Orthopedics

The latest issue of The Spine Journal is devoted to casualties of war and includes some interesting insight into how the emotional stress of combat can impact soldiers’ spine injuries.

A key finding reported on in the issue is that non-battle spinal pain is a leading cause of medical evacuation for those deployed in Iraq and Afghanistan. Among other noteworthy findings, as outlined in a journal release:

• There have been 10 times as many long-term spinal-pain casualties unrelated to battle as blast injuries
• 60 percent of veterans seeking care for spine problems have serious continued psychological distress
• Less than one percent of military-aged Americans serve in the military (compared to nearly 50 percent during World War II), which means that veterans’ burdens after combat are now far less visible to the general public

In the release, Stanford orthopedic surgeon and journal editor-in-chief Eugene Carragee, MD, who wrote several pieces on spinal injuries for this issue and has done two tours of duty in Iraq himself, comments:

While some of the findings in this special issue are new and specific to these long wars—such as the devastating effects of IED blasts—it’s clear that we need to re-learn some very old lessons about war… We repeatedly send young people into combat to experience the worst psychological stressors possible, push them beyond endurance, and yet on the home front there is little to no collective understanding of the wars they fought or the experiences of deployment and combat. Veterans seeking care for spine problems at home are shown to have continued serious psychological distress, associated with exposure to combat. This is a serious public health issue that will continue for many years.

Previously: Stanford and other medical schools to increase training and research for PTSD, combat injuries, As soldiers return home, demand for psychologists with military experience grows, Helping brain-injured soldiers return – safely – to the battlefield and Are veterans with PTSD at higher risk for medical illnesses?
Photo by Staff Sgt. Stacey Haga/U.S. Air Force

A nonprofit started by Stanford graduates is gearing up to test its latest low-cost prosthetic – the ReMotion JaipurKnee – which is designed for amputees who live on $4 a day or less.

The knee prosthesis will be fitted to 1,000 patients in Latin America and Southeast Asia to make sure it works as hoped. D-Rev (Design Revolution), designer of the device, ultimately hopes to have it available in clinics across the globe.

“Mobility is synonymous with independence and opportunity, and they suffer, too, when a person loses a limb,” Vin Narayan, the company’s product manager, told me. “With the Re-Motion JaipurKnee, D-Rev combines user-centric design with our partners’ local expertise to give amputees around the world a chance to get back their mobility, as well as the independence and opportunities they’ve lost.”

The move to create a low-cost prosthetic for use in the developing world started with a graduate student project at Stanford in 2008. Students Joel Sadler, Eric Thorsell and two others designed the first JaipurKnee for use in India. The invention was named one of the Time magazine’s 50 Best Inventions of 2009.

The project took off and the students joined with Narayan to start a company to develop the prosthetic, which was initially field-tested in 3,500 people. The group has significantly refined the prosthetic and launched the 1,000 Knees Campaign to fund clinical trials of the latest version. Testing begins in 2013.

The company is partnering with local clinics to fit amputees with the knees and collect data on fit, training, user reaction and distribution. The prosthetics will initially be supplied to clinics free of charge, but once available on the market, the device’s target price will be $80. Users, however, will only pay what they can afford.

Previously: Biotech start-up builds artful artificial limbs
Photo by ReMotion JaipurKnee

The winners of the 2012 Wellcome Image Awards range from a time-lapse photo of cancer cell undergoing mitosis to a micrograph depicting caffeine crystals. But it was the above image of a colored electron micrograph showing connective tissue removed from a human knee during arthroscopic surgery that caught my eye.

While not as high-profile as your vital organs, connective tissue is your body’s “cellular glue,” so to speak. The fibrous tissue is critical in maintaining your body’s form, providing cohesion and internal support and is associated, and it’s associated with more than 200 disorders.

To elevate the status of this basic, yet essential, tissue type, the image’s creator selected a variety of colors to distinguish individual fibers of collagen. The result is an intriguing photo that showcases the body’s most diverse tissue.

