William D. Bugbee, M.D. Wins Kappa Delta Award
William D. Bugbee, M.D. and his team at the University of California, San Diego have been honored with the prestigious Kappa Delta Award for their 15 years of research on osteochondral allograft (OCA) transplantation. Dr. Bugbee, an Attending Orthopedic Surgeon at the Scripps Clinic and Director of the Adult Reconstruction Fellowship and of the Cartilage Transplant Program, worked with colleagues Andrea Pallante-Kichura, Ph.D., Simon Görtz, M.D., Robert Sah, M.D., Sc.D., and David Amiel, Ph.D.
Dr. Bugbee and his team have done such extensive work on OCA that they have transformed the landscape of the field. He tells OTW, “For many years we have conducted basic science and clinical research on the use of osteochondral allograft for cartilage defects and joint injuries. Fifteen years ago this procedure was rarely used…there were less than 30 cases done in the U.S. in the 1990s. Then in the mid 1990s when cartilage repair became popular we thought that this could be applicable to other situations such as organ transplant. The first thing we looked at was how best to store the tissue recovered from donors. Our work on chondrocyte viability has directly led to an increased supply of fresh OCA and allowed osteochondral allografting to expand outside the universe of specialized university centers. Years later there are a number of tissue banks that can collect, test, and distribute it…and these days there are about 3, 000 of these surgeries done annually in the U.S.”
“Originally, we didn’t have much information on the biology of what happened to transplanted tissue. Then, we developed a goat model, did a transplant and looked at the tissue a year later to study all aspects of bone healing and cartilage repair. We found that preserving chondrocyte viability during graft insertion is critical to the long-term efficacy of the repair.
“Finally, we also evaluated clinical outcomes, something made easier by the fact that we have data on every patient we have ever worked on. We assessed the outcomes of different diagnoses (arthritis, osteonecrosis, osteochondritis dissecans, trauma, traumatic cartilage injury) and looked at things such as patient characteristics, size of graft, etc. Success rates varied, with fresh OCA being a reasonable option for osteonecrosis and an excellent option for treating osteochondritis dissecans.” The great majority of patients got better with allograft surgery, often in situations where many other surgeries were unsuccessful.
“It is phenomenal to receive the Kappa Delta Award. We will be thrilled to receive the award in Las Vegas!”
Dr. Bugbee and his team will be presented with the award at the 2015 AAOS meeting in Las Vegas (March 24-28).
Dual Mobility THA Design Lessens Dislocation Risk
With 485 primary hips and NO dislocations…Geoffrey H. Westrich, M.D., Professor of Clinical Orthopaedic Surgery and Director of Research for the Adult Reconstruction and Joint Replacement Service at Hospital for Special Surgery (HSS), was principal investigator on a study that is turning heads.
He tells OTW, “Although total hip replacement is one of the most life changing operations performed by orthopedic surgeons, there are occasionally serious complications such as dislocation. The literature reveals approximately a 2% dislocation rate, meaning that 1 out of 50 patients can have a dislocation in which the hip pops out. When it does, it can usually be put back in without surgery under sedation. If the hip stays in then the patients tends to be fine. The problem is that once the hip has popped out then there is a greater risk for future dislocations.”
“This is very anxiety producing for the patient as they continuously worry if, when, and where it will pop out again…and it’s painful! On the payment side, it is a significant cost to the healthcare system, in part because a third of those who dislocate will need further surgery and postop care.”
“There are designs that reduce or eliminate dislocation; this dual mobility design was originally popularized in France by Guy Bousquet, who combined two types of arthroplasties and came up with dual mobility design concept. His long term data—out to 25 years—reveals that he had NO dislocations. They did have other issues because these hips were done 25 years ago using first generation plastic and cup fixation was poor. Now companies have created modern, state of the art dual mobility hip designs. The most common design used in the U.S. is manufactured by Stryker. The engineers took all of the positive elements of the Bousquet design and combined them with modern American technology (cup fixation) and the latest, third generation polyethylene. This poly has been shown to have virtually no wear when tested in hip simulators.”
“These cups are much more stable because of the larger diameter of the ball. The tinier the ball, the easier it is for it to pop out of the hip, because it has a smaller jump distance. I have eliminated dislocations in my patients by using these cups. I have asked other surgeons around the U.S. who are using this prosthesis, and they are saying the same thing. Our study included five institutions and 485 primary hips in 452 patients. We had a two year minimum follow-up; after two years none of the 485 hips had dislocated. And in all previous studies done looking at dislocation, 70% of dislocations occur within the first year.”
“I just got an email from a French surgeon who has been using them in patients under 55, something that we are starting to do more in the U.S. Our end goal used to be pain relief, but now that’s a given. People want to go back to their yoga and zumba classes, etc. In the past we would have to tell them, ‘No, don’t do that. You will dislocate.’ With dual mobility cups we can offer patients more freedom in their postop activities without pain.”
Note: Dr. Westrich is a consultant for Stryker Orthopedics.
Galatz on Rotator Cuff Repairs: Initial Strength Is Critical
Leesa M. Galatz, M.D. is a Professor of Orthopedic Surgery and Chief of the Shoulder and Elbow Service at Washington University School of Medicine in St. Louis. She tells OTW, “At present I am utilizing a grant from the NIH [National Institutes of Health] to establish and study a model of chronic rotator cuff disease. A lot of animal models don’t resemble what we see clinically as they involve an acute injury and repair, but our rat model of chronic tears and repair should elucidate information about a common clinical condition. Most rotator cuff tears are degenerative. We are creating massive tears…tendon injuries that resemble what we see clinically. Then to drive the rotator cuff into a degenerative state, we are administering Botox to cause muscle atrophy.”
“We did find differences between acute and chronic repairs in terms of the biomechanical properties. The healing tissue was less organized histologically; we also saw a difference in bone. Botox should not affect bone, but we saw bone loss, greater in the setting of chronic tears compared to the acute injuries and repair. When we affected the muscle in that way, we increased muscle and bone loss. In order to address bone loss, we may be able to use an antibody called sclerostin. We are currently studying this in the setting of rotator cuff repair.”
“The most surprising thing was that the initial repair strength made a difference regardless whether tear was acute or chronic. If there is gapping at the repair site because the repair wasn’t strong enough, then it decreased the properties of the repair (chronic or acute). So it is important to have adequate initial strength, to minimize motion at the bone-tendon interface, and to minimize gapping…and these are especially important with large tears.”
