The Leg Bone Connected to the Thigh Bone
Advances in orthopedic surgery
by JACQUELINE M. DUDA
Once upon an orthopedic time, broken bones, arthritis, osteoporosis and basic wear and tear used to be endured with a grimace of pain and the reluctant surrender of mobility and strength. There was virtually no hope for injured spinal discs, outside of major surgery that required a mind-numbing and lengthy recovery period.
New Orleans, a town thriving with athletic activity thanks to collegiate and professional sports and high- school programs, also sees its share of sports-related injuries. It’s just as much a part of the cityscape as the trademark humidity that blankets the region every summer.
Patients are living longer, requiring stronger prosthetic devices that connect bone and tissue like pieces of a human jigsaw puzzle. Sutures must weave parts together to form an inseparable bond, and incisions are smaller than the size of a pencil eraser.
Goodbye, gigantic scars!
By the Numbers
• Orthopedic problems affect nearly everyone at some point. The American Academy of Orthopedic Surgeons Unified Musculoskeletal Research Agenda reports that 25 million Americans, 80 percent of whom are women, have osteoporosis. Every year nearly 1.5 million fractures are associated with this disease.
• According to the 2002 National Hospital Discharge Survey obtained from the U.S. Department of Health and Human Services, nearly 4 1/2 million doctor visits resulted from rotator cuff complaints and approximately 600,000 Americans underwent spinal-fusion surgery.
• Dr. Joshua Jacobs, chair of the Council on Research and Scientific Affairs for the American Academy of Orthopedic Surgeons, says the three hottest orthopedic issues today include:
–Smaller incisions and earlier hospital discharges.
–Computer-assisted navigation to place prostheses with ultra-fine precision.
–The performance and durability of prosthetic materials.
In addition, an increasing push for patient education prompted Louisiana State University to set up a new system for delivering orthopedic care. Starting Sept. 1, project participants will seek ways to teach patients the nuances of orthopedic disease and institute health fairs encouraging patient screening and education.
According to Dr. Barry Riemer, professor and chairman of orthopedics at LSU, the program will help patients understand the underlying reasons for their orthopedic problems and aid in accessing additional resources to treat these issues, such as vision or inner-ear complications that could cause frequent falls. Patient education also helps tremendously with post-surgical recovery and therapy.
Evalina Burger, spine surgeon and associate professor at LSU’s Orthopedic Spine Unit, announced the recent introduction of lumbar disc replacement to treat back pain. The procedure has been practiced in Europe for 15 years and was FDA approved in the United States in October 2004.
“This is a very dramatic advancement,” Burger says. “It’s the first time we are able to replace a disc with a movable part, rather than fusing the spine.” The term “fusing” is similar to “welding” injured areas together, which restricts mobility.
The artificial implant reduces the need for additional surgeries and minimizes wear on the individual part. The disc, titanium on the outside with a polyethylene core, allows a full range of motion through the polyethylene center. It doesn’t defy the spine’s natural mechanics, and it can improve posture.
However, Burger cautions that only 5 percent of patients, those with excellent bone quality and no arthritis or spinal instabilities, will qualify. It will not help nerve compression. Since healing time requires two to three weeks in most cases, the surgery has also received approval from the Workman’s Compensation Association.
Surgery “To Go”
Minimally invasive procedures are popular. Tiny incisions made during arthroscopic surgery to treat knee or shoulder injuries are less than a centimeter long. The injured region is then filled with water to enlarge the viewing area, and a camera is inserted to access the surgeon’s repairs.
“Arthroscopic surgery has been around for decades, but it’s become commonplace, especially for the shoulder and knee,” says Dr. Timothy Devraj, general orthopedic surgeon at Ochsner Clinic Foundation. Patients’ joints can be repaired and the patients can be on their way in a short period of time.
Rotator cuff surgeries, one of the most common procedures, no longer require a cut through the deltoid, the major muscle that sits atop the shoulder. By diminishing the size of the incision and avoiding the removal or detachment of the muscle, surgeons can reduce damage in the surrounding area, thereby speeding up the healing process.
Dr. Timothy Finney, orthopedic surgeon at Southern Orthopedic Specialists, sees a lot of sports injuries in New Orleans. The anterior cruciate ligament (ACL), a tough, rubbery band in the middle of the knee, prevents the tibia, or shin bone, from sliding out in front of the femur, the thigh bone, and provides rotational stability to the knee. ACL tears, frequent among athletes, are a popular candidate for arthroscopic surgery.
Devraj cautions, however, that in-and-out procedures aren’t for everyone. “Major reconstructions require traditional surgical methods,” he says. “The biggest thing to remember is the size of the incision can’t dictate the procedure. The goals of the surgery [repair or replacement] must be met.”
