November 20, 2024 • 23 mins
Unlock the future of orthopaedic surgery as Arun Aneja, MD, PhD, a trailblazer in trauma surgery, unveils groundbreaking advancements in surgical implants. Explore how technology is reshaping the field with fourth-generation intramedullary nails and antibiotic-coated implants that promise to treat complex fractures and minimize complications. Discover the innovative biphasic plates designed to adapt dynamically to the healing needs of fractures, offering a glimpse into a more personalized approach to patient care. Dr. Aneja's pioneering insights reveal the transformative potential of these technologies, redefining the landscape of orthopaedic trauma surgery, one innovation at a time.
Delve into crucial topics such as antibiotic stewardship in orthopaedic procedures, where Dr. Aneja emphasizes the importance of responsible usage to combat resistance. Learn about the cutting-edge attachment of antibiotics to implants for sustained release and the use of growth factors to enhance bone healing. Consider the balance between the benefits of emergent technologies and their financial implications on healthcare systems. This episode serves as an enlightening journey through the latest orthopaedic innovations, offering listeners a detailed look into the exciting trajectory of trauma surgery and its future implications.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
Speaker 2 (00:20):
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
This AOA podcast series willfocus on the future in
orthopedic surgery and theimpact on leaders in our
profession.
These podcasts will focus onthe vast spectrum of change that
will occur as the futurereveals itself.
We will consider changes asthey occur in the domains of
(00:41):
culture, employment, technology,scope of practice, compensation
and other areas.
My name is Doug Lundy, host forthis podcast series.
Joining us today is Dr ArunAneja.
Dr Aneja is a board-certifiedorthopedic trauma surgeon
(01:02):
specializing in orthopedictrauma.
He's originally from Greenville, north Carolina, where he
obtained his undergraduatemedical school degrees at the
University of North Carolina.
At Chapel Hill, he thenobtained a PhD in clinical
health sciences and then hisorthopedic surgical residency at
the University of Mississippi.
Dr Inesia's doctoral researchfocused on the use of
(01:24):
mesenchymal stem cells infracture care for patients with
osteoporosis.
He completed his oncologyfellowship at the University of
Chicago and then his orthopedictrauma fellowship at Wake Forest
University.
For the eight years prior tocoming to Mass General, dr
Inesia had been teaching as anassociate professor of
(01:44):
orthopedic trauma at theUniversity of Kentucky.
He currently serves as thedirector of orthopedic trauma
research at Mass General as anationally recognized leader in
orthopedic trauma surgery.
So, dr Anasia, welcome to thepodcast, sir.
Speaker 3 (01:59):
Well, thank you for having me.
This is quite the honor.
Speaker 2 (02:02):
First of all, you've got a very diverse and unique
educational background, not onlywith your PhD, but also with
your fellowships in oncology andin trauma, I get this is
probably not a whole lot.
You're afraid of man.
Speaker 3 (02:17):
Oh no, Always a healthy balance and healthy
skepticism and fear every singlesurgical case.
Speaker 2 (02:23):
Well, well said, but you certainly are trained
adequately to address those.
But today, and as you and Italked, we're going to be
talking about changes intechnology, specifically in the
lines of surgical implants, andyou've spoken on this before,
specifically within the AOA andother contexts.
So, sir, as the futurecontinues to change and you and
(02:46):
I are both orthopedic traumasurgeons, so hopefully the
audience will forgive us if wetend to talk about what you and
I like to talk about, the bestor the most when do you see
implants going in the future interms of surgical implants?
Speaker 3 (03:03):
Yeah, I think there's many different directions to go
.
If you look at, what we'redoing in orthopedic trauma is
we're starting to treat more andmore fractures with endosteal
implants as opposed toperiosteal implants.
So there's an explosion in theintramuscular nail market.
You also see that.
You know we're now currently inthe fourth generation of
(03:24):
intramuscular nails initially.
You know we're now currently inthe fourth generation of
intermeasure nails, initially,you know, prior to the Kushner
nails, prior to the Cloverleafnails.
You know the earliergenerations.
We are now starting to treatmuch more extreme fractures,
much more distal fractures thanjust diafseal fractures.
We're starting to treatmetafseal and articular
fractures and so there's justbeen an explosion and I think
(03:45):
they described it as a fourthgeneration inch and measure
nailing, where we're nowstarting to see nails that have
some sort of fixed angle,whether it's capture, whether
it's some sort of polymer,whether it's interlocking within
the threads of the interlockinghole or whether it's some sort
of coating within the nail.
That's kind of become popularoverseas and hopefully would get
(04:08):
adopted in the United States.
So I think the explosion inorthopedic trauma recently has
been predominant in theintramedial nail sector.
That's one area, particularlywith coating as well as ability
to have a better stability andability to treat more and more
(04:28):
extreme fractures.
The other area that's beenreally taking off is in if you
want to talk about the more sothe periosteal plates, is the
whole concept of the straintheory, having these biphasic
plates, having these plates thatsomehow modulate their strain
within so that at times when youneed the implant to be very
stiff, it can sort of modulatethat strain.
(04:51):
That can kind of give you thatand as the fracture starts
healing, whether you need moreflexibility or whether you need
more stiffness, these biphasicplates are starting to take off.
So those are the two sort ofareas that I really see.
Non-unions are problems,infections are problems.
Treating fractures withendosteal implants always
(05:12):
advantage.
So the nail sectors, I think isreally worth scrolling.
