ORTHO NEWS

Metformin Treatment in T2D Patients May Reduce Risk for Joint Replacement: Population-based Study

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Persons with type 2 diabetes (T2D) who are treated with metformin may be at significantly reduced risk for total joint replacement (hip, knee) according to research from China published online January 19, 2023, in the Canadian Medical Association Journal.

The population-based matched cohort study of more than 40 000 participants found the risk of total knee replacement (TKR) or total hip replacement (THR) was reduced by 30% in participants who received metformin compared to those who did not.

Total joint replacement is often required in older adults with osteoarthritis (OA) primarily because there are no treatments available to prevent or reverse the chronic progressive joint disease, the authors write. They point to trends in the US where the demand for both TKR and THR is expected to reach 3.5 million by 2030 when a projected 572 000 surgeries will be required annually.

The investigators, led by Changhai Ding, MD, PhD, professor and director, Clinical Research and Orthopedic Centres, Zhujiang Hospital at Southern Medical University, Guangzhou, China, also point out that OA is common in those with T2D. In fact, T2D is a known OA risk factor, independent of body mass index and there is evidence that insulin resistance may hasten the development of OA. Interestingly, metformin, in addition to being the first line antihyperglycemic agent for T2D around the world, also has been associated with reducing risk of cardiovascular and inflammatory disease and shown to have chondroprotective effects. The authors cite evidence that intra-articular metformin administered shortly after joint injury has delayed OA development in animal models, as well.

In the US…the demand for both TKR and THR is expected to reach 3.5 million by 2030 when a projected 572 000 surgeries will be required annually.

Despite some evidence of a T2D-OA association, however, Ding et al say that, overall, studies looking at the potential correlation are “uncommon and inconclusive.”

To add to and help clarify existing findings, Ding et al tapped the Taiwan National Health Insurance Research Database, selecting adults aged ≥45 years who were diagnosed with T2D between 2000 and 2012. The investigators then identified those treated with metformin, defining a metformin user as anyone who had initiated the drug within 180 days before or after a diagnosis of T2D. Researchers matched metformin users by age, sex, and time of diagnosis with nonusers in the database. They conducted separate analyses using prescription time-distribution matching (PTDM) and propensity-score matching (PSM) to balance potential confounding variables.

The primary outcomes were TKR or THR after the index date (3 months after the first metformin prescription). The authors point out that because all cases were peer-reviewed before reimbursement was approved, the accuracy of the data on TKR and THR was high.

FINDINGS

The final study cohort numbered 40 694 participants with 20 347 each in the metformin user and nonuser groups. Mean age was 63 years 49.8% were women. A total of 837 patients underwent TKR and 148 underwent THR in the PTDM cohorts and an average of 90% of replacements were related to OA (97.5% for TKR, 50.7% for THR).

When Ding and colleagues compared participants who did not use metformin with those who did, use of metformin was associated with a lower cumulative incidence probability of TKR, THR or either joint replacement. The TKR incidence in the PTDM cohort was 2.96 vs 4.15 per 10 000 person-months for metformin users and nonusers respectively (adjusted hazard ratio [aHR] 0.71, 95% CI 0.61-0.84). For THR in this cohort incidence was 0.44 vs 0.83 per 10 000 person-months for users and nonusers respectively, with an adjusted HR of 0.61 (95% CI 0.41-0.92).

In the PSM cohort, when researchers compared metformin users with those who did not use the drug, the crude HR of total joint replacement was 0.73 (95% CI 0.61–0.87), and the adjusted HR was 0.75 (95% CI 0.62–0.89). They report a significant reduction in risk for TKR in metformin users compared to nonusers (aHR 0.76, 95% CI 0.62-0.92) and a similar but not significant reduction for THR (aHR 0.71, 95% CI 0.44-1.13) in the PMS cohort. Propensity-score matching analyses (10 163 participants not treated with metformin v. 10 163 treated with metformin) and sensitivity analyses using inverse probability of treatment weighting and competing risk regression showed similar results.