Photo by Anne Weston, London Research Institute
Via New Scientist

Long before my mom lovingly scolded me for wearing high-heeled shoes while pregnant, she used to routinely plead with me to not carry my (usually heavy) backpack on one shoulder. “You’re going to hurt your back,” she warned. But wearing straps on both shoulders was very uncool (in southern Wisconsin, where I grew up, anyway), and so I dismissed my well-meaning mother with a hand wave and a reminder of my favorite mantra. “Style over comfort, Mom.”

As it turns out (and no big surprise here) my mom was on to something: Lugging around heavy books for months and years on end really can hurt your back. Today on the Well blog, Jane Brody paints the not-so-pretty picture:

Among the risks described by Dr. Pierre D’Hemecourt, a sports medicine specialist at Children’s Hospital Boston, are stress fractures in the back, inflammation of growth cartilage, back and neck strain, and nerve damage in the neck and shoulders.

The federal Consumer Product Safety Commission calculated that carrying a 12-pound backpack to and from school and lifting it 10 times a day for an entire school year puts a cumulative load on youngsters’ bodies of 21,600 pounds — the equivalent of six mid-sized cars.

…

Not surprisingly, one in four students [in a recent study on backpacks and back health] said they had suffered back pain for more than 15 days during the previous year; scoliosis — curvature of the spine — accounted for 70 percent of those with pain. The remaining 30 percent had either low back pain or contractures — continuous, involuntary muscle contractions. Girls faced a greater risk of back pain than boys, and their risk increased with age (and, presumably, years of lugging around their heavy packs).

Brody goes on to provide tips for ways to reduce a backpack’s load and minimize a child’s risks of developing problems, and her last one is to “never… carry the pack on one shoulder.” I have a feeling my mom is smiling, knowingly, as she reads this.

Photo by Elizabeth/Table4Five

I’ve mentioned before that I rarely wear flat shoes. Even two pregnancies couldn’t get me to abandon my heels: I pulled on a pair of Skechers before heading to the hospital to deliver my daughters, but I can’t remember reaching for them before that. (I considered this a sort of badge of honor at the time; in retrospect it was probably pretty foolish.)

A few studies have shown that wearing high heels may lead to pain and knee and joint problems, but as Gretchen Reynolds writes on Well today, whether these shoes “affect the wearer’s biomechanics and injury risk has received scant scientific attention.” In her piece, she discusses a new Australian study that found wearing heels “may compromise muscle efficiency in walking” and may increase the likelihood of strain injuries. And she offers advice from Neil J. Cronin, PhD, the researcher who led the work, for readers who can’t kick (sorry, couldn’t resist) their heel habit:

So, if you do wear heels and are at all concerned about muscle and joint strains, his advice is simple. Try, if possible, to ease back a bit on the towering footwear, he says. Wear high heels maybe “once or twice a week,” he says. And if that’s not practical or desirable, “try to remove the heels whenever possible, such as when you’re sitting at your desk.” The shoes can remain alluring, even nestled beside your feet.

Previously: Do pretty shoes lead to ugly problems?, Study links high heels to osteoarthritis and joint problems and Ouch! How high heels can shrink leg muscle, cause pain
Photo by NessieNoodle

Tearing of the meniscus - a cartilage-rich, crescent-shaped pad behind the kneecap that serves as a shock absorber for in joints such as the knee - is often thought of as a runner’s risk. But meniscal tears can occur spontaneously as one grows older, too. In fact, about one in five people ages 50 to 59, and more than half of people over 70 years old, have experienced one.

And meniscal tears spell increased osteoarthritis risk. Ironically, meniscectomy - surgical removal of some or all of the meniscus to relieve this condition - further elevates a patient’s risk of developing osteoarthritis over the long haul.

Throw in all the other accumulated twists and sprains and crunches of the passing years, season with a lifelong pinch of gravity, and you’ve got the recipe for a huge serving of osteoarthritis: 27 million sufferers in the United States alone.

