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The future development & its implication in next 20 years in the field of orthopaedic surgery
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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