Aging Stem Cells Affect Rotator Cuff Healing? and More…

Aging Stem Cells Affect Rotator Cuff Healing? Cole’s New Cartilage, “X” That X-Ray! and More…

“X” That X-Ray

Sonia Chaudry, M.D. is a pediatric orthopedics fellow at Hospital for Sick Children in Toronto. She has recently published an article on the minimization of radiation exposure in orthopedics. Dr. Chaudry tells OTW, “Doctors are often quick to order studies such as CT scans and X-rays of limbs. There is often a medicolegal impetus to document anytime you touch or manipulate a patient in any way, and there used to be a dogma to do this radiographically with fractures even if they were stable. So for example if you adjust a cast you get a radiograph to make sure that the bone didn’t move. Or let’s say that you’ve put a cast on and the person comes back with an ulcer. Many would say, ‘You should have taken X-rays to show that the cast was well applied.’”

“We looked at almost 250 people that had stable fractures, i.e., those that don’t need to have the bone reset, but who were splinted while healing, and afterwards we found that none had moved. This gives physicians evidence based backing to forgo unnecessary X-rays without fear of medicolegal repercussions. This is rather groundbreaking, and I’m pleased to say that this has helped to change practice in my institution.”

SIGN of a Global Take on Fracture Care?

Recently, 150 surgeons, mostly from the developing world, attended the SIGN (Surgical Implant Generation Network) Fracture Care International Orthopaedic Surgical Implant Training Conference in Richland, Washington. Fifty of the surgeons attended the flap course and research course sponsored by the Institute for Global Orthopaedics and Traumatology at the University of California at San Francisco (UCSF). Lew Zirkle, M.D., founder of SIGN, told OTW, “We were so pleased to see an enthusiastic culture of collaboration amongst attendees. Attendees agreed upon the necessity of measuring results from the SIGN database by designing statistically significant clinical studies. We are, therefore, designing and implementing studies which examine stabilization in open fractures with the SIGN nail and by using silver dressings initially for open fractures. We are working with statisticians at the University of Washington and surgeons at UCSF. We expect more clinical studies will be designed.”

“The series of SIGN nailings presented by these surgeons substantiate my impression that they are as good as any in the world; they have excellent results, especially when it comes to putting the SIGN nail into infected bones. To date, the SIGN network has performed 105, 000 SIGN fracture surgeries worldwide. We are continuing to expand. We will visit our newest program in South Sudan where they have excellent surgeons but few implants and equipment. Then, on a visit to Vietnam where SIGN started in 1999 will we knew many friendships. They helped in the early design and technique of SIGN surgery. In December we will travel to Haiti where the Haitian orthopedic residents are providing excellent results for the Haitian people.”

Aging Stem Cells Affect Rotator Cuff Healing?

Evan Flatow, M.D., Chair of Orthopaedics at the Mount Sinai Medical Center, tells OTW, “Herb Sun (Albert Einstein College of Medicine) and I were just awarded an R01 grant from the NIH [National Institutes of Health] to examine stem cells in tendon damage. The preliminary results show that stem cells in tendons age as we do. The challenge is to determine why rotator cuff tears do not heal well with surgeries in older people. One reason is that while these cells are regenerative, they also age and divide less. We studied gene transcription factors and found that some regulators of DNA transcription were able to undo that and make the cells young again. We are now looking at tendon healing in rats and mice, and trying to determine if we can help tendons heal by modulating stem cell activity.”

“Nellie Andares, Ph.D., Assistant Professor of Orthopaedics at Mount Sinai, joined us last year. She has worked with me to look at how exercise affects tendon healing. Her own original research seeks to understand how fetal tissues heal without scar, and how we could use that information to improve adult healing. We are also trying to understand why tendons tear in the first place. We have used a model in which anesthetized rats undergo loading of their knee tendons in a special device. We have shown that small amounts of loading, such as exercise, can protect tendons against damaging loads.”

“My clinical partner, Brad Parsons, M.D., and I have looked at rotator cuff healing in patients after arthroscopic repair. The traditional teaching was that these patients would get stiff if not moved vigorously, but we found that they heal better and still get good motion if protected in a sling for several weeks after repair before therapy begins. We will know more in a year.”

