Hand/Upper ExtremityPerspective

Three decades of orthopedic advances have resulted in many benefits for patients

As Orthopedics Today turns 30, we look back at the last 3 decades and choose the Top 5 advances to affect the specialty.

It has been 30 years since the first issue of Orthopedics Today was printed and during this time we have seen many significant advances in the field of orthopedic surgery and in medicine in general. The procedures I perform today on my patients and the imaging capabilities that are available were not taught or even conceptualized during my residency.

We asked our editorial board to choose what they think are the Top 5 advances in orthopedic surgery over the past 30 years. We found that choosing only five to highlight was a difficult task because there are so many. Our editorial board members were quite similar in their choices arriving at our top five.

Thirty years ago when trying to estimate the needed orthopedic work force for the future, these advances were totally underestimated in meeting the demands and benefits they would bring with them.

It is now estimated that up to 80% of orthopedic procedures are amenable to the outpatient setting and many orthopedic practices have sophisticated imaging capabilities in their office and surgery centers. The shortened recovery and associated disability with less invasive and more stable and rigid fixation have allowed patients to be more functional sooner, and reduced the morbidity of some of the previous approaches.

As we celebrate our first 30 years of Orthopedics Today, it is also important to celebrate what we have covered and reported to our readers during this time period. The Top 5 chosen topics have occupied much of our publication’s pages throughout this past 30 years. We look forward to the next 30 years and the advances, some of which may not even be conceptualized, we all will experience in our practices and patient care. Orthopedics Today will be there covering the changes, their implications and analyzing the behind the scenes thinking for our readers.

Douglas W. Jackson, MD


Arthroscopy uses increase in 21st century as hip and shoulder applications expand

Robert W. Jackson, MD
Robert W. Jackson

Over the past three decades, orthopedic surgeons and their patients have come to appreciate the advances in diagnosing and treating musculoskeletal conditions made possible by introduction of the arthroscope. More recently, steady improvement in arthroscopic techniques and instrumentation and expanded use in the hip joint has furthered this subspecialty area of orthopedics.

Arthroscopy pioneer Masaki Watanabe, MD, of Tokyo, laid the groundwork in the field, developing early models of arthroscopes in the 1950s. Robert W. Jackson, MD, learned arthroscopy from Watanabe and is credited with bringing this technology to North America in the 1960s. But acceptance of this approach was decidedly slow since clinicians needed some time to see the benefits of this less-invasive surgery over open surgery, which they argued enabled them to better see more structures and areas of the joint.

In North America, early clinical use of the arthroscope by Jackson, Lanny Johnson, MD, John B. McGinty, MD, and other orthopedists was limited to the knee and nearly entirely to sports medicine applications such as treating meniscal tears, anterior cruciate ligament pathology and cartilage defects. Richard L. O’Connor, MD, is credited with first developing the operative arthroscope.

Eventually, arthroscopy also proved to be a superior tool for teaching the diagnosis and treatment of nearly any type of intra-articular pathology.

Gradually, arthroscopists moved from working in the knee to exploring and treating the shoulder, elbow, wrist, ankle and even finger joint, some of which have remained popular uses of the arthroscope. Johnson, who pioneered using the arthroscope in the shoulder, once told Orthopedics Today he was the first to use it in the temporomandibular joint.

The arthroscope is now credited with helping speed the growth of the sports medicine field, which was new when it was introduced. With a nod to that development, Sports Illustrated honored Jackson and his efforts at championing arthroscopy in its 40th anniversary issue.

Perspective

With the development of TV monitors and arthroscopically assisted knee ligament reconstruction in the 1980s, the subspecialty became the gold standard. The public advanced the cause as they demanded to have this new, less-invasive technology. The rapid acceptance was patient-driven.

This concept drove all the other specialties to advance and develop similar procedures such as laparoscopic cholecystectomy.

The community benefitted from the teaching of arthroscopic techniques to residents who could effectively perform these procedures. The specialty has continued to advance into other areas such as hip arthroscopy and labral reconstruction. Many of these techniques came from work in the shoulder.