Speaker 2 (05:16):
So you brought up the coated implants.
That in and of itself is anabsolutely amazing thing.
Where do you see coatedimplants going?
What are we coating them withand why are we doing it?
Speaker 3 (05:29):
to have just with their non-union rates.
So, believe it or not, overseas, in Europe, you know antibiotic
coated nails are already beingmade and used, right, they don't
have as tight FDA regulations,so they're one of the largest
(05:50):
vendors.
Synthes already has a genomizedand coated nail that's well
approved and used in Europe.
However, that never gotapproved in the United States,
whether it's FDA or whatever.
But I see within the nearfuture that there is going,
instead of us having to dooff-label, you know assembly of
(06:11):
antibiotic coated nails that wedo in our back table with the
cement gun and you know the heat.
Stable tubing, tigon tubing,whichever tubing you decide to
use stable tubing, tigon tubing,whichever tubing you decide to
use I anticipate in the nearfuture you will have major,
large vendors produce antibioticcoated nails.
In addition, you know, is itpossible that certain nails
(06:35):
might also have BMPs attached toit?
Yeah, that's also somethingthat's been looked into.
I don't know of any vendorthat's specifically making that,
but I think that there has beentalk on that issue as well.
But I see infection control asone of the biggest things.
Speaker 2 (06:45):
I was talking with Dan Barry.
I heard him give a talk at ameeting I was attending and
believe that infected totaljoint arthroplasty was the big
frontier in total joints thatstill nothing had progressed
along with.
Let's hop back to theantibiotic-coated nails.
What about the risks ofdeveloping resistance
(07:08):
overtreating?
I mean, I get what you'resaying.
However, let me play devil'sadvocate for a minute.
There's a fair number of tibiafractures, femoral fractures,
that never get infected.
Are we causing any additionalproblems by coating these with
antibiotics versus just treatingthe ones that would have been
infected?
Speaker 3 (07:27):
You know this is a great question, but if you see
the wave of practice, currentlythe whole topic of local
antibiotic delivery has takenoff.
You know whether it's the, theVanco trial or whatnot, but
reality is we're using localantibiotics a lot more
frequently than we were, youknow, and so this whole concept
(07:49):
of resistance is a very keyissue.
I don't see this sort of goingaway.
I see us still continuing touse it despite the evidence.
Right, like vancomycinresistant enterococcal VRE is
like a huge concern, right, butwe still use vanco, right.
What do we do?
We combine it.
Well, let's combine.
Let's do synergism.
Let's combine it with anotherantibiotic that works a
(08:10):
different mechanism.
So that way I have less concernabout resistance.
Right now I'm giving twoantibiotics that work different
mechanisms.
So I'm adding bank withtilbomycin and I'm hoping that
now the likelihood of gettingresistance is going to be less.
The likelihood of eradicatingthe bacteria is going to be much
higher.
But it's definitely a validconcern.
(08:32):
I don't see it playing outquite yet in that sense, in the
sense that we're still going tocontinue using local antibiotics
.
Hopefully we will use localantibiotics that aren't the big
guns, right.
Hopefully we're not alwaysjumping to vancomycin you know
meropenem like the one of thelargest guns.
Fortunately, you know I don'tknow about heat stability, but
(08:53):
we aren't mixing that withantibiotic, right?
Nobody's sprinkling meropenemin the wound, right Like that's
one of our biggest guns.
And I think if you start doingthat, I anticipate you're going
to be getting phone calls fromthe infectious disease doctors.
I've definitely had times whereI've wanted certain antifungals
in my antibiotic implants andI've definitely gotten calls
from the pharmacist at theacademic center and be like hey,
(09:15):
why do you need this?
And so I, and that there'senough stewardship within these
large academic center wherethere's some sort of regulatory
oversight.
As of now, I still see certainantibiotics that we're allowed
to use, but if we use some ofthe ones that are the bigger
guns per se, I could see that asbeing a huge problem.
(09:38):
But I think tobramycin will beused, I think genomycin will be
used, I think vancomycin, evendespite BRE and other things, is
still going to be used.
Speaker 2 (09:47):
How do the antibiotics?
How do they attach theantibiotics to the nail?
I've heard of nanotubes, someof the things.
Do you know?
How does that work?
Speaker 3 (09:55):
Yeah.
So I think that's a greatquestion.
You know it has to be in somesort of manner that provides the
best sustained delivery.
So, whether you know, whatevercore site that gets fabricated
has to have some bioavailabilitydata to show that, hey, you're
going to see this peak ofantibiotic at 48 hours, but
(10:16):
you're going to get constantelution that is good for
bactericidal activity for asgood as two weeks.
The last thing you want is youjust want to rush of antibiotics
and then you know it's nolonger effective, and that's how
I think you might lead to moreresistance happening.
So, from what I've seen not theones that have been approved,
(10:36):
the one in Europe, it's usuallysort of four size particles that
are attached and manufacturedto the actual nail itself.
Speaker 2 (10:46):
So you have also talked about the growth factors
attached to the nails.
How does that work, and whatgrowth factors are you aware
that are being considered?
Speaker 3 (10:54):
Yeah, I think there's a lot of debate on this right
Like so I could see BMP2s, bmp7,op1.
Way that we're going is we'renow starting to realize it's not
a single bone morphogenicprotein.
Rather, there's nothing as goodas Autograph right, the whole
(11:21):
constellation of factors.
