New Study Looks at Osteonecrotic Cell Interactions…and much more

New Study Looks at Osteonecrotic Cell Interactions

What is happening at a cellular level in a normal hip versus a hip with osteonecrosis? It’s a relatively unexplored question, until now. Thomas Vail, M.D. is Professor and Chairman of the Department of Orthopaedic Surgery at the University of California, San Francisco (UCSF). “We are doing some basic science work here at UCSF with a team of clinicians, developmental biologists, and engineers where we are looking closely at cell interactions and local tissue environment in osteonecrosis of the femoral head. This research takes a new perspective on this condition and the factors that have made it so difficulty to treat. The work is particularly exciting because osteonecrosis affects many young people and has devastating consequences on hip health…and it remains an unsolved problem. Using the seed funding we recently acquired from a generous individual, we will begin to test our hypotheses about cell interactions that would distinguish what’s happening at a cellular level in an osteonecrotic hip as opposed to normal cell healing that we see in fractures. We’ll be asking, ‘What are the differences in terms of gene expression?’ and ‘Are there other ways we can test cell response to loading and injury in the femoral head?’ The results of this work will lead us in directions that would then be potentially applicable to clinical trials.”

“We are hypothesizing that there is a disruption in cell signaling such that the cells are not responding normally to mechanical stresses in the hip joint. Under normal conditions mechanical stresses are really important to healing and remodeling. We are seeing in the femoral head that the cellular response to mechanical stress is abnormal and leads to deterioration or loss of spherical shape of hip. Our team believes that there are certain pathways within the cell where signaling protein[s] aren’t produced or recognized as they are in other conditions. My ultimate hope is that this work will lead us to cell-based therapies for this condition.”

Double or Single Row Rotator Cuff Repair

It seems that the issue of whether to use a double or single row repair for the rotator cuff won’t be resolved any time soon. But we can get a sense of the trend. Peter Millett, M.D., M.Sc. is director of Shoulder Surgery at The Steadman Clinic in Vail, Colorado. “I recently attended the American Academy of Orthopaedic Surgeons/American Orthopaedic Society for Sports Medicine winter meeting in Park City, Utah. The shoulder section contained a good discussion about the rotator cuff; when we surveyed the audience we found that the vast majority of participants indicated that they favored double row repair. This, despite the results of a recent randomized controlled trial that showed better healing rates with double row repairs but no differences in clinical outcomes. At this point we’re waiting for more clinical research. In the meantime, many opinion leaders are airing their thoughts and experiences in a blog discussion on VuMedi.com.”

“The principles of tendon repair have not changed: a low tension repair with multiple points of fixation is desirable. This minimizes the force per unit area of the rotator cuff tendon. The goal is to holds things in place ‘long enough and strong enough’ so that the tendon can heal. Many of my colleagues and I believe that double row is biomechanically stronger and anatomically better than single row. We believe that this will result in better clinical outcomes, although, to date, clinical studies haven’t borne that out. Sample sizes have been small, however, and follow ups have been short. Larger, longer term studies are needed.”

“At this meeting there was also quite a bit of interest in the controversy over whether to immobilize patients after rotator cuff surgery or to get them up and moving early. Kevin Wilk, D.P.T. was there and he is a real expert in this arena. He feels strongly that we should try to move patients as early as we can so as to prevent deconditioning and facilitate healing; I tend to agree with him. Basic science studies suggest that tendon loading improves healing and movement of the tendon is helpful for healing. The reason this is controversial is because of studies that suggested immobilization resulted in lower re-tear rates. We have to consider, however, that if we can improve initial repair strength when fixing the rotator cuff, then we can probably move them earlier which should hasten healing.”

Cartilage Transplant for Younger Shoulder Patients

Your average 32 year old with arthritis isn’t going to be amenable to a shoulder replacement. Fortunately, there is a new surgical option. Reuben Gobezie, M.D. is the director of the Cleveland Shoulder Institute. He tells OTW about his work with a new cartilage transplant procedure. “When a young person has arthritis they typically don’t want a shoulder replacement. With this arthroscopic procedure, I take a fresh cadaver graft (no more than 28 days deceased), cut the cartilage out of the graft, and transplant it to the shoulder. This technique, which is completely different from anything else in shoulder, involves drilling a hole through the arm and putting the instruments together inside the shoulder. It’s challenging, but an experienced arthroscopist can do it. At this point we are closer to two year minimum follow up data; so far, the data show that the procedure is a success for the majority of patients.”

“However, there are issues that I didn’t appreciate at the outset of the project, namely that the technical details of sizing the grafts are important. To optimize the outcomes you must pay attention to the size of graft…placing smaller grafts into patients with large bones does appear to significantly affect the outcome of the procedure. Interestingly, the results thus far are much worse in worker’s compensation patients. If you only focus on the objective criterion of range of motion, strength, and imaging, they look identical to the patients who do well…but when you ask the worker’s compensation patients about pain and satisfaction they will often report marked pain even though their range of motion has improved and higher dissatisfaction. We will soon be submitting this work—a first in the field—to a major journal.”

R. Michael Meneghini, M.D. Named “Top Emerging Leader”

The Indiana University School of Medicine has announced that Michael Meneghini, M.D. has “been chosen as one of the top emerging leaders among orthopedic surgeons.” A selection committee of orthopedic experts and key opinion leaders voted on the best up and coming talent within the field. Dr. Meneghini’s accomplishments have awarded him a spot among the top 40 winners. Dr. Meneghini and the other 39 winners will be honored at the “Leaders in Total Joint Replacement: Generation Next” Reception on March 20, 2013 at the Trump International Hotel Tower in Chicago, Illinois. There will be leaders in joint replacement and orthopedics attending to celebrate the “next era of clinical excellence.” Poster displays will highlight selected physicians’ techniques and technologies that contributed to their success.

Francis Y. Lee, M.D., Ph.D. Awarded Fourth R01

Francis Y. Lee, M.D., Ph.D., Professor of Orthopaedic Surgery, Vice-Chairman for Research and Director of the Center for Orthopaedic Research at Columbia University Medical Center, has received a $1.7 million award from the National Institute of Arthritis & Musculoskeletal & Skin Diseases. This award represents a five-year competitive renewal of Dr. Lee’s second R01 grant, “ERK Signaling in Inflammatory Bone Loss.”

Dr. Lee’s long-term goals for this project are to develop new pharmacologic methods for preserving and enhancing bone mass that will address the future needs of the increasing elderly population. Other research projects are focused on the development of novel therapeutic strategies that will enhance bone health, regulate bone loss, prevent cancer spread to bone and improve orthopedic implant integration and healing. Dr. Lee specializes in bone tumors, soft tissue sarcomas, metastatic bone cancers, and pediatric orthopedic disorders. He serves as both researcher and mentor to students, postdoctoral fellows, residents and junior faculty internally and nationally through AAOS/ORS/OREF mentoring programs.