Marc Swiontkowski, M.D. New Editor at JBJS

The Journal of Bone & Joint Surgery, Inc., (JBJS, Inc.) has announced the appointment of Marc Swiontkowski, M.D. as editor of JBJS Case Connector. Dr. Swiontkowski is professor in the Department of Orthopaedic Surgery at the University of Minnesota and CEO of TRIA Orthopaedic Center in Bloomington, Minnesota. He received his medical degree from the University of Southern California and completed his orthopedic residency at University of Washington. He completed a Fellowship in orthopedic research at the Laboratory for Experimental Surgery in Davos, Switzerland. Dr. Swiontkowski has served on the Editorial Board of JBJS since 1995

HSS Teams Up With NFL

Researchers at Hospital for Special Surgery will be giving their all when they begin using their new $100, 000 grant from the National Football League (NFL) Charities. The team will be researching the use of platelet-rich plasma (PRP) and stem cells as treatments for tendon injury and degeneration. For years, PRP has been used to improve healing in various sports injuries, but there is little evidence of its efficacy. The hope is that this research would lead to the development of an effective therapeutic strategy for tendinopathy that may allow NFL players to return to competition more quickly. The researchers also say that it may lead to a decrease in complications related to tendinosis, such as tendon ruptures. The grant money will be used to investigate how degenerated tendons respond to PRP and bone marrow-derived stem cells as well as if these two treatments will be synergistic if they are combined. Researchers will test these treatments in a preclinical model of tendon injury and degeneration. Among the goals of the research are to examine the structural and mechanical properties of the treated tendon tissue and to see how it responds to PRP and stem cells.

Cole’s New Cartilage Is a Single-Stage Knee Repair!

Brian Cole, M.D., M.B.A. is a professor in the Department of Orthopedics at Rush University Medical Center and section head at the Cartilage Restoration Center at Rush. Dr. Cole has recently performed five surgeries using BioCartilage, a desiccated micronized cartilage extracellular matrix tissue provided by Arthrex. He tells OTW, “As a field we are in need of a single-stage cartilage repair procedure for chondral defects of the knee. To date, we have used microfracture, but that has shown mixed results. We have also used autologous chondrocyte implantation, a technique that requires two separate procedures and is relatively expensive. Other current options do not take advantage of readily available autologous biological sources of regeneration through the use of platelet-rich-plasma (PRP) and/or microfracture. BioCartilage is a unique new product containing micronized allogeneic cartilage; it is implanted with the addition of platelet rich plasma (PRP) in combination with atraumatically performed microfracture of the defect. The potentiation benefits come through access to the mesenchymal cells present in the subchondral bone in combination with a regeneration-friendly scaffold (BioCartilage) and the pro-anabolic and anti-catabolic effects of PRP.”

Describing his experience with the surgery, Dr. Cole tells OTW, “In pursuing this procedure, we first needed to determine the best surgical technique. During the process, I learned that we should place the mixture of BioCartilage and PRP into the defect and then place the fibrin glue on top rather than at the base of the defect. Allowing the fibrin to set for 5 to 7 minutes leads to a stable scaffold that is very difficult to dislodge through range of motion. Also, the mixture is currently a 1:1 ratio of collagen scaffold and PRP and if it dries out a bit, the handling properties can be improved by adding a small amount of additional PRP.”

“My colleagues and I are actively applying for grant support to perform a prospective clinical trial of patients receiving BioCartilage for the treatment of International Cartilage Repair Society (ICRS) grade 3 articular cartilage defects of the femoral condyle, trochlear groove, patella or tibia that measure between 1-5 cm². While eventually this study will be a prospective, longitudinal, non-randomized study of up to 40 human subjects, at present we are adding to the in vivo literature by performing a pivotal equine study beginning October 1, 2012 in collaboration with Dr. Lisa Fortier from Cornell Veterinary School and Jimi Cook, D.V.M., Ph.D. from University of Missouri Veterinary School. We will create two defects in five to six horses and compare this to microfracture alone. This will also be performed entirely arthroscopically.”

“As for the multicenter clinical study, we will be using marrow stimulation as a historical control. The protocol is written and we have applied for a grant to support this initiative. We need to move slowly to assure that we are making a difference for our patients and continue to perform sound post-market research with clinical follow up.”