Diabetes and metabolic syndrome have both been linked to OA in the past, the investigators write. They point out also that although the biological mechanisms linking metformin with protection against OA remain unclear, the reduction in need for total joint replacement in T2D patients may be explained by metformin’s anti-inflammatory properties, its ability to sustain adenosine 5′-monophosphate–activated protein kinase activity in chondrocytes and to regulate metabolism.

“Given our findings and those of a previous observational study, a randomized trial of the efficacy of metformin in patients with OA is indicated. Metformin has been studied in patients without diabetes mellitus and was found to be safe,” they conclude.

Reference: Zhu Z, Huang J-Y, Ruan G, et al. Metformin use and associated risk of total joint replacement in patients with type 2 diabetes: a population-based matched cohort study. CMAJ. 2022;194:E1672-84. doi:10.1503/cmaj.220952

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Originally Appeared Here

Surgery for Juvenile Idiopathic Arthritis

Most kids with juvenile idiopathic arthritis never need surgery, but if your child does, here’s what you can expect.

Some 300,000 children ages 16 or younger have juvenile idiopathic arthritis (JIA), an umbrella term for various health conditions that can cause joint pain, swelling, stiffness, and loss of motion. Like other forms of arthritis, JIA starts when a child’s immune system becomes overactive, triggering an inflammatory response.

It’s not uncommon for JIA to be a long-term health condition, but there are many effective medications that can treat your child’s arthritis. Thanks to these drugs, inflammation is often brought under control before it reaches the point of causing joint damage. That means kids diagnosed with JIA today are much less likely to need surgery than in generations past.

Medication, along with active treatment tools like exercise and assistive devices such as splints, mean that your child’s joint pain can often be kept to a minimum.

Still, though considered a last resort, surgery may sometimes benefit some of the most severe cases of JIA. This could be either because medication is unable to stop the progression of joint damage, or your child was not diagnosed with JIA until after joint damage had already occurred. In these cases, surgery may offer pain relief with JIA and could also restore function to damaged joints.

Who Needs Surgery for JIA?

Step one, say experts, is to try and avoid invasive procedures for JIA kids. “We try to treat children aggressively with medication so we can preserve their joints and avoid surgery,” says Farzana Nuruzzaman, M.D., a pediatric rheumatologist at Stony Brook Children’s Hospital and clinical assistant professor at the Renaissance School of Medicine at Stony Brook University in Stony Brook, NY. “Unfortunately, in some cases the arthritis has caused so much damage that certain types of surgery are needed.” In those cases, if your child is not improving on medication and her quality of life is suffering, surgery may be an option.

If your child’s jaw is affected by arthritis pain, for instance, surgery might be recommended, says Beth Susan Gottlieb, M.D., chief of the division of pediatric rheumatology at Northwell Health in New Hyde Park, NY. “Arthritis in the jaw can slow down the growth of the lower jaw, which causes a smaller jaw,” Dr. Gottlieb explains. “Surgery can improve the appearance of the face and make the joint healthier.”

Types of JIA Surgery

If your child is a candidate for JIA surgery, it helps to know what to expect. The surgical procedures that may be recommended include:

Osteotomy

In an osteotomy, explains Dr. Nuruzzaman, a bone is cut and repositioned to fix a bone deformity. Then the bone is reset into a better position. An osteotomy could be performed on the foot, hip, knee, or the temporomandibular joint (TMJ) in the jaw. Jaw surgery can not only make eating and chewing easier but can improve a child’s facial structure and self-confidence. This procedure is considered low-risk and safer than a total knee or hip replacement, according to the American College of Rheumatology.

