Three Biomarkers Predict ACL Injury!…Too MUCH Patient Pressure to Use Biologics?…Genetic Breakthrough for Osteoarthritis…PRP—Sure It Works but What’s the Dosage?…HSS Does It Again: Garners #1 Spot in Orthopedics…Stanley L. James, M.D. Inducted into AOSSM Hall of Fame…and more.
Three Biomarkers Consistently Pre-Date ACL Injury!
U.S. Army Lt. Col. Steven J. Svoboda is this year’s winner of the O’Donoghue Sports Injury Research Award from the American Orthopaedic Society for Sports Medicine (AOSSM). His work, presented at the society’s recent annual meeting, is entitled, “The Association Between Serum Biomarkers of Cartilage Turnover and Subsequent Anterior Cruciate Ligament Rupture.” An orthopedic surgeon and head team doctor at West Point, Dr. Svoboda told OTW, “We measured pre-injury levels of four biomarkers of cartilage turnover and metabolism in 45 cadets with ACL injuries and 45 control subjects. Each control was matched to the injured subjects by height, sex, weight and age to see if there were differences. We were very surprised to find that three of the four serum biomarkers revealed measurable differences months or years prior to injury.”
“We can’t go as far as to say that biomarkers predict ACL tears; to do that we’d have to test the serum of everybody coming in and follow them for four years…then, once you have that data, go back and compare the pre-injury samples of the ones with ACL tears to the ones who never injured their ACL.”
“We had originally looked at this issue from the angle of post-traumatic OA [osteoarthritis], trying to see if there were changes in biomarkers of cartilage turnover after injury that may presage radiographic changes consistent with arthritis. In that case we could use the patient him or herself as the control because we had the pre-injury serum. We also used a cohort of ‘normals’ matched by age, sex, height, and weight. As they were all West Point cadets subject to similar physical requirements, the expectation was that they would be active—and that the matched samples at baseline pre-injury would have the same biomarker profile as those who went on to injury. We found that people who tore their ACL versus those who didn’t saw a different rate of change in their biomarkers over time.”
“Our results lead us to think that these seemingly normal people, in excellent physical condition, may have higher levels of these markers associated with cartilage turnover due to subtle biomechanical movement abnormalities. Further study including biomechanical analysis combined with biomarker analysis would be a good idea to prove a causal link. Our research team did get funding recently to prospectively follow a group of people on whom movement data will be collected and analyzed with their biomarker data.”
Genetic Breakthrough for Osteoarthritis
A team of researchers from Newcastle University in the UK has uncovered eight new genetic variants that seem to increase susceptibility to osteoarthritis (OA). Dr. John Loughlin’s team compared the genomes of more than 7, 400 people with severe hip and knee osteoarthritis with over 11, 000 unrelated controls from the UK. Dr. Loughlin, professor of musculoskeletal research at Newcastle University, told OTW, “We found that nucleostemin protein levels were substantially increased in cultured chondrocytes from patients with osteoarthritis, meaning that this gene might be important in understanding the pathogenesis of osteoarthritis. The first step on the road to prevention and treatment possibilities is to work out how the identified polymorphisms influence gene function or protein activity and where and when this happens (which tissues and at what point in development)…perhaps OA susceptibility is laid down early on and only becomes apparent as we age. We also have to acknowledge that there’s an awful lot of genetic susceptibility not yet identified, so it will be a while before we have anything approaching a complete picture of OA genetic risk. We will move forward with laboratory-based functional studies that will involve in-vitro studies as well as the use of patient tissues (collected at joint replacement), cell lines and animal models.”
PRP Dosing Questions and the Decline in the Double Bundle
John Kelly, M.D., associate professor of Clinical Orthopaedic Surgery at the University of Pennsylvania, was also on the scene at the recent AOSSM meeting. He told OTW, “There are an increasing number of papers demonstrating the basic science effects of platelet rich plasma (PRP). However, the jury is still out regarding the correct dosage for cuff repairs. I expect that in the next few years we will see emerging evidence that points us in the right direction as far as the best vehicle for PRP and the right dose. As for the vehicle, we are seeing some collagen scaffolds and matrices for rotator cuffs, but the results are mixed. For osteoarthritis it’s pretty simple: just do direct injections into the joint. You’re not going to grow new cartilage, but we may find that it helps to modulate inflammation.”
