future shock in orthopaedics

Orthopaedics → 2020Orthopaedics →→ 2020

Vinod Vinod NaneriaNaneria

Our Journey 7 million years ago - present

Hands & feet of tarsier, orangutan, gorilla and man

Change in shape of dental arches

Pelvic girdle

Changes in skull from ape to human. Arrows position of foramen magnum

Essential changes

July 20, 1969 Aldrin stepping onto the surface of the Moon

Giant step to moon

Leonov’sA quantum leap in space8th March, 1965.

"too much change in too short a period of time".

The world is gettingReady for “Future Shock”

TRUTH?

• There is nothing like absolute truth.• Truth is time bound.• Truth of yesterday is not the truth

of today and truth of today will not be the truth of tomorrow.

Change = Reality

WHAT WAS YESTERDAYTrauma and arthritis

• Plaster of Paris• Thomas Splint/ traction• Open nailing/plating/ wiring• Bone grafting• Corrective surgery for malunion and

neuromuscular disorders• Arthritis – conservative - NSAIDs

Why change?• Plaster disease? Prolonged immobilization• Complicated fractures – high velocity• High morbidity and mortality• Infection – antibiotics – drug resistance –

another antibiotic• Arthritis crippling deformities and

uncontrolled pain and disability

What we have today• Closed interlocking nailing/ MIS plating• Illizarov” technique - answer to all• Arthroscopy – diagnostic and operative• Early mobilization and Rehabilitation• Minimal but still infection and antibiotics• Atleast 15 years – 25 lasting arthroplasty

for all major joints • Good DMRDs and safe NSAIDs

Philosophy of Replacement V/s repair

• Disc implantation and Joint replacements• Newer bio compatible materials like

ceramics, highly cross linked polyethylene, better design consideration.

• MRI, Dynamic MRI, Ultrasound, Isotopes scanning, & Multi-slicer 3D CT scanning.

• Image intensifier and key – hole surgery.

Tx Between “4 R”• Repair • Replace• Reconstruct• Regenerate

Time line

Why then Change?• Implant failure common.• Fixing fracture is no guarantee of union.• Who has time to wait for 6 – 12 weeks for

fracture union? • Patients expectations, demands and

requirements have changed.• Metallurgy can not replace biology. • Arthroplasty failing in young patients

What should change?• Any thing which-

– Guarantee Healing / union in minimal• Time• Minimally invasive• Minimal risk of infection

• Biology should replace metallurgy• Prevention – trauma and auto immune

diseases.• Philosophy of replacement than repair

Biology —> Biology

What is going on?• Tissue engineering• Gene therapy• Bio-compatible material• Early detection of diseases• Better diagnostic techniques• Precision (computer assisted) surgery

Tissue Engineering• Regeneration of tissue and the restoration of the

function of the organs by the implantation of cells or tissues grown outside the body, or by the stimulation of cells to grow into an implanted matrix.

• Articular cartilage defects.• Large bone defects in limb salvage surgery.• Extremely comminuted fractures with boneloss.

A titanium surface covered by carbon nanotubes for faster, better growth of implanted bone-growing cells.The nanotubes could even self-reporting, informing about the healing process.

a "smart" implant that can sense and report on bone growth.

Nanotechnology

Gene therapy

• Transfer of a gene is to compensate for genetic defects in recipients suffering from monogenic diseases such as hemophilia. Genes may also be transferred to individuals who are genetically unremarkable but in whom the product of the transferred gene may nevertheless produce a beneficial clinical effect.

Gene therapy• In Gene therapy of rheumatoid arthritis,

the human IL-1Ra gene is transferred to the synovial lining of the joint by an ex vivo method utilizing a retrovirus. Encouraging pre-clinical data have been obtained for osteoarthritis, bone healing , cartilage repair, meniscus healing and the healing of ligaments and tendon.

Year 2020 – Bone healing• Prevention – strict traffic regulation• Precision surgery

– Robotic telesurgery– Computer assisted navigation surgery– No infection – no antibiotics

• MIS / Key-hole surgery• Bio degradable- bio-compatible, &

bio-inductive material.

Bone healing• Supplementation with BMP-2 and bio

absorbable cement / glue to speed up union

• Supplementation by factory made osteoprogenitor cells / stem cells and bone matrix.

This micro-CT image provides a detailed look at boththe vascularization and mineralization of a bone sample

Cartilage • Prevention of age related chondrocyte

damage • Replacement of damaged cartilage by

cartilage transplantation with factory made cartilage matrix.

• Surface resurfacing of damaged cartilage in arthritic joints by cartilage transplantation

Cartilage• Identification of genes responsible for collagen

disorders.• Correction of gene therapy • Early detection and Immuno-regulatory drugs.• Better understanding of triggering mechanism for

increased production of endo morphine level in brain – for pain tolerance and no pain killer.

• Computer assisted non cemented bio-compatible implant material for replacement arthroplasty, if required.

2020 and beyond• What we want?

– Minimum accidents– Immediate fixation and mobility in polytrauma– NO to all preventable gene related arthritis /

musculo skeletal disorder.– Availability of factory made spare parts in

cases of loss of limb due to injury or disease– Regaining the natural power of tissue

regeneration in cases of tissue loss.– NO to osteoporosis/no fracture risk in elderly– Normal fully enjoyable life, as long as alive

Program cell death (apoptosis)Is genetically predisposed, which can be modified by:Changing the environmental factorsIncrease synthesis of dying cells.All degenerative conditions including aging can be delayed for indefinite time.The best example of it:Certain African community in spite ofhighly loaded with HIV virus, do not have any effect because of extra production of B-Lymphocytes. Means, there is always a surplus of B-Lymphocytes then the number of Lymphocytes destroyed by HIV virus. - osteocytes - ↓ - osteoporosis↑ - Chondrocytes - ↓ - Osteoarthritis

Every Homo sapiens will be labeled according to his genotype. That label will be added with his name, making people aware of his genotypes.The best example will be prevention of AVN

Journey Continue………….

It’s a crime to think small- A.P.J. Abdul Kalam