Joint Fusion (Arthrodesis)

In a joint fusion, “the surgeon removes the damaged cartilage from the ends of two bones that form a joint and then holds [the bones] in place with a pin or a rod,” Dr. Nuruzzaman explains. Over time, the two bones fuse to form a single unit, much as a broken bone fuses when it heals. While arthrodesis can stabilize a joint and help it bear weight better, the fusion of these bones will result in the loss of some mobility. It’s usually performed on joints in the foot and ankle, hand and wrist, or spine, per the Arthritis Foundation.

Synovectomy

The synovium is a thin membrane that lines the joint capsule, but when JIA causes chronic inflammation of this lining, it grows much thicker and can affect the structure and function of the joint. In this procedure, explains Dr. Nuruzzaman, the surgeon removes inflamed synovial lining that develops from chronic inflammation.A synovectomy alsocan be done arthroscopically, says Daniel Lovell, M.D., professor of pediatrics at the University of Cincinnati School of Medicine at the Cincinnati Children’s Hospital Medical Center. “The surgeon can go in using a scope and can also do an injection of steroids at the same time, which can reduce pain,” he says.

Epiphysiodesis

This procedure can help correct a difference in leg lengths, Dr. Nuruzzaman explains. (Leg-length discrepancy is a common symptom of JIA, per the American Academy of Orthopeadic Surgeons). Epiphysiodesis is usually is for children whose anticipated leg-length discrepancy is nearly an inch and who have a year or two of growth remaining. In a temporary epiphysiodesis, metal plates may be used to temporarily halt bone growth in the longer leg. With a permanent epiphysiodesis, part of the growth plate is removed.

“The growth plate of the longer leg is removed or replaced with a metal plate so the longer leg growth stops,” Dr. Nuruzzaman says. In addition, Dr. Lovell explains, if a leg has excessive angulation due to arthritis causing one side of the knee to grow faster, then a temporary epiphysiodesis may be used to straighten the leg by limiting the growth on the faster growing side of the knee joint.

Total Joint Replacement (Arthroplasty)

An arthroplasty “is when the damaged joint is removed and replaced with an artificial joint,” Dr. Nuruzzaman says. Considered a last-ditch option for children, it is usually reserved for a joint that is so damaged, painful, and stiff that it interferes with a child’s quality of life and ability to function. The hip is the joint that is most commonly replaced, followed by the knee. “Total joint replacement is usually done in later adolescence or young adulthood,” says Dr. Lovell.

The Pros and Cons of Surgery for JIA

All surgeries have a potential risk, and the surgeon should carefully explain both risks and benefits. And keep in mind: surgery is generally not a cure. “Surgeries do not protect against the progression of the underlying inflammatory disorder,” Dr. Nuruzzaman says.

Moreover, some surgeries may need to be repeated. For instance, performing TMJ surgery before facial growth is complete (15 years for girls and 17 to 18 years for boys) may mean that repeat operations may be necessary.

One con of joint fusion is that after the surgery, your child will not be able to bend the joint. And sometimes, the bone does not fuse, the wound may not properly heal, or arthritis develops in nearby joints due to stress from the fusion. It is important that you and your child understand both the benefits and risks of joint fusion.

Another consideration: Artificial joints cannot grow like natural joints so if the joint is replaced before growth is complete, then the growth in the area of the replaced joint will stop. In addition, an artificial joint does not last forever. For this reason, repeat surgeries are typically needed and can be more challenging to perform.

The main benefit of surgery for JIA is that for many children with juvenile arthritis, surgery can offer pain relief and improve their quality of life.

What You Can Expect After Surgery

Recuperation from surgery for JIA varies depending on the surgery, the joint, your child’s overall health, and more. Full recovery from a joint fusion may take months. After an epiphysiodesis, the recovery is brief and has few complications, per the Arthritis Foundation. One possible complication is that the metal plates could loosen, or a leg that is corrected temporarily could revert to its previous length.

Osteotomy procedures are generally low risk, but recovery can be rough: The Arthritis Foundation notes that for a few months after the procedure, kids have to wear elastic bands to support the jaw. They may also need to use a palatal splint and eat a soft diet.

