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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