Orthopaedics → 2020
Vinod Naneria
consultant Ortho surgeon
Choithram Hospital & Research centre, Indore,India
Dream, Dream, Dream,
Dream put in to thoughts,
Thoughts brings action
Action brings changes
In this changing scene
TRUTH?
Truth is time bound.
There is nothing like absolute truth.
Truth of yesterday is not the truth of today.
Truth of today will not be the truth of tomorrow.
WHAT WAS YESTERDAY
Trauma (bone) and arthritis (cartilage)
Plaster of Paris
Thomas Splint/ traction
Open nailing/plating/ wiring
Bone grafting
Corrective surgery for malunion and neuromuscular disorders (Polio)
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
Early mobilization and Rehabilitation
Illizarov" technique - answer to all
Arthroscopy - diagnostic and operative
Allografts and other bone substitutes
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
Joint replacements and Disc implantation
Newer bio compatible materials like ceramics, highly cross linked polyethylene, better design consideration.
MRI, Isotopes scanning, Multi-slicer 3D CT scanning.
Image intensifier and key - hole surgery.
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/complications
Biology should replace metallurgy
Prevention - trauma and auto immune diseases.
Philosophy of replacement than repair
What is going on?
Tissue engineering - repair
Gene therapy - prevention
Bio-compatible material - implants
Early detection of diseases - dynamic MRI, PET scan,
Better diagnostic techniques - Markers
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.
For example: Articular cartilage defects.
Gene therapy
Transfer of a gene is to compensate for genetic defects in recipients suffering from monogenic diseases such as hemophilia, and cystic fibrosis.
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, meniscal healing and the healing of ligaments and tendon.
Year 2020 - Bone healing
Prevention - strict traffic regulation
5 million young deaths/ per annum
WHO - 2004 - Road safety.
Precision surgery
Robotic telesurgery in space, remote places, combat field, site of accedent.
Computer assisted navigation surgery
No infection - no antibiotics
Immuno-potentiation and regulation
MIS / Key-hole surgery
Bio degradable- bio-compatible material.
Bone healing
Supplementation with BMP-2, growth factors and bio absorbable cement / glue to speed up union
Supplementation by factory made osteoprogenitor cells / stem cells and bone matrix.
Cartilage healing
Prevention of age related chondrocyte damage (over load failure)
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 diseases by 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
A supply of ready made parts from clones.
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
It's a crime to think small
- A.P.J. Abdul Kalam
