Editor’s Choice – Feb 3, 2014
The article “Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial menisectomy” is an interesting report of a randomized, double-blind, controlled study carried out over a 2-year period following subtotal medial menisectomy.
While the positive impact of mesenchymal stem cells (MSCs) on both the meniscus and articular cartilage has been demonstrated in animal models, this study looks at the potentially beneficial effects in humans after partial menisectomy. MSC injection in this setting resulted in no apparent complication secondary to these injections. Pain in patients with osteoarthritis was also improved over 2 years compared to those patients treated only with hyaluronate injection. Most intriguing, though, was that in 24% of patients with lower dose MSC and in 6% with higher dose MSC, there was an increase in meniscal volume on MRI by > 15%. None in the control group showed any volume change.
With the large number of meniscal injuries treated surgically in all age groups, MSC injection following partial menisectomy may prove to be a safe method to decrease osteoarthritic pain and potentially increase the volume of the remaining meniscus.
Minority of Orthopaedists Know the Cost of Implants They Commonly Use
When it comes to knowing the costs of the devices they implant, orthopaedic surgeons and residents are batting only .210 and. 170, respectively. More than 500 orthopaedic surgeons surveyed at seven US academic medical centers correctly estimated the cost of common orthopaedic devices only 21% of the time. Residents at the same institutions did so only 17% of the time. Many of these respondents (36% of surgeons and 75% of residents) admitted that their knowledge of device costs was “below average” or “poor.” All respondents tended to overestimate the price of low-cost devices and to underestimate the price of high-cost devices. The implication of that tendency, say the authors of the Health Affairs study, is that “physicians may underestimate the amount that could be saved by choosing the lower-cost alternative.” The biggest barrier to physicians knowing device prices is confidentiality clauses in the contracts between device vendors and hospitals. “Widespread dissemination of device prices is not an option at many institutions,” wrote the authors. It remains to be seen whether the proliferation of accountable care organizations, with their emphasis on cost-efficient care, will alter this situation. For more about cost variation in orthopaedic devices, see the JBJS article “Variability in Costs Associated with Total Hip and Knee Replacement Implants.”
Should Aging Athletes Consider These Treatments?
In 2009, older patients spent more than $72 billion on products that purportedly slow the aging process. That figure is expected to rise to an estimated $114 billion in 2015. Here are some of the treatments that are touted to help older athletes stay active:
Antioxidants: Examples include vitamins C & E, carotenes, and flavonoids. Antioxidants prevent cell damage that occurs with oxidative reactions, but we don’t know enough to conclude that they can effectively treat or prevent disease.
Human Growth Hormones: Naturally secreted by the pituitary gland, hGH supplements could theoretically reverse age-related physical decline. But hGH hasn’t been proven to improve muscle strength, bone density, or athletic performance.
Testosterone: Testosterone replacement in older men can increase lean muscle mass and bone density and decrease body fat. The most concerning side effect of testosterone replacement is the hormone’s potentially harmful effect on the prostrate. Scientists are exploring testosterone-boosting approaches that sidestep the potential side effects.
Stem Cell Grafts can Help Brittle-Boned Babies
Osteogenesis imperfecta, also known as brittle-bone disease, is a genetic bone disorder that stunts growth and causes bones to break easily. Doctors recently found that this disease can be treated by injecting babies in utero with bone-forming mesenchymal stem cells. An international team of researchers has treated two babies this way with some success.
The stem cells were extracted from the livers of donors, and the genetically unmatched transplanted cells were accepted by the recipient as their own. “We believe that the stem cells have helped to relieve the disease since none of the children broke bones for a period following the grafts, and both increased their growth rate,” says study leader Dr. Cecilia Götherström, researcher at Karolinska Institute’s Department of Clinical Sciences, Intervention and Technology. “Today, the children are doing much better than if the transplantations had not been given.”
Doctors Save Hand…by Attaching It to an Ankle.
At a hospital in China, doctors took a very different approach to reattaching an amputated hand. Xiao Wei lost his right hand in an industrial accident, and his arm was severely compromised during the same accident. The dilemma that doctors faced was two-fold; saving the right hand and dealing with severe trauma to the rest of Wei’s arm. Their approach to salvaging his hand was to attach it to his ankle so the arteries and veins in the ankle would continue to supply blood to it. A month later, after his arm injuries healed and blood supply was sufficient, Xiao’s right hand was reattached to his arm. He is expected to regain full use of his hand.
How Far Will Patients Travel for Free Joint Replacements?
Workers with health insurance coverage through several large employers including Walmart and Lowes now have the option of getting a joint replacement free of charge. Through the Employers Centers of Excellence Network established by the Pacific Business Group on Health (PBGH), four providers—Johns Hopkins Bayview Medical Center (Baltimore), Virginia Mason (Seattle), Kaiser Permanente Orange County (Irvine, CA), and Mercy Hospital (Springfield, MO)—negotiated bundled-payment agreements based on their high volumes, better-than-average outcomes, and lower-than-average complication rates. Instead of paying the usual deductibles and copays, patients travel to one of these four providers and don’t pay a penny for the procedure or travel expenses. The non-profit PBGH has 60 large-company members that provide health care coverage to 10 million people, including active employees, retirees, and dependents.
UC Davis Docs Demonstrate Live-Action MRIs
Magnetic resonance imaging has revolutionized the field of orthopaedic diagnostics, but it has until now been limited by delivering largely static images. Researchers at the University of California, Davis have developed a new MRI technique called “active MRI” that can depict wrist joints in motion at an amazingly fast temporal resolution of 475 milliseconds. The advance could permit a patient to replicate a motion that causes pain while allowing a physician to “see inside” for the cause while the joint is moving.
Evidence of Safety, Efficacy in Hip Implants Lacking
A systematic literature review in BMJ found that most British orthopaedists use hip prostheses that have a solid evidence base. However, almost one in four hip-prosthesis brands available to UK surgeons have no evidence to support their use, and 8% of all hip prostheses implanted in 2011 had no safety or efficacy evidence available. The authors say the difficulty of running randomized controlled trials with orthopaedic implants “may…have contributed to the paucity of good quality evidence in this sphere.” They conclude that the “phased introduction of new orthopaedic implants would seem prudent.” For additional perspectives on phased introduction of orthopaedic devices, see Graduated Introduction of Orthopaedic Implants: Encouraging Innovation and Minimizing Harm in JBJS, Nov. 7, 2012.
Still, No “Magic Pill” for Hip Osteoarthritis
Most patients with hip osteoarthritis dream of a nutritional supplement that will improve their clinical symptoms. Findings from a new study of a soybean-avocado supplement suggest they’ll have to keep dreaming. However, relative to placebo takers, those taking 300 mg a day of a proprietary soybean-avocado supplement over three years were 20% less likely to experience a loss of joint-space width of 0.5 mm or more. Alas, there were no significant differences between the two groups in important patient-centered outcomes such as pain and the use of analgesics or NSAIDs. The industry-funded study of nearly 400 patients initially set out to determine changes in joint-space narrowing (JSN) between the two groups, but researchers amended the protocol to measure progression because JSN was found not to be a “quantitative linear normally distributed parameter.”
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