– Donald H. Johnson, MD
Orthopedics Today Editorial Board Member

I look at arthroscopy as evolving in three phases: Performing diagnosis; performing small surgical procedures; and performing extraordinary surgical procedures. I started my orthopedic experience somewhere between the first and second eras of arthroscopy.

Where the arthroscope used to be the domain of the knee surgeon, it has now permeated the domain of those who work in virtually every joint. Even the spine guys have found uses for the arthroscope.

– Elizabeth A. Arendt, MD
Orthopedics Today Editorial Board Member


BMPs progress from Urist’s 1965 discovery to clinical use in spine and trauma surgery

Demineralized bone matrix and bone morphogenetic proteins
Demineralized bone matrix and bone morphogenetic proteins have augmented many orthopedic procedures.

Image: Stryker Biotech

This year marks 45 years since orthopedic surgeon Marshall R. Urist, MD, showed that demineralized bone matrix can induce new bone formation, a development that paved the way for the discovery of bone morphogenetic proteins and eventual clinical use of this “wonder protein” in orthopedic surgery.

After Urist’s 1965 discovery concerning bone growth induced by a demineralized matrix, he developed the concept of bone morphogenetic proteins (BMPs) in 1971. What ensued were several research milestones that paved the way toward clinical use of BMPs, made by such pioneers in the field as A. Hari Reddi, PhD, John M. Wozney, PhD, Vicki Rosen, PhD, T. Kuber Sampath, PhD, David C. Reuger, PhD and Scott D. Boden, MD, a member of the Orthopedics Today Editorial Board.

Two BMP achievements in 1991 moved these proteins even closer to use in humans: Orthopedic surgeons began using BMPs clinically in the form of commercial demineralized bone matrix and then in simultaneous, but independent developments at two labs — Wozney’s and Sampath’s — human BMPs expressed recombinantly were assayed in rats and shown to be active.

Fast-forward 10 years to when the FDA granted Humanitarian Device Exemption (HDE) approval to Stryker Biotech for Osteogenic Protein-1 (OP-1; rhBMP-7) for long-bone nonunions. In 2002 FDA approved rhBMP-2 (Infuse, Medtronic) for single-level spine fusion. Two years later the agency granted HDE approval for OP-1 putty used in revision spine fusions and the following month approved Infuse for treating acute open tibial shaft fractures.

To date, the clinical use of BMPs has probably been most widely practiced in orthopedic surgery. While many areas exist where they can potentially be used in humans, such as articular cartilage repair and regeneration of degenerative discs, one of the biggest areas of ongoing research has been identifying effective carrier materials. With the availability of new carriers, experts predict more BMP-based products will be close behind.

Perspective

Marshall Urist may not have known the real impact of his discovery when he noted “the morphogenetic properties of decalcified bone matrix which acted as a growth factor that stimulated bone formation in a variety of tissues.” What we have come to know as bone morphogenic proteins, or BMPs, are the most researched musculoskeletal agents. The discovery of BMPs has not only allowed orthopedic surgeons and scientists to climb to the higher quantum in providing care to patients with orthopedic ailments, but their discovery has provided a brilliant insight into the basic science of how musculoskeletal tissues are regulated. Now we know that BMPs regulate cellular differentiation, proliferation, extracellular matrix production and the process of apoptosis. Continued interest in BMPs has led us to the discovery of intricate and sophisticated cellular signaling in osteoblasts, chondrocytes and even osteoclasts.

BMPs have found their place in the clinical arena for fusion and treatment of nonunions of fractures and segmental bone defects. They have truly impacted the practice of orthopedic surgery and, in my opinion, more than anything else that has been discovered in this field so far.

– Javad Parvizi, MD, FRCS
Orthopedics Today Editorial Board Member


Joint arthroplasty advancements add to longevity, function and reproducible results

large-diameter head
Using large-diameter heads is a trend that has been extended to hip resurfacings.

Image: Lavigne M

Improvements and innovations in materials, articulation surfaces, peri- and postoperative management strategies and outcomes research have worked together during the last 30 years to decrease implant wear and increase function following joint replacement procedures.

Hip arthroplasty has benefited from the advent of porous metals, improvements in alternative bearing surface technologies, polyethylene advances and newer procedures, such as resurfacing surgery.