After a synovectomy, symptoms like pain and swelling should get better. Usually, though, the synovium will grow back over time if there is not control of the inflammation in the joint with the medicines used to treat the arthritis, Dr. Lovell says. The synovectomy can be repeated if this happens.

Outlook for Children with JIA

The good news is that JIA is treatable, most children who have it can expect to live normal lives, and very few will need joint surgery, Dr. Lovell says. Some children will see their JIA go into remission.

And surgery can be a good option for some children with JIA. “We try to avoid surgery,” says Dr. Nuruzzaman. “But in some cases, it can improve a child’s quality of life.”

Meet Our Writer

Rosemary Black

Rosemary, the mom of seven, was food editor at the New York Daily News for many years and currently writes on health, food, and parenting for various magazines and websites. She is the co-author of six cookbooks, most

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Originally Appeared Here

Can Metformin Lower Need for Joint Replacement in Diabetes?

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Metformin may help reduce risk for total joint replacement in patients with type 2 diabetes (T2D), data suggest.

Dr Changhai Ding

Over a 24-month follow-up period, metformin use was associated with a 30% decrease in the risk of total knee and hip replacements, according to Changhai Ding, MBBS, MMed, MD, associate director of the Menzies Institute for Medical Research at the University of Tasmania in Hobart, Australia, and colleagues.

“Randomized controlled clinical trials in patients with osteoarthritis are warranted to determine whether metformin is effective in decreasing the need for joint replacement,” wrote the investigators.

Their findings were published online December 19 in the Canadian Medical Association Journal.

Low Doses Beneficial

The investigators identified patients diagnosed with T2D from 2000 to 2012 in the Taiwan National Health Insurance Research Database and compared those who used metformin with those who did not. They used prescription time-distribution matching and propensity-score matching to balance potential confounders between users and nonusers.

The study included 20,347 metformin-treated participants and 20,347 nonusers. The mean age at baseline was 63 years, and 49.8% of participants were women. Metformin users tended to have more severe diabetes. Common comorbidities in the cohort included hypertension and hyperlipidemia, but only about 16% in both groups had osteoarthritis. At baseline, participants also used various analgesics, as well as other diabetes drugs ranging from sulfonylureas to insulin.

Compared with nonusers, metformin users had had a 30% lower risk of total knee or hip replacement (adjusted hazard ratio [HR], 0.70). The incidence of total knee replacement among metformin nonusers and users was 4.15 per 10,000 person-months and 2.96 per 10,000 person-months, respectively. The incidence of total hip replacement was 0.83 per 10,000 person-months in nonusers and 0.44 per 10,000 person-months in users.

By joint type, the adjusted HR was 0.71 for total knee replacement and 0.61 for total hip replacement among metformin users.

The effect was observed at daily doses of less than 1 g, as well as daily doses of 1 g or more. “This suggests that metformin at a lower dosage could have effects on osteoarthritis,” Ding told Medscape Medical News. “Metformin is a safe, well-tolerated oral medication, even at higher but routinely used dosages. Therefore, for initial clinical trials, we still recommend the efficacy of metformin at routine dosages on knee osteoarthritis. If the effects are confirmed, we may explore whether a lower dosage of metformin is effective.”

Similar results emerged from propensity-score matching analyses and sensitivity analyses of 10,163 participants in each treatment group using inverse probability-of-treatment weighting and competing risk regression.

The biological mechanisms linking metformin and osteoarthritis have yet to be clarified, Ding explained. “Multiple mechanisms may be involved, including anti-inflammation, sustaining adenosine 5′-monophosphate-activated protein kinase activity in chondrocytes and dorsal root ganglia, and regulating metabolism.”