New Procedures on the Rise
According to Finney, the new Carticel transplants – a process where cartilage cells are taken from one part of the body, grown as new cartilage in a lab and returned to the affected area – depends on the nature of the injury and its progression. The two-step process also requires a longer recovery time. Jacobs indicates that Carticel transplants are generally used in young patients for isolated cartilage defects.
Dr. Donald Faust, clinical associate professor of Orthopedics at LSU and past president of the Louisiana Orthopedics Association, describes kyphoplasty, a new treatment for osteoporosis fractures or compression fractures in the spine where early diagnosis is key. The minimally invasive surgery works by inserting a special balloon and gently inflating the fractured vertebrae, helping to restore height and reducing the chance of spinal deformity. A cement-like material is then injected directly into the fractured bone to stabilize it, and provides immediate pain relief in many cases. Most patients return to normal daily activities shortly after the procedure.
Dr. Claude Williams IV, a hand and upper-extremity surgeon with Southern Orthopedic Specialists, notes an alternative to fusion in the wrist and hands. Artificial parts made of cutting-edge metals and polyethylene replace bones or joints and restore optimal mobility, similar, in some ways, to the results of lumbar disc replacement.
However, it’s not for the busy laborer who constantly works with his hands.
“The wrist requires full-range motion and handles a lot of stress,” says Williams. Wrist bones require three to four months to heal to the implant, although the joint is functional during the healing process.
During an orthopedic fracture fixation, doctors countersink screws and firmly anchor them inside the plate used to stabilize the fracture, lessening the chance that the prosthesis will loosen and also reducing the need for a cast. Joints can move sooner and heal in a better position.
Putting it all Together – The Prosthesis
Suture techniques have improved. Bioabsorbable suture anchors, placed inside joints to connect wayward ligaments and reattach tissue, are being used more frequently. As the body heals itself, its own glue takes over and reabsorbs the sutures, limiting the likelihood you’ll sound off alarms when passing through airport metal detectors. Fiberwire, an ultra-thin suture, is extremely strong and can be used with suture anchors to attach tendons and ligaments to bone.
Prosthetic materials have also come a long way. Improvements in their “ingredients” help replacements perform better and last longer. “We’re always looking for ways to reduce friction between the bones and at joints that hinge and rotate,” Finney explains.
The “one-size-fits-all” approach to prosthetics has taken a dramatically different turn. Doctors better understand body biomechanics, and computer-aided surgery and precise insertion make a good prosthetic fit like a glove.
But surgeons and medical manufacturers have individual preferences regarding materials. None thus far is considered the gold standard or is favored over another. All have theoretical advantages, and their use is cyclical in nature according to research findings of patient success rates.
For example, polyethylene, a high-molecular-weight plastic, is able to withstand the rigors of active living. “We’ve found ways to make [patients’] surgical replacements last longer,” Devraj says. Polyethylene is smooth, glides well and is usually placed in between the two metal parts to reduce friction. It’s easy to manufacture and cost-effective but is susceptible to fragmentation after a decade or more.
Ceramic, a costly but durable, smooth substance, glides easily and reduces friction. It is used predominantly in younger patients who need longer wear value, although ceramic can eventually crack and break over time.
The new diamond prostheses are much harder and won’t wear as quickly; however, they are costly – consider the cost of a diamond engagement ring these days.
Although metals such as titanium and chromium alloys are strong, they can cause allergic reactions within the body, and friction might cause debris to break off. Bones are flexible; metal isn’t. The constant interface of metal on bone can eventually loosen the prosthesis. Faust compares the body to a beach. “The sand there today won’t be in the same place in a few years. Bone in the body also ‘erodes’ from the prosthesis as it ages.”
Faust says the latest developments in computer-assisted surgery control the precision of the cut and prosthesis placement. “Exact positioning is critical, especially when dealing with artificial joints that must perfectly mimic the original joints in the body.
“Bones can wither away around the metal prosthesis, and bacteria can enter,” he adds. If the metal is properly placed, it will last – but after 10 years, anything can wear down.
No matter what the procedure or the materials used, recovery times and therapy have consistently improved through communication between surgeons and therapists. Surgeons give therapists vital details about patients, including their surgeries, complications and therapy options.
On the Horizon
Biological-based joint repair, gene therapy and the use of DNA methods to diagnose and understand orthopedic disease are looming on the next frontier. As advancements surge forward, patients can enjoy the benefits of longer, fuller lives free from the pain and limited ability wrought by orthopedic disease and injury. The pieces of the puzzle will eventually fall right into place. •