“On another note, it is interesting to see the downward trend in double bundle ACLs. They are technically difficult and the clinical advantage remains unclear. This is not a procedure that is going to appeal to John Q. Orthopod…there is a huge hassle factor involved. Instead we are moving more toward an anatomic, holistic ACL that respects the old graft.”
Too Much Patient Pressure to Use Biologics?
Peter J. Millett, M.D., M.Sc., director of Shoulder Surgery at the Steadman Clinic, in Vail, Colorado, is known for his work with elite athletes and weekend warriors. Dr. Millett told OTW, “The use of biologics to enhance healing—and the explosion of media attention—is certainly very exciting, but it is also getting us to the point where some of our patient-athletes are pressuring us to use the treatment…despite the lack of scientific evidence of its efficacy. This has led to an explosion of patient expectations and inquiries, something that has left orthopedic surgeons in a difficult spot. Insurance companies are reluctant to approve or pay for the use of biologics. Some physicians are doing it anyway and are just charging patients for the treatment. But in many cases the treatments remain what I consider to be experimental.”
“The FDA regulates some of these treatments, so quite a few are now being done outside the U.S. In these case we don’t know exactly what our patients are getting…there is also likely to be a placebo effect that enhances results. We need better collaboration amongst the pioneers who are introducing these treatments, the scientists who can tell us what’s in them, and the clinicians using them. There is enough safety data to show that many of the treatments are safe; now we need to pool outcome data and do more scientific studies to bring us closer to where we need to be.”
HSS Ranked Top Orthopedic Hospital…Again!
For the third year in a row, U.S. News & World Report has named Hospital for Special Surgery (HSS) the top hospital in the country for orthopedics. In addition to this honor, 52 physicians from Hospital for Special Surgery were recently named as some of the “Best Doctors” in New York City by New York magazine. In November 2011, the American Nurses Credentialing Center announced that Hospital for Special Surgery received its third Magnet designation. The New York State Department of Health also found that of the 167 hospitals in New York State that performed hip replacement/revision surgery in 2010, Hospital for Special Surgery was, for the third year in a row, the only hospital with a statistically lower rate of surgical site infection compared to the state average.
Anthony Rinella, M.D. Receives SRS Humanitarian Award
As of September, says the Scoliosis Research Society (SRS), Anthony Rinella will be the next recipient of its Walter P. Blount Humanitarian Award. Dr. Rinella, who is being recognized for his outstanding work with SpineHope (www.spinehope.org), a 501(c)(3) nonprofit organization that performs global outreach to indigent children with complex spinal deformities in South America, is on staff at Silver Cross Hospital in New Lenox, Illinois. Dr. Rinella is co-founder of SpineHope and to date has completed 16 week-long outreach trips. Through SpineHope and other nonprofits, he currently travels three to four weeks per year to treat the underserved, and sponsors young surgeons and ancillary staff using his own funds. Dr. Rinella attended medical school at the University of Illinois College of Medicine and completed his residency at Northwestern University. He then undertook a fellowship in adult and pediatric spinal surgery at Washington University in St. Louis with Drs. Bridwell, Lenke, and Riew.
Stanley L. James, M.D. Inducted into AOSSM Hall of Fame
Dr. Stanley James has joined the elite ranks of the American Orthopaedic Society for Sports Medicine’s (AOSSM) Hall of Fame. Directly after completing his undergraduate studies at Iowa, Dr. James—who would go on to become a founding member of the AOSSM—went on active duty as an army aviator, then returned to his home state to attend the University of Iowa Medical School. While completing his residency in orthopedic surgery at Iowa, Dr. James collaborated with exercise physiologist, Charles Tipton Ph.D. They studied the influence of exercise on ligament healing, finding that exercise actually enhanced ligament healing as opposed to immobilization, which was the standard of treatment at that time. Published in The American Journal of Physiology in 1970, the study was several years ahead of the curve when early motion following surgery became a standard of treatment. In the early 1970s, he collaborated with University of Oregon track coach, Bill Bowerman, co-founder of Nike, and was a member of Bowerman’s select think-tank for shoe design. He served as Medical Director for the U.S. Olympic Trials in 1976, 1980, and 2008, and is at present treating elite runners preparing for the 2012 Olympics.