So I don't know if it's goingto be a single bone morphogenic
protein or a single growthfactor.
I think whatever it's going tobe, it's likely going to be a
constellation and again it'sgoing to have to demonstrate
some sort of peak elutionproperty that is super
advantageous.
I don't know any nail on themarket in the United States that
(11:42):
has done that quite yet, butwhatever the way it goes in the
future, they would have to showreally good elution properties
and it'd be something that isnot individualistic in the sense
of a single bone morphogeneticprotein, but rather a
constellation, and it's got tobe as good, if not somewhat
resemblance of autographed.
Speaker 2 (12:03):
So let's continue on our non-union theme here.
As you and I are well aware,sometimes supraconolar distal
femoral fractures of differenttypes are prone to go to
non-union, and the implants thatwe currently utilize are often
accused of being too stiff.
So we've heard of far distallocking and all the other
modifications that you can do tothe plating techniques to
(12:25):
increase or decrease therigidity of the construct.
Can you tell us more aboutthese biphasic plates?
How does that work and how doyou modulate the stiffness of
the plate?
Speaker 3 (12:37):
Yeah, I know.
So this is a great question inthe sense that what I've seen so
far is at certain industrydevelopment centers there have
actually been implants that havestrain gauges which can
actually record data about theplate of the implant that's
being used and deliver it to theiPhone or some sort of computer
(12:59):
device.
So it gives you an idea of like, hey, at early fracture healing
, this is the amount of strainthat needed.
At later fracture healing, thisis the amount of strain that is
much more optimal forconsolidation healing.
The biphase plates is somethingthat's just been recently
introduced.
I am still kind of fully tryingto understand it.
You know it is on the market inEurope but it hasn't made its
(13:22):
way all the way to the UnitedStates and it's very much in its
experimental developmentalstages.
I know it's won severalincubator awards.
But to be honest with you, Iknow that somehow and I don't
know exactly it definitelydoesn't have an internal strain
gauge built in, but it somehowit modulates strain.
So that way they know, at acertain time point where you
(13:44):
want flexibility to get thatmicromotion and callus formation
, it can induce it, thatmicromotion, and callus
formation.
Speaker 2 (13:50):
It can induce it so many times, especially now with
the finite amount of money inhealthcare.
One could argue that thesetechnologies, although they're
incredibly cool, are anadditional expense to the system
.
So can you talk at all aboutthe value basis of healthcare in
terms of what is the additionalcost of these implants and the
(14:13):
development of these implantsworth the overall spend?
Are we treating enough adequatedisease with the amount of
money that we're spending withthis, or are these just cool
gadgets that we like to use?
Speaker 3 (14:24):
Yeah, that's a good problem to notice, right, Like I
mean these newer technology,guess what R&D is going into it?
Big companies are going to bewanting to push and pedal it
because they cost a lot more.
And what does that mean?
That means your patients aregoing to get charged a lot more.
So, yes, is it worth paying forall these bells and whistles?
Probably not.
So another area of explosionthat's been happening is now
(14:44):
you're starting to get, you know, pre-contoured plates for the
medial distal femur.
You're getting pre-contouredplates for the posterior tibia.
You know, like, does that, dothese areas really need it, or
can you just do cheaper or muchmore utilitarian use with
off-label use?
So I 100% agree.
(15:05):
I do think we're saturating themarket and I definitely think
this is something that theindustry sector is kind of
pushing and doesn't need to bedone.
Probably not.
You can.
You know fractures can bedefinitely treated with standard
implants, right?
That's something I think ofalmost every day, because I know
there's a charge master sheetthat the hospital is using and
(15:26):
so even if the vendor tells youoh, this is only $100, $200 more
, I know the patient's gettingcharged a lot more.
So you're a hundred percentright, the value.
Cost is probably not worth allthese bells and whistles, and so
there's oversaturation.
Speaker 2 (15:39):
And you're at Mass General where a bunch of this
research is going on.
Don't tell us anything thatyou're not supposed to tell us.
But where can you tell us aboutwhat y'all are doing over in
Boston to make things better forthe rest of us?
Speaker 3 (15:50):
Yeah, so.
So maybe not so much in thetrauma line, but one thing that
Mass General has been prolificin is making the highly
cross-linked polyethylene that'sused in all the tibial trays
and now in reverse shoulders andalmost any sort of arthroplasty
.
So just highly cross-linkedpoly.
(16:11):
I don't know what the status ofpatent is.
I imagine patents run out afterX amount of time, right?
So industry definitely feelsthe pressure to add newer,
cooler technology, more bellsand whistles, so they can keep a
new patent that can charge justas much, as opposed to selling
something that's a lot lessexpensive and has more
(16:33):
competitors now because thepatents run out.
So I know in the polyethylenespace for arthroplasty they have
been doing something similar towhat we talked about is having
polyethylene that hasantimicrobial particles etched
in so that it also elutesantibiotic in the arthroplasty
(16:56):
setting, right, like so if youget a total knee, now you've got
this highly crossing polythat's eluting antibiotics, you
know, for X number of days.
That's microcytal orbactericidal for, you know,
preventing infection.
So that's one thing thatthey're definitely working on.
At the same time, if you notice,pain cocktails have really
taken off in the arthroplastyliterature and so, like you know
, a lot of patients, after theyget the total knees or total
(17:16):
hips done, they get like acocktail injection at the site.
And so again, similar conceptnow that are also trying to, you
know, have these sort ofanalgesic drugs attached to this
polyethylene.