Bearing surfaces

In an Orthopedics Today Round Table discussion in 2004 on total hip replacement (THR) technologies, John J. Callaghan, MD, said that bearing surface issues had some of the greatest impact on the evolution of THR. “I say this because most of us firmly believe that with the use of the cementless devices available today, fixation should not be an issue. Bearing surface wear with subsequent development of osteolysis is the long-term clinical problem.”

Bearing-surface evolution in THR has seen a pendulum-like swing from metal-on-metal, to metal-on-polyethylene and back to metal-on-metal with some of the newer designs. However, each of these iterations has come with concerns. Metal-on-polyethylene bearings in the 80s and 90s demonstrated that they were not immune from wear, osteolysis and loosening. Metal-on-metal THR, although once avoided after results of some of the earlier hip implant articulations, is becoming popular once again but is not indicated for use in all patients due to published data on the generation of metal ions and the concerns of some surgeons about metal hypersensitivity.

Porous metals have also played an important role in increasing survivorship in cementless THR.

“Cementless fixation at this point has proven, at least in my mind, superior durability over cement. There are still problems with wear and osteolysis, but hopefully with more wear-resistant bearing surfaces the rate of re-operation will decrease with time,” Craig J. Della Valle, MD, said at a recent Current Concepts in Joint Replacement meeting while discussing how investigations have revealed that, depending on the cup used, 20-year survivorship of cementless acetabular fixation now ranges from 90% to 96%.

Knee arthroplasty

Some of the developments that have enhanced knee arthroplasty over the past 30 years include unicompartmental implants, modular components, fixed and mobile bearing designs, newer polyethylenes and computer assistance.

In a recent Orthopedics Today Round Table discussion, S. David Stulberg, MD, named characteristics of current knee designs that he thought to be associated with long-term in vivo durability as:

  • articular surface congruency of either cruciate retaining or posterior stabilized implants;
  • minimal motion between the polyethylene and tibial base plate or elimination of motion, as in monoblock implants;
  • non-aged, compression molded polyethylene with moderate crosslinking, sterilized in an inert environment;
  • CoCr tibial and CoCr or ceramic coated (Oxinium) femoral components;
  • mobile bearing implants; and
  • congruous, capacious patellar-femoral designs.

“In order to be associated with long-term in vivo durability, these designs must be inserted with instrumentation that assures consistent alignment, soft tissue balance in flexion and extension and appropriate stability,” he said.

In the same discussion, moderator A. Seth Greenwald, DPhil (Oxon), noted that although some of the advances in total knee arthroplasty are the widening of applications and indications to make it beneficial for younger and more active patient populations, implant longevity is one of the hallmarks of the current state of implant design.

“While pain relief and restoration of function remain the two cardinal rules of these procedures, there is increasing emphasis on in vivo device longevity as well as the continuity of successful patient outcomes,” he wrote.

Perspective

The improvements in joint replacement during the past 30 years have been due to technological improvements, design modifications, more standardized surgical instrumentation and techniques, education of surgeons — from hands-on experience to didactic presentations — and critical sharing of outcomes.

The refinement in joint replacement and how it is performed has seen steady improvement in patient outcomes. It has become one of the most satisfying orthopedic surgeries to perform because it brings significant functional results in most cases for our patients.

– Douglas W. Jackson, MD
Orthopedics Today Chief Medical Editor

Although cemented total hips were successful there were concerns about longevity. The mid- to long-term results from various centers were variable. The ingrowth with the cementless components has been very reliable — > 95%. Wear of the bearing surfaces is the big issue now.

– Jay R. Lieberman, MD
Orthopedics Today Editorial Board Member


Over three decades, intramedullary nailing gains popularity despite initial resistance

intramedullary nailing
Although developed more than 60 years ago, intramedullary nailing did not become a standard treatment for fractures in the United States until the last 30 years.

Image: Obremskey WT

Though reports of somewhat crude internal fixation go all the way back to the early 20th century, advancements such as intramedullary (IM) nails, screws and plates helped spread the concept globally — even in the face of conventional wisdom at the time, which was largely rallied against the practice.

Perhaps the most important paper in terms of shifting the common opinion on IM nailing didn’t come until 1984, when Robert Winquist, MD, Sigvard Hansen Jr., MD, and D. Kay Clawson, MD, published a study in the Journal of Bone and Joint Surgery and helped establish IM nailing’s credibility.