A previous study suggested an association between metformin and reduced annual loss of medial cartilage volume, and another found an association between metformin and reduced joint replacement surgery, said Ding. But another study reported no significant association between metformin use and osteoarthritis risk in patients with T2D. Recently, a retrospective cohort study by Li et al found that metformin users with diabetes had a 19% lower risk for total knee replacement than nonusers.

Ding’s group has begun a randomized clinical trial to see whether metformin can alleviate tibiofemoral cartilage volume loss in overweight patients with osteoarthritis.

No Uniform Indications

Commenting on the current findings for Medscape, Grace Hsiao-Wei Lo, MD, an assistant professor of immunology, allergy, and rheumatology at Baylor College of Medicine in Houston, Texas, called the observational study “thought-provoking.” She had concerns about the way it was conducted, however, including the potentially problematic features of the small percentage of the T2D cohort who had osteoarthritis. Another concern was the fact that the investigators only examined metformin, although patients used various other diabetic and analgesic drugs that might have had an effect. Metformin’s effect on osteoarthritis may result partly from its modest weight-loss effects, said Lo, who was not involved in the study.

Dr Grace Hsiao-Wei Lo

“Another issue with the study is that there is no set indication of the need for total knee or hip replacement. Each surgeon has a different standard,” she added. “And there’s lots of evidence that replacements are largely dependent not on need but on the interest of participants. “So, it’s not necessarily that a patient needs total joint replacement, it’s that they want it.”

Observational studies like this one are a long way from getting us to the prescribing of metformin specifically to prevent or mitigate osteoarthritis, David T. Felson, MD, MPH, a rheumatology researcher and a professor of medicine at Boston University, Boston, Massachusetts, told Medscape. Felson was not involved in the study.

Dr David Felson

“The drug’s mechanisms in osteoarthritis are still unclear. Its effect may be related to adenosine 5′-monophosphate-activated protein kinase activity,” he said. “The drug has pleiotropic effects and is safely used to treat other diseases such as polycystic ovarian syndrome. It may have antisenescence properties, since it’s been shown to extend life a bit in animals.” That said, Felson added, “Like statins, it’s not going be added to the drinking water anytime soon!”

This study was supported by the National Natural Science Foundation of China, Guangzhou Science and Technology Program, Guangdong Basic and Applied Basic Research Foundation, and Wu Jieping Medical Foundation Program. Ding, Lo, and Felson reported no competing interests.

CMAJ. Published online December 19, 2022. Full text.

Diana Swift is a freelance medical journalist based in Toronto, Ontario, Canada.

For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube.

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Originally Appeared Here

Patients with late-stage knee OA incur high costs for nonoperative treatments before total knee arthroplasty

In the year before total knee arthroplasty (TKA), patients incur considerable costs for nonoperative treatments and other procedures for osteoarthritis (OA) – raising questions about the value of those procedures, reports a study in The Journal of Bone & Joint Surgery. The journal is published in the Lippincott portfolio in partnership with Wolters Kluwer.

The study shows “substantial variation in the type and cost of nonoperative procedures for patients with late-stage knee OA prior to TKA,” according to the report by Eric L. Smith, MD, of New England Baptist Hospital, Boston, and colleagues.

Estimated costs of $2.4 billion over 3 years for nonoperative procedures before TKA

Using nationwide commercial insurance databases, the researchers analyzed claims for nearly 24,500 patients who underwent primary TKA in 2018 and 2019. The study examined the types and costs of nonoperative procedures in the months leading up to TKA.

Average costs for nonoperative procedures in the year before TKA were $1,355 per patient. Knee imaging studies were the most common procedure overall, performed in about 96% of patients. Intra-articular steroid injections were the most frequent treatment procedure, performed in 54%. Bracing was the least common nonoperative treatment, performed in approximately 8% of patients.

Intra-articular injection of hyaluronic acid, excluding professional administration fees, was the most costly procedure: performed in about 13% of patients, it made up 10% of total costs. By comparison, steroid injections were performed in more than half of patients, but accounted to just over 1% of costs. Physical therapy was used in about 27% of patients and accounted for about 17% of costs.