That again gets eluded out.
So now you're treatingconstellation.
Not only are you treating and,you know, preventing infection,
but this will also help withyour pain.
So, yes, this whole concept oflocal delivery of drugs, whether
(17:39):
it's antibiotics, painanalgesic medication or whatever
bone morphogenic proteins, Ithink that's something that's
really appealing.
Speaker 2 (17:46):
Just local drug delivery very good, and you guys
are working on that over thereat Mass General.
Speaker 3 (17:54):
I think that's the new from what I heard from
attending me going to the HarrisLab, which is the lab that
developed it.
That's where they're sort ofheading.
Speaker 2 (18:02):
Very interesting.
So where do you see perhaps 10to 15 to 20 years from now?
What's it going to be like interms of when we pop the trays
in the back table to do totaljoint arthroplasty or trauma
surgery or whatever?
Do you see any new standards ofwhat it would look like then
and how our children may go?
Well, mom, dad, they did thebest they could with what they
(18:24):
had, but, as we know, that oldtitanium rod is not used anymore
, do you have any insight as towhere that'll be at that time?
Dr Justin Marchegiani.
Speaker 3 (18:32):
I hope we will continue to evolve and get
better.
If history has been any sort ofrepresentation of our future,
you know, like the whole fieldof orthopedics has really
advanced a lot, right, like Imean from World War II, like we
talked about Kunchner nails,right, this whole concept of a
slotted nail or that you kind ofcompress, you stick into the
(18:54):
medial canal and let the nailexpand, kind of compress, you
stick into the medullary canaland let the nail expand.
Then you come up with the ideaof, hey, let's go and create
some interlocking holes.
So now that we have rotationalas well as we can prevent
shortening.
And then you bring in theconcept of reaming.
We're definitely moving in theright direction.
Right, like reaming, we findthe biological value of that.
We started using reamerirrigator aspirators, you know.
(19:15):
So I think we're, I hope we'removing in the right direction.
But it's going to be a finebalance.
Like you mentioned, the wholeidea is not to get oversaturated
.
You don't want to be the firstone to jump on the bag when
bandwagon and you definitelydon't want to be the last right?
So so I anticipate technologyis going to keep innovating.
There's going to be failures,but there will also be successes
, and time and well-testedresearch is really going to help
(19:40):
us sort of figure out whichimplants are better and which
implants are of value, and whichones are worth innovating,
which ones are worth notredesigning and failure.
Speaker 2 (19:50):
And it's interesting, the Harvard Business School, of
course, is not very far fromyou all over there, of course,
is not very far from you allover there, and you could.
One could say that the futurein implant design is the
introduction in the advent ofcheaper, more cost-effective
implants.
I mean, like, as our iphonesbecome more and more technology,
have more and more technology,the prices also tend to go down
(20:11):
over time.
So that could also be a certainway that technology could
progress.
But we keep talking aboutranking the right, the ranking
cost up.
But it could go the other wayas well.
Speaker 3 (20:22):
Yeah, without a doubt .
You know, I mean, I don't haveto tell anyone.
You're like the expert onhealth care, you know the costs
associated with it.
But, like plastic example ofsign nail right, sign nail is
super cheap, right, but yet theyhaven't taken off in the United
States, right, and overseasthey're getting used all the
time, but, yeah, does thepharmaceutical?
Does the big vendors have somepart in this?
Yeah, probably.
But yes, I do think thathealthcare costs are immense and
(20:46):
I do not think they'resustainable at the rate that
we're going.
So somewhere something's gonnagive, so it's value.
Cost analysis always gotta beon the top of your mind.
Speaker 2 (20:55):
But to your point on that, as leaders in surgery, it
is incumbent on us to help focusnot just another cool gadget
that really doesn't solve aproblem but we just think it's
cool and want to do that, asopposed to, like I said before,
of the issues of infection andtotal joint arthroplasty
infection and trauma, trauma,nine unions and trauma to help
(21:17):
push industry to actuallyspending money and doing cool
things on areas that actuallymake a difference and not so
much things that we just thinkare fun to use, right?
Speaker 3 (21:29):
Yeah, yeah.
Now you have so many differentcompanies, right, like earlier,
we only had a couple of majorcompanies.
Now you got so many differentvendors.
Now a one foot and anklecompany is now starting to come
up with their trauma line, sothey've got their own.
So, yes, all these things needto be thought.
It'd be ideal, it'd be great toget companies to work together,
but that's not going to happenin a capitalistic market.
But all great points.
Speaker 2 (21:52):
All right, parting shot, my friend.
Any other additions to whereyou see things going in the
future, anything that we shouldbe looking for, anything fun and
edgy in the future of implants.
Speaker 3 (22:04):
No, you know exciting times, but at the same time I
kind of want to stress somethingthat we've already talked about
just as a healthy skepticism.
You know, don't be the firstone to jump on a bandwagon and
don't be the last kind of reallysee how the literature plays
out for certain implants.
We've seen various implantsthat come into the market and
have significant failure ratesassociated with it.
So just stay tried and true toprinciples and I think that will
(22:28):
guide you the best.
Speaker 2 (22:31):
It has been an absolute pleasure talking about
the future of surgical implantswith Dr Arun Aneja, who is an
orthopedic trauma surgeon atMass General.
He's got his PhD as well inthis and is certainly an expert
in these areas and has a veryinteresting and intriguing
viewpoint on these things.