In a study published in Nature Medicine, Stanford immunologist Bill Robinson, MD, PhD, and his collegues have now shown how an initial insult, such as a torn meniscus, triggers a cascade of low-grade-inflammatory activities in the joint that can result in the cartilage destruction that is osteoarthritis.

This discovery is a big deal because right now there are no decent drugs to slow, halt, or reverse the course of osteoarthritis - just painkillers providing symptomatic relief as the disease worsens.

But by implicating the so-called complement cascade, an all-important “first strike” immune defense system against microbial infection, in the initiation of osteoarthritis, Robinson and his colleagues have pointed at a new new target for drugs that could cut the rug out from under osteoarthritis before it ever hits the dance floor.

“People in the field predominantly view osteoarthritis as a matter of simple wear and tear, like tires gradually wearing out on a car,” Robinson told me in an interview for my news release on his study:

Recent findings suggest that low-grade complement activation contributes to the development of degenerative diseases including Alzheimer’s disease and macular degeneration. Our results suggest that osteoarthritis can be added to this list of diseases. . . . Right now we don’t have anything to offer osteoarthritis patients to treat their underlying disease. . . . It would be incredible, for the one-third of humans over 60 who have it, to find a way to slow it down.

Robinson suggests that delivering a complement-system-impeding drug only to the affected joint might someday prove therapeutic at a much more fundamental level. (You don’t want that drug roaming around in the circulatory system, because knocking out complement willy-nilly would vastly increase infection risk.)

Discovering molecular mechanisms operating very early in the course of a chronic disease gives you a chance to monitor promising therapies long before overt symptoms manifest, which in the case of osteoarthritis probably means irreversible damage to affected joints. A few years ago I wrote about another Stanford researcher, radiologist Garry Gold, MD, who’s working on a form of MRI that can visualize osteoarthritis early on. Robinson’s and Gold’s line of work, combined, could perhaps greatly speed up the search for a cure, not a palliative, for osteoarthritis.

Photo by Monstar888

Bespoke Innovations has gone out on a limb by building a new business around a bold idea – that prosthetic legs can communicate a message of personal style more than disability.

In a packed lecture hall at Stanford last week, Scott Summit, Bespoke’s chief technology officer and a Stanford engineering lecturer, told those of us in the audience about his start-up company’s vision — to bring humanity and self-esteem back to people who have suffered traumatic limb loss.

Using a 3D scanner, technicians create a digital image of an amputee’s surviving limb and create a mirror image of that morphology using parametric computer modeling. They feed this data into a laser-powered 3D printer that fabricates a custom superstructure, which can then be adorned with fashion-oriented materials like wood, metal, cloth, and leather. “We can create a personalized limb in 30 hours for about $4,000,” Summit told us.

Both utilitarian and beautiful, the Bespoke staff works with people to customize the designs and materials to reflect individual personality and tastes. Some are finished with ballistic nylon or polished nickel. One was covered in quilted leather, like a Chanel handbag. For a military veteran with a love of tribal tattoos, the team scanned a favorite tattoo design from one leg and fabricated the fairing using that theme. A competitive soccer player who lost his leg to cancer chose an aircraft-like honeycomb design that allowed him to play soccer again.

Summit, who works alongside co-founder Kenneth Trauner, MD, a Bay Area orthopedic surgeon, hinted that his interdisciplinary team of designers, engineers, physicians, and entrepreneurs has other innovations under wraps that will push the boundaries of human prosthetics and be “the coolest things you’ve ever seen.”

A video of the lecture is available on Stanford University’s Entrepreneurship Corner website.

Previously: Program helps local entrepreneurs get business ideas off the ground, Dean Kamen’s robot arm shakes hands on The Colbert Report, Haiti day 3: Amputees, Medical technology on display at upcoming Robot Block Party
Photo by Eva Kolenko

The day I turned 60, I hiked up to a place in Yosemite called Cloud’s Rest. It’s nearly 10,000 feet tall, with some very big boulders to boot. I was grateful that all that time I spent in the gym and on local trails prepared me for the 15 miles I trod that day. My aging feet were safely supported in well-cushioned hiking boots.