Most patients underwent at least two nonoperative treatments, while more than one-third underwent three or more. Costs increased with time between diagnosis and surgery, exceeding $2,000 in patients with a 12-month duration before undergoing TKA.

Women had higher total costs for nonoperative treatment, with the greatest differences in physical therapy and prescription of nonsteroidal anti-inflammatory drugs. Men had higher costs for opioids. Procedures and costs also varied by region, with the Northeast region having the highest average cost ($1,740).

TKA is a highly effective and cost-efficient treatment for knee OA. The researchers note that decisions about TKA can be “extremely complicated,” involving factors related to patients, providers, and insurers. For example, insurers may require some period of nonoperative treatment before authorizing coverage for TKA. With the national focus on reducing costs while delivering high-value care, the requirement of nonoperative treatment in the months before TKA warrants evaluation.

Extrapolated to the 600,000 TKAs performed each year in the United States, the total costs of nonoperative treatment are estimated at $2.4 billion over a 3-year period and are likely to increase in the future. The authors point out some limitations of their study, mainly related to the use of insurance claims data.

“For patients who eventually undergo TKA, the cost-effectiveness of these nonoperative treatments right before TKA needs to be carefully considered as the health-care system transitions toward a value-based model,” Dr. Smith and coauthors conclude. They also note that some nonoperative treatments – for example, intra-articular steroid or hyaluronic acid injections or bracing – do not have strong evidence of effectiveness. The researchers call for further studies focusing on the benefits of nonoperative treatments at different stages of knee OA.

Source:

Journal reference:

Nin, D.Z., et al. (2022) Costs of Nonoperative Procedures for Knee Osteoarthritis in the Year Prior to Primary Total Knee Arthroplasty. The Journal of Bone and Joint Surgery. doi.org/10.2106/JBJS.21.01415.

Originally Appeared Here

A Road to Recovery After Knee Surgery: 6 Tips to Follow

Recovery from knee surgery can be full of ups and downs, but there are steps you can take to make the process as smooth as possible.

We find that patients who know what to expect and are proactive in their recovery tend to do better overall. With that in mind, here are six tips to follow in your recovery after knee surgery.

1. Get Plenty of Rest

Most people know that getting a good night’s sleep is essential for feeling rested and alert the next day, but few realize just how important it is for recovering from surgery. This doesn’t mean you have to stay in bed all day – although you should take it easy for the first few days – it does mean getting enough sleep at night and taking periodic naps during the day.

Good rest is crucial for healing because it gives your body the time it needs to repair the damage from surgery. When you’re well-rested, you’ll also have more energy for physical therapy and other essential activities for recovery. The recovery timelines for patients who get adequate rest are usually shorter than for those who don’t. So, make sure to get your ZZZs.

2. Eat a Nutritious Diet

As with sleep, eating a nutritious diet is vital for everyone but especially crucial for people recovering from surgery. A healthy diet will give your body the nutrients it needs to heal properly and fight infection. It’s also essential to avoid constipation, which can be a problem after surgery due to pain medication and inactivity.

To stay on top of your nutrition, eat plenty of fruits, vegetables, and whole grains. These foods are packed with vitamins, minerals, and fiber that will help keep your digestive system moving and your body healthy. It would help if you also drank plenty of water to stay hydrated.

3. Stay Active

It may seem counterintuitive, but staying active is vital for recovery after knee surgery. Of course, you shouldn’t overdo it – too much activity can delay healing – but getting some gentle exercise will help keep your joints mobile and prevent stiffness. Physical therapy is a great way to get the proper exercise for your needs.

Walking is another excellent way to stay active while recovering from knee surgery. Just be sure to start slowly and increase your distance gradually. If walking is painful or makes your incision feel uncomfortable, stop and rest until the pain subsides. As long as you listen to your body, staying active will speed up your recovery.