It's been fun to give a peekinto the future on this and also
(22:51):
talk to a fellow leader inorthopedic trauma surgery, Dr
Aneja.
Sir, thank you for being on thepodcast.
Speaker 3 (22:57):
Dr Lundy, Thank you so much for having me.
This has been extremelyenjoyable, informative and I
look forward to listening tothis when it gets released.
Speaker 2 (23:07):
Yes, sir, and y'all look forward to future episodes
in the future in orthopedicsurgery podcast series.
Speaker 1 (23:14):
Orthopedic Surgery Podcast Series.
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
Speaker 2 (00:20):
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
This AOA podcast series willfocus on the future in
orthopedic surgery and theimpact on leaders in our
profession.
These podcasts will focus onthe vast spectrum of change that
will occur as the futurereveals itself.
We will consider changes asthey occur in the domains of
(00:41):
culture, employment, technology,scope of practice, compensation
and other areas.
My name is Doug Lundy, host forthis podcast series.
Joining us today is Dr ArunAneja.
Dr Aneja is a board-certifiedorthopedic trauma surgeon
(01:02):
specializing in orthopedictrauma.
He's originally from Greenville, north Carolina, where he
obtained his undergraduatemedical school degrees at the
University of North Carolina.
At Chapel Hill, he thenobtained a PhD in clinical
health sciences and then hisorthopedic surgical residency at
the University of Mississippi.
Dr Inesia's doctoral researchfocused on the use of
(01:24):
mesenchymal stem cells infracture care for patients with
osteoporosis.
He completed his oncologyfellowship at the University of
Chicago and then his orthopedictrauma fellowship at Wake Forest
University.
For the eight years prior tocoming to Mass General, dr
Inesia had been teaching as anassociate professor of
(01:44):
orthopedic trauma at theUniversity of Kentucky.
He currently serves as thedirector of orthopedic trauma
research at Mass General as anationally recognized leader in
orthopedic trauma surgery.
So, dr Anasia, welcome to thepodcast, sir.
Speaker 3 (01:59):
Well, thank you for having me.
This is quite the honor.
Speaker 2 (02:02):
First of all, you've got a very diverse and unique
educational background, not onlywith your PhD, but also with
your fellowships in oncology andin trauma, I get this is
probably not a whole lot.
You're afraid of man.
Speaker 3 (02:17):
Oh no, Always a healthy balance and healthy
skepticism and fear every singlesurgical case.
Speaker 2 (02:23):
Well, well said, but you certainly are trained
adequately to address those.
But today, and as you and Italked, we're going to be
talking about changes intechnology, specifically in the
lines of surgical implants, andyou've spoken on this before,
specifically within the AOA andother contexts.
So, sir, as the futurecontinues to change and you and
(02:46):
I are both orthopedic traumasurgeons, so hopefully the
audience will forgive us if wetend to talk about what you and
I like to talk about, the bestor the most when do you see
implants going in the future interms of surgical implants?
Speaker 3 (03:03):
Yeah, I think there's many different directions to go
.
If you look at, what we'redoing in orthopedic trauma is
we're starting to treat more andmore fractures with endosteal
implants as opposed toperiosteal implants.
So there's an explosion in theintramuscular nail market.
You also see that.
You know we're now currently inthe fourth generation of
(03:24):
intramuscular nails initially.
You know we're now currently inthe fourth generation of
intermeasure nails, initially,you know, prior to the Kushner
nails, prior to the Cloverleafnails.
You know the earliergenerations.
We are now starting to treatmuch more extreme fractures,
much more distal fractures thanjust diafseal fractures.
We're starting to treatmetafseal and articular
fractures and so there's justbeen an explosion and I think
(03:45):
they described it as a fourthgeneration inch and measure
nailing, where we're nowstarting to see nails that have
some sort of fixed angle,whether it's capture, whether
it's some sort of polymer,whether it's interlocking within
the threads of the interlockinghole or whether it's some sort
of coating within the nail.
That's kind of become popularoverseas and hopefully would get
(04:08):
adopted in the United States.
So I think the explosion inorthopedic trauma recently has
been predominant in theintramedial nail sector.
That's one area, particularlywith coating as well as ability
to have a better stability andability to treat more and more
(04:28):
extreme fractures.
The other area that's beenreally taking off is in if you
want to talk about the more sothe periosteal plates, is the
whole concept of the straintheory, having these biphasic
plates, having these plates thatsomehow modulate their strain
within so that at times when youneed the implant to be very
stiff, it can sort of modulatethat strain.
(04:51):
That can kind of give you thatand as the fracture starts
healing, whether you need moreflexibility or whether you need
more stiffness, these biphasicplates are starting to take off.
So those are the two sort ofareas that I really see.
Non-unions are problems,infections are problems.
Treating fractures withendosteal implants always
(05:12):
advantage.
So the nail sectors, I think isreally worth scrolling.
Speaker 2 (05:16):
So you brought up the coated implants.
That in and of itself is anabsolutely amazing thing.
Where do you see coatedimplants going?
What are we coating them withand why are we doing it?
Speaker 3 (05:29):
to have just with their non-union rates.
So, believe it or not, overseas, in Europe, you know antibiotic
coated nails are already beingmade and used, right, they don't
have as tight FDA regulations,so they're one of the largest
(05:50):
vendors.
Synthes already has a genomizedand coated nail that's well
approved and used in Europe.
However, that never gotapproved in the United States,
whether it's FDA or whatever.