Back in the real world, professional attire does not allow comfy hiking boots to substitute for the youthful fatty padding my vintage bones have lost through nature’s wear and tear. When I read recently about some new, biomechanically-engineered, arthritis-assuaging shoes designed by Tom Andriacchi, PhD, at Stanford’s BioMotion Lab - and available at retail stores - I stood up and cheered. Another option to maintain my mobility!

Andriacchi, a world-class expert on gait and osteoarthritis, was persuaded by Laura Carstensen, PhD, founding director of the Stanford Center on Longevity, to apply his knowledge and creativity to the challenge of therapeutic footwear. She saw the opportunity to break out of the classic thinktank syndrome with a breakthrough bench-to-bedside project. She explains:

This is the poster child for us. There are an awful lot of important ideas that academics generate and then sit back and hope someone adopts. Most researchers are not trained to move ideas past the conceptual stage. What we do at the center is to show how and where those ideas can be useful. We help to move practical ideas, based on science, forward to a place where they can positively affect peoples’ lives.

On behalf of my age group and up, I am grateful for that thought.

Previously: Exercise may alleviate symptoms of arthritis regardless of weight loss

For people suffering from back pain, there’s about a 25 percent chance the culprit is a herniated disc, commonly known as a slipped disc, which occurs most often in the lower back. While the condition generally gets better within six months, it can be quite painful, resulting in soreness in the legs and rear end. Physicians often try to relieve this pain with a steroid injection in the spine, but according to Stanford orthopaedic surgeon Gaetano Scuderi, MD, there’s only about a 50 percent chance this approach will work.

“Most people figure, ‘Hey, I have nothing to lose,’” Scuderi recently told me. “However, there is a significant expense, not to mention the procedural risks and lost productivity.”

In a study appearing in the Aug. 15 edition of Spine, Scuderi and colleagues show how they identified a unique protein complex that may signal whether a patient will respond to an epidural steroid injection. As I write in a press release, testing for this biomarker could offer several advantages to patients:

If patients with lower-back pain could be screened to determine whether they would respond to the injections, they could be spared the discomfort and cost of a futile procedure, Scuderi said, as well as its potential complications, such as bleeding, infection and thinning and even death of bone tissue.

This research involved 26 patients, and the authors say larger trials are needed.

Photo by planetc1

We’ve written extensively about a recent Stanford study (.pdf) that links health problems and an increased cancer risk with a bone-growth product sold by Medtronic. Now The Spine Journal, which published this and other reports on the product in a special issue in June, has received the 2011 “Journalism That Matters” award from the American Society of Business Publication Editors. Stanford orthopedist Eugene J. Carragee, MD, edits the journal.

From the New York Times’ Media Decoder:

It is highly unusual for one group of researchers to publicly repudiate the work of professional colleagues. And by throwing down its challenge, the special issue of The Spine Journal, which is the official journal of the North American Spine Society, was something of a turning point in the debate over conflicts of interest in research paid for by makers of medical products.

For their part, the Medtronic-supported researchers who were scrutinized by The Spine Journal have defended their findings. And Medtronic has said it reported all adverse reactions related to Infuse to the Food and Drug Administration.

But there is little doubt that The Spine Journal’s coverage has had an effect. Last week, Medtronic took the unusual step of announcing that it was giving a $2.5 million grant to Yale so that independent researchers could conduct a broad review of all Infuse studies in order to determine the facts. The editor of The Spine Journal, Dr. Eugene J. Carragee, called the move an important first step.

Previously: For the record: Carragee on Medtronic spine stories, Stanford-led study on Medtronic bone product dominates the headlines, Stanford orthopedist reveals problems with Medtronic spinal fusion product and Stanford study links spine product to male infertility