4. Follow Your Physical Therapy Regimen

Physical therapy is essential to recovering from knee surgery, but it’s important to follow your therapist’s recommendations. Depending on the surgery you had, you may need to start physical therapy a week after your procedure. This may seem like a lot, but getting the rehabilitation process started early is vital.

Your physical therapist will design a customized exercise program that gradually increases in intensity as you heal. Sticking to this program even when you feel like you can do more is essential. Pushing yourself too hard can delay healing and lead to setbacks. Trust your therapist and follow their guidelines for a successful recovery.

5. Use Pain Medication as Directed

Recovering knee surgery can be painful, but taking pain medication only as directed is essential. Taking too much medication can be dangerous and make it difficult to gauge your level of activity. It’s vital to listen to your body and rest when necessary, even if that means taking a little extra medication.

Of course, you shouldn’t suffer unnecessarily. Talk to your doctor or surgeon about adjusting your medication regimen if your pain is severe or persistent. It’s also important to let them know if you have any concerns about the side effects of your medication. In most cases, the benefits of pain relief outweigh the risks, but it’s always best to err on the side of caution.

6. Be Patient

Recovery from knee surgery takes time, so it’s essential to be patient and realistic about your expectations. Depending on the procedure, it may be several months before you’re back to your old self. And even then, you may have some lingering stiffness or pain. It’s important to listen to your body and take things slowly to avoid setbacks.

If you’re having trouble staying positive, talk to your doctor or surgeon about ways to cope with the frustration of a long recovery. In the meantime, focus on following your rehabilitation program and taking care of yourself. The better you take care of yourself now, the sooner you’ll be back to your old self.

Following these tips will help you have a successful recovery after knee surgery. However, every patient is different, so talk to your surgeon about what you should expect during your recovery process. Just remember to listen to your body and take things one day at a time – before you know it, you’ll be back on your feet again.

Originally Appeared Here

New laser surface modification process with silver provides antimicrobial defense to titanium orthopedic devices

Process to create nanostructures on implant surfaces also enhances bone cells’ attachment

WEST LAFAYETTE, Ind. – A patent-pending process developed by Purdue University engineers could improve the quality of life for the more than 6 million people who undergo orthopedic and trauma surgery annually, according to a paper published in Langmuir: The ACS Journal of Fundamental Interface Science.

Infection is a major complication when rods, plates, screws and other devices are embedded into people during procedures like joint replacement surgery and spinal fusion surgery. Most infections occur because the devices’ titanium implant surfaces have poor antibacterial and osteoinductive properties; osteoinduction is the process that prompts bone formation.

Rahim Rahimi, a Purdue University assistant professor in the School of Materials Engineering, has created a process that immobilizes silver onto the implant surfaces of titanium orthopedic devices to improve antibacterial properties and cellular integration. The process can be implemented onto many currently utilized metal implant surfaces.

The antibacterial efficacy of laser-nanotextured titanium surfaces with laser-immobilized silver was tested against both gram-positive (Staphylococcus aureus) and gram-negative (Escherichia coli) bacteria. The surfaces were observed to have efficient and stable antimicrobial properties for more than six days. The laser-nanotextured titanium surfaces also provided a 2.5-fold increase in osseointegration properties as compared to the pristine titanium implant surface.

“The first step of the two-step process creates a hierarchical nanostructure onto the titanium implant surface to enhance the bone cells’ attachment,” Rahimi said. “The second step immobilizes silver with antibacterial properties onto the titanium implant surface.

“The technology allows us to not only immobilize antibacterial silver compounds onto the surface of the titanium implants but also provide a unique surface nanotexturing that allows better settle attachment mineralization.

“These unique characteristics will allow improving implant outcomes, including less risk of infection and fewer complications like device failure.”