But I see within the nearfuture that there is going,
instead of us having to dooff-label, you know assembly of
(06:11):
antibiotic coated nails that wedo in our back table with the
cement gun and you know the heat.
Stable tubing, tigon tubing,whichever tubing you decide to
use stable tubing, tigon tubing,whichever tubing you decide to
use I anticipate in the nearfuture you will have major,
large vendors produce antibioticcoated nails.
In addition, you know, is itpossible that certain nails
(06:35):
might also have BMPs attached toit?
Yeah, that's also somethingthat's been looked into.
I don't know of any vendorthat's specifically making that,
but I think that there has beentalk on that issue as well.
But I see infection control asone of the biggest things.
Speaker 2 (06:45):
I was talking with Dan Barry.
I heard him give a talk at ameeting I was attending and
believe that infected totaljoint arthroplasty was the big
frontier in total joints thatstill nothing had progressed
along with.
Let's hop back to theantibiotic-coated nails.
What about the risks ofdeveloping resistance
(07:08):
overtreating?
I mean, I get what you'resaying.
However, let me play devil'sadvocate for a minute.
There's a fair number of tibiafractures, femoral fractures,
that never get infected.
Are we causing any additionalproblems by coating these with
antibiotics versus just treatingthe ones that would have been
infected?
Speaker 3 (07:27):
You know this is a great question, but if you see
the wave of practice, currentlythe whole topic of local
antibiotic delivery has takenoff.
You know whether it's the, theVanco trial or whatnot, but
reality is we're using localantibiotics a lot more
frequently than we were, youknow, and so this whole concept
(07:49):
of resistance is a very keyissue.
I don't see this sort of goingaway.
I see us still continuing touse it despite the evidence.
Right, like vancomycinresistant enterococcal VRE is
like a huge concern, right, butwe still use vanco, right.
What do we do?
We combine it.
Well, let's combine.
Let's do synergism.
Let's combine it with anotherantibiotic that works a
(08:10):
different mechanism.
So that way I have less concernabout resistance.
Right now I'm giving twoantibiotics that work different
mechanisms.
So I'm adding bank withtilbomycin and I'm hoping that
now the likelihood of gettingresistance is going to be less.
The likelihood of eradicatingthe bacteria is going to be much
higher.
But it's definitely a validconcern.
(08:32):
I don't see it playing outquite yet in that sense, in the
sense that we're still going tocontinue using local antibiotics
.
Hopefully we will use localantibiotics that aren't the big
guns, right.
Hopefully we're not alwaysjumping to vancomycin you know
meropenem like the one of thelargest guns.
Fortunately, you know I don'tknow about heat stability, but
(08:53):
we aren't mixing that withantibiotic, right?
Nobody's sprinkling meropenemin the wound, right Like that's
one of our biggest guns.
And I think if you start doingthat, I anticipate you're going
to be getting phone calls fromthe infectious disease doctors.
I've definitely had times whereI've wanted certain antifungals
in my antibiotic implants andI've definitely gotten calls
from the pharmacist at theacademic center and be like hey,
(09:15):
why do you need this?
And so I, and that there'senough stewardship within these
large academic center wherethere's some sort of regulatory
oversight.
As of now, I still see certainantibiotics that we're allowed
to use, but if we use some ofthe ones that are the bigger
guns per se, I could see that asbeing a huge problem.
(09:38):
But I think tobramycin will beused, I think genomycin will be
used, I think vancomycin, evendespite BRE and other things, is
still going to be used.
Speaker 2 (09:47):
How do the antibiotics?
How do they attach theantibiotics to the nail?
I've heard of nanotubes, someof the things.
Do you know?
How does that work?
Speaker 3 (09:55):
Yeah.
So I think that's a greatquestion.
You know it has to be in somesort of manner that provides the
best sustained delivery.
So, whether you know, whatevercore site that gets fabricated
has to have some bioavailabilitydata to show that, hey, you're
going to see this peak ofantibiotic at 48 hours, but
(10:16):
you're going to get constantelution that is good for
bactericidal activity for asgood as two weeks.
The last thing you want is youjust want to rush of antibiotics
and then you know it's nolonger effective, and that's how
I think you might lead to moreresistance happening.
So, from what I've seen not theones that have been approved,
(10:36):
the one in Europe, it's usuallysort of four size particles that
are attached and manufacturedto the actual nail itself.
Speaker 2 (10:46):
So you have also talked about the growth factors
attached to the nails.
How does that work, and whatgrowth factors are you aware
that are being considered?
Speaker 3 (10:54):
Yeah, I think there's a lot of debate on this right
Like so I could see BMP2s, bmp7,op1.
Way that we're going is we'renow starting to realize it's not
a single bone morphogenicprotein.
Rather, there's nothing as goodas Autograph right, the whole
(11:21):
constellation of factors.
So I don't know if it's goingto be a single bone morphogenic
protein or a single growthfactor.
I think whatever it's going tobe, it's likely going to be a
constellation and again it'sgoing to have to demonstrate
some sort of peak elutionproperty that is super
advantageous.
I don't know any nail on themarket in the United States that
(11:42):
has done that quite yet, butwhatever the way it goes in the
future, they would have to showreally good elution properties
and it'd be something that isnot individualistic in the sense
of a single bone morphogeneticprotein, but rather a
constellation, and it's got tobe as good, if not somewhat
resemblance of autographed.
