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Bankart Repair Questioned for Certain Young Athletes // Stem Cells for Cartilage Defects // and More!

Elizabeth Hofheinz, M.P.H., M.Ed. • Wed, September 23rd, 2015

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Bankart Repair Insufficient for Young Athletes With Repeated Instability

Arthroscopic surgery is an effective treatment for many patients with anterior shoulder instability, however it doesn’t always meet the needs of younger, high risk athletes. Dr. Frank Cordasco, an attending orthopedic surgeon in the Sports Medicine and Shoulder Service at the Hospital for Special Surgery (HSS) and Professor of Orthopaedic Surgery at Weill Cornell Medical College, has co-authored a review article on open versus arthroscopic repair for anterior shoulder instability. He commented to OTW, “Historically, we have moved towards the less invasive arthroscopic stabilization (Bankart Repair) for anterior shoulder instability. While that has worked well in the population at large, young athletes who experience more than two or three episodes of instability are at higher risk for failure following arthroscopic Bankart Repair.”

Dr. Cordasco, the co-medical director of the Leon Root, M.D. Motion Analysis Laboratory, noted, “When a 17 year old high school football player comes to see me after he has already had three dislocations then I am going to be more concerned about bone loss. With each repeated instability episode there is the potential for bone loss from the anterior/inferior glenoid or posterolateral humeral head. Surgeons need to lower the threshold for considering bone loss; plain radiographs alone are often not sufficient to analyze bone deficiencies.

A CT scan with 3-D reconstruction and an en face view with the humerus subtracted can be very helpful at assessing the degree of antero-inferior glenoid bone loss. Recently, studies have shown that in so-called ‘bipolar lesions, ’ which are combined lesions of the glenoid and posterolateral humeral head, bone loss may be significant even with lesser degrees of deficiency because of the combined effect. If indeed the bone loss is significant then one should consider performing surgery to augment the bone. Because each instability episode is associated with progressive pathology and the potential need for more advanced reconstructions, there is a compelling reason to consider surgery following the first dislocation in younger athletes.”

“The menu of operations available to sports medicine and shoulder surgeons includes a spectrum of treatments, beginning with arthroscopic single-row labral repair, advanced arthroscopic techniques (including double-row labral repair and/or remplissage), open Bankart Repair and capsular reconstruction, and ending with bone augmentation techniques such as the latarjet reconstruction. The objective criteria and evidence regarding which operation should be selected in a given circumstance are in a process of evolution. This clinical problem is currently an area of intensive interest and research among academic sports medicine and shoulder surgeons.”

“My message is this: a single-row arthroscopic Bankart Repair, while the standard of care, may not be enough for younger athletes who have had additional instability events. At HSS we have found that if these young athletes have 3-5 episodes of instability then they are more likely to require advanced arthroscopic techniques, open capsulolabral repair or glenoid bone augmentation such as the latarjet reconstruction.”

Stem Cell Trial Showing Promise for Knee Cartilage Defects

What do you get when you implant immature mesenchymal stem cells (MSC) as an adjunct to microfracture in patients with knee damage? Thus far, success for cartilage defects of the knee joint. Brigham and Women’s Hospital (BWH) and Midwest Orthopaedics at Rush have a clinical trial underway involving 12 patients. Andreas Gomoll, M.D., is an orthopedic surgeon with BWH. He tells OTW, “This is an FDA Phase 2 trial that we have undertaken with a company in Korea. This company has a stem cell product that has been approved by the Korean equivalent of the FDA; these are allogeneic stem cells from maternal umbilical cord blood that are grown in culture. The stem cells are immature and they don’t have many antigens on their surface, meaning that there is little chance of a rejection reaction. Thus far, all 12 patients who are involved have shown no signs of complications.”

Brian Cole, M.D. is section head of the Cartilage Research and Restoration Center at Rush University Medical Center. He tells OTW, “The group in Korea had good initial results showing that the use of allogeneic stem cells led to better tissue repair than marrow stimulation alone. Allograft MSCs are appealing due to the absence of donor site morbidity and the ability to deliver a large number of cells that have been expanded in a controlled aseptic environment. Clinically, the way they look in the first few weeks is far better than our patients who receive marrow stimulation alone. Things are more ‘quiet’ posteroperatively with these patients than with the marrow stimulation patients, perhaps because of an antinociceptive or anti-inflammatory effect.”

