perfected over the years.

It is now " one of the most successful and cost-effective procedures in

all of surgerynot just orthopedic surgery, " he says.

Today, patients are usually fully ambulatory without aids within several

months and the replacement lasts 15 years or more, he says.

Other total hip-replacement surgery advances include prevention of

infection using aseptic technique and prophylactic antibiotics; advances

in prosthetic design for both primary and revision surgeries; and

advances in choice of materials for joint replacement, including

superalloys of cobalt chrome and titanium, composites,

alternative-bearing surfaces including highly cross-linked polyethylene,

metal-on-metal, ceramics, and diamondlike coatings, he says.

When asked what the best materials are, he says, " there are many

different materials for total joint replacement that are biocompatible,

and polyethylene is still a very good material. "

When it comes to the cement issue, Goodman says that there is no right

or wrong answer and he does both cement and cementless procedures.

" In younger patients with excellent bone stock, on the femoral side, I

go cementless, but in an older patient we cement the femoral side, " he

says.

Former surgical patient/martial-arts instructor Ted Sumner is a walking

example of the progress.

Prior to his first hip replacement, Sumner says that he had to teach

martial arts sitting down. After his primary surgery, he was able to

spend more time on his feet but still had pain on his right side and

took up to 2000 mg of ibuprofen each day.

After undergoing revision surgery several years later, he now says, " I

don't have any pain to speak of. I can sit, I can sleepwhereas before I

would sleep an hour at a time before I woke upand I can walk pain free. "

Goodman adds, " In the future it, is likely that we will identify and

treat arthritis at an earlier stage to prevent progression. " But " when

necessary, future joint replacements will probably be less invasive

operations using more biocompatible materials that will allow the

patient to be more active without excessive wear of the joint surfaces, "

he says, adding, " The ultimate aim is to devise a joint replacement that

will last the patient's lifetime and allow full normal function. "

Mann

Source

1. Orthopaedic Research Society. Presentation: Press conference. San

Francisco, CA: Orthopaedic Research Society: 50th annual meeting; March

7-10, 2004:NA.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org