“Jimmy” Andrews Breaks Ground on New Institute in Texas
Famed orthopedic surgeon James Andrews, M.D. hauled a few shovels of dirt on November 6 in order to celebrate the opening of the Children’s Health Andrews Institute for Orthopedics & Sports Medicine. Dr. Andrews told OTW, “The Children’s Health in Dallas, Texas has a boutique hospital in Plano that is a general children’s facility. They decided they wanted to develop an orthopaedic section, particularly to get involved with youth sports medicine. There are some two million children in the Dallas area and a high percentage are active in youth sports. Such activity brings with it an epidemic of youth sports injuries. They contacted me and asked if I would help develop a sports medicine complex at the Plano facility in the Dallas area. That came to fruition, and we had the groundbreaking for the Children’s Health Andrews Institute last Friday.”
“The vision for the facility is to provide a first-class treatment facility for injuries in youth sports at all levels, and to become a national leader in research and education for the prevention of injuries in youth sports.”
“The reason that I am involved in this project is primarily because of my passion for the prevention of injuries in youth sports. The Children’s Health of Dallas is going to provide a research and education foundation at the facility in Plano to conduct research which would improve the prevention of youth sports injuries as well as provide an educational platform for prevention at the grassroots level.”
“It appears that we have 100% cooperation with the parent organizations which will make a difference with prevention—not only locally, but nationally. Children’s Health have become a collaborative partner with our national initiative which is entitled, ‘The STOP Program’ (Stop Trauma and Overuse Prevention in Youth Sports). STOP is an initiative which is led by the American Orthopaedic Society for Sports Medicine. I am very excited about this opportunity and I think we can make a difference, not only in that region, but nationally, due to the backing of the Children’s Health program in Dallas.”
Fewer Falls, Reduced LOS With Bupivacaine Liposome!
With the groundswell of attention on opioid problems in the orthopedic realm, it is timely that new research has found an alternative. Richard Iorio, M.D., professor of orthopaedic surgery at NYU School of Medicine, was lead author on a study comparing bupivacaine liposome and femoral nerve blocks after total knee arthroplasty (TKA). Dr. Iorio tells OTW, “Liposomal bupivacaine has been highly controversial because it is expensive and because the FDA reprimanded the manufacturer for claiming that the length of action was 72 hours rather than a demonstration of 48 hours for bunionectomy and hemorrhoidectomy. The manufacturer was reprimanded for making claims related to non-investigated procedures as well.”
“Our study found that this drug resulted in a shorter length of stay [LOS], a lower 30-day all-cause re-admission rate, a reduced inpatient fall rate, and an increased rate of discharge to home. Specifically, we were able to show a meaningful increase in patient milestones such as walking 100 feet sooner and climbing stairs sooner than those who received femoral nerve blocks. Even the decreased amount of narcotic use was statistically significant.”
“When you do femoral nerve blocks with a catheter it knocks out the femoral nerve and thus the patient has poor motor and sensory functioning. When you use liposomal bupivacaine without a femoral nerve block then there is no motor weakness and the person can get up and walk on the same day of surgery. At our institution we were able to completely stop using femoral nerve blocks in total knee replacement patients.”
“While some studies have shown negative results with this drug, they are comparing them against conventional local anesthesia, which is not long acting. And in my opinion, if you don’t do any injection correctly then of course you will have equal results. If the doctor exits the OR and leaves the injection to the trainees then you are not likely to see a benefit. We need a non-conflicted prospective randomized study. I am conservative with regard to implementing new paradigms, but this is a winner and we are not going back to femoral nerve blocks.”
“My recommendation is that if you choose to use liposomal bupivacaine, then study the technique with someone who is experienced with these injections. You need small aliquots, a small gauge needle, and small amounts in contiguous areas. It doesn’t diffuse as much as a local anesthesia, so if you have large globs of the drug in different areas then you will get large, numb areas, but no continuous pain relief throughout wound. If you don’t study the technique with someone who knows what they are doing then you will have wasted time and money.”
Articulation DOESN’T Cause Wear?
Researchers from the University of Delaware wanted to know why the cartilage in our joints doesn’t deflate over the course of days, months or years. Their answer? Movement. David Burris, Ph.D., an assistant professor in the Mechanical Engineering Department at the University of Delaware, led the research.
Dr. Burris told OTW, “From biphasic modeling, we know that cartilage loses fluid during loading over time, but in-vivo measurements show that although this is true in static conditions, articulation actually drives fluid back into the tissue. The community has not understood this mechanism and given the importance of the fluid in the tissue for mechanical and biological function, we felt this was an absolutely critical scientific question to answer. To date the only hypotheses have been that migration limits time in contact and articulation exposes the contact to the bath, which enable it to imbibe fluid to recover. We were shocked to find the same recovery mechanism others observe in the natural joint in a contact that did not involve migration and bath exposure. The results suggest that hydrodynamic pressure develops during articulation, but instead of creating fluid films as described in biomechanics textbooks, these external pressures combat the exudation process associated with interstitial pressurization. We believe this ‘tribiological rehydration’ mechanism is critical for sustaining joint function and health and can be leveraged to provide unprecedented control in cartilage studies while maintaining physiological fluid pressures.”
“Firstly, the results contradict the conventional wisdom that articulation causes wear. The mechanism we propose based on our results suggest that the mechanical intensity felt by the solid is far less when active than when inactive. It suggests that obesity, inactivity, and low amplitude oscillations are more damaging mechanically than normal activity. In other words, we expect recommendations of 10, 000 steps per day to also benefit joint health (in addition to cardiovascular, etc.).”
“Secondly, most textbooks focus on lubrication during articulation and suggest that fluid films are responsible for exceptionally low friction and wear. The problem with this mental model is that it fails to address how our joints deal with static conditions in which there are no fluid films. This is critical since our joints are static ~95% of the time. Our research suggests that the joint excels because it is designed specifically to address inactivity. Cartilage acts as a buffer to the inevitable ‘crash landing’ when motion stops. The extremely slow exudation process ensures negligible losses of lubrication over ~1 hour of inactivity. When activity resumes, this buffer is quickly refilled to prepare cartilage for the next crash landing. Joint replacement devices do not possess such a buffer and therefore experience the full brunt of the crash landing, poor lubrication, surface damage, wear, and the biological consequences thereof. If we want reliable joint replacement devices, we must stop striving to create fluid films during articulation at all cost and start focusing on mitigating stresses and damage during long periods of static loading; we need to leverage the interstitial lubrication that nature exploits so effectively.”
Asked what kind of movement might be best and why, Dr. Burris commented to OTW, “Static conditions are the enemy in my opinion and cartilage deals with them effectively for long periods when cartilage is fully hydrated. High speeds, light loads and longer distances maximize rehydration after static exudation and are therefore the most effective way to prepare the joint for subsequent inactivity. I believe this is one reason OA [osteoarthritis] correlates so strongly with inactivity and weight. Unloaded or deloaded articulation would drastically accelerate the rehydration process; once the buffer is full, any additional input would create fluid films