Dr. Gomoll adds, “We are following the 12 patients clinically, with MRI and blood-work to rule out any immune response to the allogeneic cells. Early recovery is promising but final results of the study will not be published until the two year follow-up is complete. The company sponsor previously concluded a Phase 3 randomized trial with over 100 patients in Korea, and the product was subsequently approved and is currently being used in routine clinical practice there.”

“Dating Service” for Industry, Science

It’s a vast goal, but they have a myriad of talent involved. The Center for Disruptive Musculoskeletal Innovations (CDMI), led by Jeffrey Lotz, Ph.D. and Vijay Goel, Ph.D., aims to identify and address unmet needs in the musculoskeletal world. Jeffrey Lotz, Ph.D. is vice chair of Orthopaedic Research at the University of California, San Francisco (UCSF). He tells OTW, “I call it a ‘dating’ service for industry and science. The ‘backstory’ is that the National Science Foundation (NSF) already had an established model to facilitate university/industry collaboration whereby the fruits of those labors generated additional dollars to support graduate student training. Vijay Goel and I approached the NSF about creating such an initiative that would focus on bringing together industry and universities to assess the gaps in musculoskeletal science and medicine, and drive technology with clinical value to market. Healthcare reform and reimbursement trends dictate that industry carefully weighs evidence for how patient benefits compare to costs when considering investments in new technology. Unfortunately, this means that some promising technology may never reach the patient. And on the university side, traditional funding and promotion mechanisms encourage scientists to push the frontiers of basic science as opposed to refining existing concepts along a translational track. The CDMI strives to overcome these challenges by providing a structured environment for university faculty and industry to collaborate.”

“CDMI receives funding from the NSF to help cover the cost of administrative overhead. The bulk of the Center funds for research come via pooled contributions from our industry partners that have indirect costs capped at 10%. Potential conflicts between Center members is minimized through a focus on pre-competitive, industry-inspired fundamental research. We have a uniform membership agreement that addresses confidentiality and intellectual property issues. These features help overcome the inherent challenge of getting potential competing companies to identify shared values and identify projects of mutual benefit.”

“Our advisory board works collectively to define unmet needs and, based on that, a 5-10 year vision that becomes our research roadmap that faculty use to create new project ideas.”

“The CDMI recently held its Fall Symposium, an event that attracted executives from Depuy Spine, Orthofix, Eli Lily, NuVasive, K2M, Medtronic, Zimmer Biomet, and other companies. Twenty new project proposals were presented and discussed, proposals that represent the culmination of a six-month dialog between CDMI faculty and members of the Industrial Advisory Board (IAB) that started with over 90 project seed ideas triggered by the Center research roadmap. In addition, four other universities are in talks with the CDMI to join the center as new sites. New sites would add value to the IAB by bringing in new expertise and technologies.”

“Also, the CDMI has a partnership with the UCSF/Stanford Center of Excellence in Regulatory Science and Innovation (CERSI) to support a graduate student in residence at FDA to do data mining of 510(k) submissions so that we can develop better criteria for pre-submission thresholds for implant mechanical performance (What is a ‘good’ result? How good does it have to be?). The FDA and Industry would benefit from more clear-cut guidelines in this regard. We are analyzing the data in a blinded fashion and will eventually publish the standards and modeling approaches.”

“From the physician’s standpoint healthcare reform requires a better alignment between clinical data (on cost and value) and commercial market needs to help accelerate new discoveries to patient benefit. Industry can’t do that alone…they must have an ongoing, structured dialog with clinical and research faculty.”

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2 Responses to “Bankart Repair Questioned for Certain Young Athletes // Stem Cells for Cartilage Defects // and More!”

  1. Maranne Doyle-Laszlo says:

    Is there a clinical trial coming up for meniscus injuries/ stem cell therapy. Please let me know if there is. I’m interested….and in knee pain. Not wanting surgery. Thanks, M

    • Matt Ohlinger says:

      Did you ever receive a response3 to your question about clinical trials for meniscal injuries/

      I’d be interested to hear of any other studies being done

      Thanks, Matt

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