$293, 000 for Nanotechnology Rotator Cuff Repair
A researcher from Marshall University, Dr. Jingwei Xie, has been awarded a $293, 000 grant from the National Institutes of Health (NIH) to lead a project to develop a technique that may improve surgical repair of rotator cuff injuries. Dr. Xie, a senior scientist at the Marshall Institute for Interdisciplinary Research (MIIR), is an expert in bone growth and development.
He and his team will be working with Dr. Franklin D. Shuler, associate professor and vice chair of research in the Department of Orthopaedic Surgery at the university’s Joan C. Edwards School of Medicine. Dr. Xie told OTW:
“We will be combining principles of engineering and biomedicine to construct a new type of biological device that will better mimic an uninjured tendon-to-bone attachment, which will ultimately mean improved healing.
Attaching tendon to bone is very similar to asking somebody to attach a mop to a wall—a very difficult task. This project is using a scaffold produced with nanotechnology that mimics the native tendon-to-bone insertion site. By combining a nanofiber scaffold with adipose-derived stem cells, we can address the common failures after surgical rotator cuff repair.
This tissue engineering approach is attempting to better mimic the native tendon-to-bone insertion site and has the capability to be biologically tailored to improve and direct the tissue repair.”
Asked for details on the tissue engineering, Dr. Xie commented to OTW:
“The ultimate goal of tissue engineering is to use a combination of cells, engineered materials, and suitable biochemical and physical cues to restore, maintain or improve biological functions of damaged tissues or organs.
This work combines the use of nanofiber scaffolds and adipose stem cells to improve the success rate of rotator cuff injury repair. Overall, this project will last for three years. We will develop nanofiber scaffolds in two years and will test the performance in a rat rotator cuff injury model in the third year. We anticipate that the biological devices will be tested in large animals in the next 3-5 years and clinical trials will be performed in 5-10 years.
One of the challenges is to fabricate nanofiber scaffolds which can closely mimic the composition, structure and function (mechanical properties) of tendon-to-bone insertion site. We have demonstrated expertise in this area with several peer-reviewed manuscripts, book chapters and national presentations. This work could generate an alternative and improved tissue engineering approach, augmenting tendon-to-bone insertion repair, as the failure rate for the current surgical treatment ranges from 20-90%. By addressing this problem with nanotechnology, we are able to improve the transfer of mechanical loads through the reparative tissue, improving the healing response and decreasing the risk of repair failure.”
Six Year Residency Model: Coming to a School Near You?
If you want to improve operative decision making and independence amongst your trainees, you might consider the training model out of Brown University. At the request of Brown’s program director (and study co-author) Christopher DiGiovanni, M.D., Alan Daniels, M.D. recently undertook an assessment of the university’s orthopedic surgery residency program, which includes a mandatory trauma fellowship during the PGY6 (post-graduate year 6), and is one of the few orthopedic programs in the country that requires a sixth year of training. The trauma fellowship year at Brown provides trainees with the opportunity to provide care for orthopedic trauma patients as attending surgeons, with support and supervision from senior attending staff.
Dr. Daniels, himself a graduate of the Brown program, told OTW,
“While we have received positive anecdotal feedback about the sixth year, we wanted to perform a more critical assessment of the program. When the program started, it was the only six-year orthopedic program in the U.S. with a mandatory trauma fellowship year following the traditional five-year residency. The idea is catching on now, however, and others have recently implemented similar six-year orthopedic training programs.
To perform this study, we obtained a list of every graduate from the program since its inception; the trauma fellowship year began in 1995 so we gathered data from graduates from then until 2012. We developed the survey in conjunction with the Graduate Medical Education office at Rhode Island hospital, distributed it to all 69 graduates, and were able to achieve a 100% response rate.