Speaker 2 (12:03):
So let's continue on our non-union theme here.
As you and I are well aware,sometimes supraconolar distal
femoral fractures of differenttypes are prone to go to
non-union, and the implants thatwe currently utilize are often
accused of being too stiff.
So we've heard of far distallocking and all the other
modifications that you can do tothe plating techniques to
(12:25):
increase or decrease therigidity of the construct.
Can you tell us more aboutthese biphasic plates?
How does that work and how doyou modulate the stiffness of
the plate?
Speaker 3 (12:37):
Yeah, I know.
So this is a great question inthe sense that what I've seen so
far is at certain industrydevelopment centers there have
actually been implants that havestrain gauges which can
actually record data about theplate of the implant that's
being used and deliver it to theiPhone or some sort of computer
(12:59):
device.
So it gives you an idea of like, hey, at early fracture healing
, this is the amount of strainthat needed.
At later fracture healing, thisis the amount of strain that is
much more optimal forconsolidation healing.
The biphase plates is somethingthat's just been recently
introduced.
I am still kind of fully tryingto understand it.
You know it is on the market inEurope but it hasn't made its
(13:22):
way all the way to the UnitedStates and it's very much in its
experimental developmentalstages.
I know it's won severalincubator awards.
But to be honest with you, Iknow that somehow and I don't
know exactly it definitelydoesn't have an internal strain
gauge built in, but it somehowit modulates strain.
So that way they know, at acertain time point where you
(13:44):
want flexibility to get thatmicromotion and callus formation
, it can induce it, thatmicromotion, and callus
formation.
Speaker 2 (13:50):
It can induce it so many times, especially now with
the finite amount of money inhealthcare.
One could argue that thesetechnologies, although they're
incredibly cool, are anadditional expense to the system
.
So can you talk at all aboutthe value basis of healthcare in
terms of what is the additionalcost of these implants and the
(14:13):
development of these implantsworth the overall spend?
Are we treating enough adequatedisease with the amount of
money that we're spending withthis, or are these just cool
gadgets that we like to use?
Speaker 3 (14:24):
Yeah, that's a good problem to notice, right, Like I
mean these newer technology,guess what R&D is going into it?
Big companies are going to bewanting to push and pedal it
because they cost a lot more.
And what does that mean?
That means your patients aregoing to get charged a lot more.
So, yes, is it worth paying forall these bells and whistles?
Probably not.
So another area of explosionthat's been happening is now
(14:44):
you're starting to get, you know, pre-contoured plates for the
medial distal femur.
You're getting pre-contouredplates for the posterior tibia.
You know, like, does that, dothese areas really need it, or
can you just do cheaper or muchmore utilitarian use with
off-label use?
So I 100% agree.
(15:05):
I do think we're saturating themarket and I definitely think
this is something that theindustry sector is kind of
pushing and doesn't need to bedone.
Probably not.
You can.
You know fractures can bedefinitely treated with standard
implants, right?
That's something I think ofalmost every day, because I know
there's a charge master sheetthat the hospital is using and
(15:26):
so even if the vendor tells youoh, this is only $100, $200 more
, I know the patient's gettingcharged a lot more.
So you're a hundred percentright, the value.
Cost is probably not worth allthese bells and whistles, and so
there's oversaturation.
Speaker 2 (15:39):
And you're at Mass General where a bunch of this
research is going on.
Don't tell us anything thatyou're not supposed to tell us.
But where can you tell us aboutwhat y'all are doing over in
Boston to make things better forthe rest of us?
Speaker 3 (15:50):
Yeah, so.
So maybe not so much in thetrauma line, but one thing that
Mass General has been prolificin is making the highly
cross-linked polyethylene that'sused in all the tibial trays
and now in reverse shoulders andalmost any sort of arthroplasty
.
So just highly cross-linkedpoly.
(16:11):
I don't know what the status ofpatent is.
I imagine patents run out afterX amount of time, right?
So industry definitely feelsthe pressure to add newer,
cooler technology, more bellsand whistles, so they can keep a
new patent that can charge justas much, as opposed to selling
something that's a lot lessexpensive and has more
(16:33):
competitors now because thepatents run out.
So I know in the polyethylenespace for arthroplasty they have
been doing something similar towhat we talked about is having
polyethylene that hasantimicrobial particles etched
in so that it also elutesantibiotic in the arthroplasty
(16:56):
setting, right, like so if youget a total knee, now you've got
this highly crossing polythat's eluting antibiotics, you
know, for X number of days.
That's microcytal orbactericidal for, you know,
preventing infection.
So that's one thing thatthey're definitely working on.
At the same time, if you notice,pain cocktails have really
taken off in the arthroplastyliterature and so, like you know
, a lot of patients, after theyget the total knees or total
(17:16):
hips done, they get like acocktail injection at the site.
And so again, similar conceptnow that are also trying to, you
know, have these sort ofanalgesic drugs attached to this
polyethylene.
That again gets eluded out.
So now you're treatingconstellation.
Not only are you treating and,you know, preventing infection,
but this will also help withyour pain.
So, yes, this whole concept oflocal delivery of drugs, whether
(17:39):
it's antibiotics, painanalgesic medication or whatever
bone morphogenic proteins, Ithink that's something that's
really appealing.
Speaker 2 (17:46):
Just local drug delivery very good, and you guys
are working on that over thereat Mass General.
Speaker 3 (17:54):
I think that's the new from what I heard from
attending me going to the HarrisLab, which is the lab that
developed it.