Out of 500 cases treated with the closed IM nailing technique, Winquist’s group was able to report a 99% union rate.

“That was the best union rate published up to that point in the literature,” Thomas A. Russell, MD, told Orthopedics Today in 2005. “I was at meetings where they called them liars. Those guys really carried the banner and took the hits.”

Later that year, Johnson, Johnston and Parker gave IM nailing an even bigger push by publishing their comparative study of roller traction, IM nailing with cerclage wiring and interlocking IM nailing.

The study was small – under 100 patients – but the results were crucial, especially so soon after the Winquist study. Overall, the failure rate with roller traction was 66%, 39% for the IM nails with cerclage wiring and 4% for interlocking nails.

Russell credited the two papers with changing the face of internal fixation within a span of 18 months.

Elastic stable intramedullary nailing has also made an impact over the past three decades, providing shorter immobilization time and hospital stays while maintaining anatomic reduction. Controversy over the cost-effectiveness of the technique has arisen, especially if the nails are removed. These costs can partially be offset by the aforementioned reduced hospital stay, but for many families they can still be difficult to overcome.

Perspective

Locked nails have permitted small incisions, decreased operating time and blood loss, maintenance of rotational stability and bone length, preservation of endosteal bone and periosteal blood supply, facilitation of care to soft tissue and neurovascular injuries, early mobility and range of joint motion. The intramedullary hip screw (IMHS) may represent the quintessential locked intramedullary nail. It disrupted large incisions, lots of blood loss, large retractors (Bennett’s and Israel’s) and poor fracture outcomes.

– Douglas E. Garland, MD
Orthopedics Today Editorial Board Member


Digital X-rays, ultrasound among changes in imaging since 1980

Imaging and its use in improving outcomes in orthopedic surgery have developed concurrently throughout the past 30 years, with smaller and more convenient methods giving physicians a wider range of possibilities. Even MRI and CT have seen recent changes in their implementation, with surgeons moving toward utilizing them for patient-specific implants or guides.

Ultrasound growing in popularity

One of the major developments in imaging over the previous three decades, the increasing clarity of ultrasound imaging has enabled physicians to better diagnose soft-tissue abnormalities and incorporate the technology into tendon healing. Within the past 15 years, the technology has improved dramatically.

“It allows you to target specific areas with much greater accuracy than you can using just about any other technique,” Ronald S. Adler, MD, PhD, told Orthopedics Today in a 2004 interview.

Digital X-rays

The development of digital X-rays has also been a factor, allowing for improved efficiency as well as a reduction in lost X-ray films and retakes. The obvious advantages include less storage space and higher-quality images; however the move to digital X-rays has been cautious due to the high costs of the necessary computer infrastructure. Regardless, due to the increased portability and convenience associated with having X-rays in digital rather than film format, many offices are making the switch.

C-arm developments

Though it was initially introduced more than 55 years ago, C-arm fluoroscopy has become an almost indispensible tool for surgeons within the past 30 years as well. Advances such as the mobile C-arm and mini C-arm allow quality imagery in a smaller package that can be utilized in a variety of settings. Cutting costs and difficulty of use while exhibiting impressive versatility, the smaller and more portable versions of the C-arm have enabled surgeons to work with the imaging equipment in the operating rooms of large hospitals as well as smaller surgi-centers.

Furthermore, patients can be more comfortable with C-arm fluoroscopy, as physicians can inform them that its use can mean a more precise and possibly less-invasive procedure.

3-D models from CT and MRI

More advanced uses for imaging equipment have also developed, with CT and MRI recently being implemented in the creation of patient-specific guides and templates. The 3-D models provided by these imaging techniques allow for surgeons and manufacturers to provide patients with implants that are unique to their own physiology.

“Because all the planning and preparation is performed before surgery, this approach shortens the preparation time in the operating room and significantly reduces instrumentation,” wrote Anthony M. DiGioia III, MD and Branislav Jaramaz, PhD, in the Feb. 2010 issue of Orthopedics Today. – by Lee Beadling, Susan Rapp and Robert Press