We found a very high level satisfaction with this year. Over 75% said that they would choose to complete the PGY6 year if they had to do residency again; we think this says a lot given that at this point they have been in training for so long. Also, over 70% of respondents said that they would recommend the six-year trauma fellowship training model to individuals entering training today. We also looked at the responses of graduates who trained before the ACGME (Accreditation Council for Graduate Medical Education) work hour restrictions and those who trained with those restrictions; we found that those who trained with work hour restrictions were more likely to rank the sixth year as highly valuable. Most of those who said that they wouldn’t recommend the program were those who trained before the work hour restrictions were in place. We think that this model may become an increasingly popular trend, possibly in part because of increasing work hour and supervisory restrictions during residency training.
Over 85% of respondents indicated that this year improved their operative decision making, operative skills and independence, confidence with complex cases, complication management, as well as their ability to understand documentation/coding as compared to graduates of traditional five-year training programs. The caveat to a successful training program like the Brown Orthopaedic six-year program is that an institution deciding to implement such as program must have sufficient supervision and support. The trauma fellowship year must be supported by knowledgeable and supportive mentors like we have at Brown.”
Rotator Cuff News From Penn Orthopedics Lab
Louis J. Soslowsky, Ph.D. is the director of McKay Orthopaedic Research Laboratory at the University of Pennsylvania. Dr. Soslowsky, who is also the director of the Penn Center for Musculoskeletal Disorders, told OTW:
“We are currently working on an NIH-funded study where we are trying to understand when one should operate on a rotator cuff tear and the effects of that choice on the whole joint.
There is a lot of decision making associated with someone who has a rotator cuff tendon tear, i.e., can that person go back to his job if it involves repetitive use or overhead work. Our research employs an established rat model. In one aspect of the study, in one group of animals we made a supraspinatus tear and sent the animal back to a low level activity; in the other group we made the same tear and sent them back to a high level of activity.
We found that animals in both groups had the same ability (same function) for use of the limb; but in the group that returned to overuse activity there was damage to the glenoid cartilage and the long head of the biceps tendon. This shows that we must look at the whole joint and not just the one tissue being treated.
This is particularly important since, in humans, we would never know about this associated joint damage until many years later when the person needed a joint replacement or other significant surgery. This grant also asks a question related to whether the shoulder joint can get injured simply due to overuse alone or if disruption of force couple/balance across the joint was necessary.
In contrasting two groups—one where the supraspinatus was torn and the other where the supraspinatus and the infraspinatus were torn, we evaluated joint function and associated tissue damage. We found significant damage to the joint; not only was there a difference in functional ability but there were detrimental changes in the cartilage and in the subscapularis tendon, demonstrating the importance of force balance across the joint.
It is important to remember that even if it’s a supraspinatus-only tear, it may not need repair and people can function at an acceptable level; however, in those cases, it should be noted that you are doing damage to the other tissues which may be unacceptable.”
Foot, Ankle Patients More Neurotic
Is foot pain really just foot pain? Or is it mixed with psychosocial issues? This is what researchers from Wirral University Hospitals NHS Trust in the UK set out to learn. Simon R. Platt, F.R.C.S., a co-author on the study, told OTW,
“We were interested in other factors or influences that may affect an individual’s response to chronic foot pain. Much of this has been looked at in general health surveys. We wanted to know whether the fact that an individual may have chronic foot pain may be reflected or have bearing on validated psychological scoring tests. We found that patients with chronic foot and ankle pain had significantly higher neuroticism scores than the control group. It was surprising to see such a significant difference in the anxiety and depression scores as compared to a matched population.
We think that the high scores in depression and anxiety should give orthopaedic surgeons a clue as to how individuals are affected by chronic foot pain. The study unfortunately cannot say with certainty what personality traits orthopaedic surgeons should be on the lookout for. It raises awareness however that other factors may be contributing to pain.”
Asked about a situation that an orthopedic surgeon might find him or herself in, Dr. Platt noted, “A hypothetical challenging situation would be in a patient with chronic foot pain with paucity of clinical findings would be determining the precise and specific cause of the pain. The decision making process in such patients is critical. The decision to operate may not be the optimum choice due to the influence of other factors. We are hoping that further work in this field may give surgeons and patients help with judgment in making such decisions.”