That's where they're sort ofheading.
Speaker 2 (18:02):
Very interesting.
So where do you see perhaps 10to 15 to 20 years from now?
What's it going to be like interms of when we pop the trays
in the back table to do totaljoint arthroplasty or trauma
surgery or whatever?
Do you see any new standards ofwhat it would look like then
and how our children may go?
Well, mom, dad, they did thebest they could with what they
(18:24):
had, but, as we know, that oldtitanium rod is not used anymore
, do you have any insight as towhere that'll be at that time?
Dr Justin Marchegiani.
Speaker 3 (18:32):
I hope we will continue to evolve and get
better.
If history has been any sort ofrepresentation of our future,
you know, like the whole fieldof orthopedics has really
advanced a lot, right, like Imean from World War II, like we
talked about Kunchner nails,right, this whole concept of a
slotted nail or that you kind ofcompress, you stick into the
(18:54):
medial canal and let the nailexpand, kind of compress, you
stick into the medullary canaland let the nail expand.
Then you come up with the ideaof, hey, let's go and create
some interlocking holes.
So now that we have rotationalas well as we can prevent
shortening.
And then you bring in theconcept of reaming.
We're definitely moving in theright direction.
Right, like reaming, we findthe biological value of that.
We started using reamerirrigator aspirators, you know.
(19:15):
So I think we're, I hope we'removing in the right direction.
But it's going to be a finebalance.
Like you mentioned, the wholeidea is not to get oversaturated
.
You don't want to be the firstone to jump on the bag when
bandwagon and you definitelydon't want to be the last right?
So so I anticipate technologyis going to keep innovating.
There's going to be failures,but there will also be successes
, and time and well-testedresearch is really going to help
(19:40):
us sort of figure out whichimplants are better and which
implants are of value, and whichones are worth innovating,
which ones are worth notredesigning and failure.
Speaker 2 (19:50):
And it's interesting, the Harvard Business School, of
course, is not very far fromyou all over there, of course,
is not very far from you allover there, and you could.
One could say that the futurein implant design is the
introduction in the advent ofcheaper, more cost-effective
implants.
I mean, like, as our iphonesbecome more and more technology,
have more and more technology,the prices also tend to go down
(20:11):
over time.
So that could also be a certainway that technology could
progress.
But we keep talking aboutranking the right, the ranking
cost up.
But it could go the other wayas well.
Speaker 3 (20:22):
Yeah, without a doubt .
You know, I mean, I don't haveto tell anyone.
You're like the expert onhealth care, you know the costs
associated with it.
But, like plastic example ofsign nail right, sign nail is
super cheap, right, but yet theyhaven't taken off in the United
States, right, and overseasthey're getting used all the
time, but, yeah, does thepharmaceutical?
Does the big vendors have somepart in this?
Yeah, probably.
But yes, I do think thathealthcare costs are immense and
(20:46):
I do not think they'resustainable at the rate that
we're going.
So somewhere something's gonnagive, so it's value.
Cost analysis always gotta beon the top of your mind.
Speaker 2 (20:55):
But to your point on that, as leaders in surgery, it
is incumbent on us to help focusnot just another cool gadget
that really doesn't solve aproblem but we just think it's
cool and want to do that, asopposed to, like I said before,
of the issues of infection andtotal joint arthroplasty
infection and trauma, trauma,nine unions and trauma to help
(21:17):
push industry to actuallyspending money and doing cool
things on areas that actuallymake a difference and not so
much things that we just thinkare fun to use, right?
Speaker 3 (21:29):
Yeah, yeah.
Now you have so many differentcompanies, right, like earlier,
we only had a couple of majorcompanies.
Now you got so many differentvendors.
Now a one foot and anklecompany is now starting to come
up with their trauma line, sothey've got their own.
So, yes, all these things needto be thought.
It'd be ideal, it'd be great toget companies to work together,
but that's not going to happenin a capitalistic market.
But all great points.
Speaker 2 (21:52):
All right, parting shot, my friend.
Any other additions to whereyou see things going in the
future, anything that we shouldbe looking for, anything fun and
edgy in the future of implants.
Speaker 3 (22:04):
No, you know exciting times, but at the same time I
kind of want to stress somethingthat we've already talked about
just as a healthy skepticism.
You know, don't be the firstone to jump on a bandwagon and
don't be the last kind of reallysee how the literature plays
out for certain implants.
We've seen various implantsthat come into the market and
have significant failure ratesassociated with it.
So just stay tried and true toprinciples and I think that will
(22:28):
guide you the best.
Speaker 2 (22:31):
It has been an absolute pleasure talking about
the future of surgical implantswith Dr Arun Aneja, who is an
orthopedic trauma surgeon atMass General.
He's got his PhD as well inthis and is certainly an expert
in these areas and has a veryinteresting and intriguing
viewpoint on these things.
It's been fun to give a peekinto the future on this and also
(22:51):
talk to a fellow leader inorthopedic trauma surgery, Dr
Aneja.
Sir, thank you for being on thepodcast.
Speaker 3 (22:57):
Dr Lundy, Thank you so much for having me.
This has been extremelyenjoyable, informative and I
look forward to listening tothis when it gets released.
Speaker 2 (23:07):
Yes, sir, and y'all look forward to future episodes
in the future in orthopedicsurgery podcast series.
Speaker 1 (23:14):
Orthopedic Surgery Podcast Series.
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