Rahimi said the traditional method to address infections caused by implanted orthopedic devices often utilizes antibiotics or other surface modifications that have their own associated complications.

“Long-term antibacterial protection is not possible with these traditional drug coatings because a large portion of the loaded drug is released in a short time,” Rahimi said. “There also is often a mixture of microbes that are found in implant-associated infection; it is essential to choose a bactericidal agent that covers a broad spectrum.”

Rahimi disclosed the innovation to the Purdue Research Foundation Office of Technology Commercialization, which has applied for a patent on the intellectual property. Industry partners seeking to further develop this innovation should contact Patrick Finnerty, pwfinnerty@prf.org, about reference number 2022-RAHI-69768.

Rahimi said the next steps to develop the laser process to texturize and immobilize silver onto orthopedic devices are to implement it onto standard orthopedic fixtures, validate the technology to get approval from the U.S. Food and Drug Administration, and license it to companies working in the orthopedic sector.

Rahimi’s research was funded by Purdue’s School of Materials Engineering.

About Purdue University

Purdue University is a top public research institution developing practical solutions to today’s toughest challenges. Ranked in each of the last five years as one of the 10 Most Innovative universities in the United States by U.S. News & World Report, Purdue delivers world-changing research and out-of-this-world discovery. Committed to hands-on and online, real-world learning, Purdue offers a transformative education to all. Committed to affordability and accessibility, Purdue has frozen tuition and most fees at 2012-13 levels, enabling more students than ever to graduate debt-free. See how Purdue never stops in the persistent pursuit of the next giant leap at https://stories.purdue.edu.

About Purdue Research Foundation Office of Technology Commercialization

The Purdue Research Foundation Office of Technology Commercialization operates one of the most comprehensive technology transfer programs among leading research universities in the U.S. Services provided by this office support the economic development initiatives of Purdue University and benefit the university’s academic activities through commercializing, licensing and protecting Purdue intellectual property. In fiscal year 2021, the office reported 159 deals finalized with 236 technologies signed, 394 disclosures received and 187 issued U.S. patents. The office is managed by the Purdue Research Foundation, which received the 2019 Innovation and Economic Prosperity Universities Award for Place from the Association of Public and Land-grant Universities. In 2020, IPWatchdog Institute ranked Purdue third nationally in startup creation and in the top 20 for patents. The Purdue Research Foundation is a private, nonprofit foundation created to advance the mission of Purdue University. Contact otcip@prf.org for more information.

Writer: Steve Martin, sgmartin@prf.org

Source: Rahim Rahimi, rrahimi@purdue.edu

ABSTRACT

Laser-Assisted Nanotexturing and Silver Immobilization on Titanium Implant Surfaces to Enhance Bone Cell Mineralization and Antimicrobial Properties

Vidhya Selvamani, SachinKadian, David A. Detwiler, Amin Zareei, Ian Woodhouse, Zhimin Qi, Samuel Peana, Alejandro M. Alcaraz, Haiyan Wang, Rahim Rahimi

Despite the great advancement and wide use of Titanium (Ti) and Ti-based alloys in different orthopedic implants, device-related infections remain the major complication in modern orthopedic and trauma surgery. Most of these infections are often caused by both poor antibacterial and osteoinductive properties of the implant surface. Here, we have demonstrated a facile two-step laser nanotexturing and immobilization of silver onto the titanium implants to improve both cellular integration and antibacterial properties of Ti surfaces. The required threshold laser processing power for effective nanotexturing and osseointegration was systematically determined by the level of osteoblast cells mineralized on the laser nanotextured Ti (LN-Ti) surfaces using a Neodymium-doped yttrium aluminum garnet laser (Nd-YAG, wavelength of 1.06 μm). Laser processing powers above 24 W resulted in the formation of hierarchical nanoporous structures (average pore 190 nm) on the Ti surface with a 2.5-fold increase in osseointegration as compared to the pristine Ti surface. Immobilization of silver nanoparticles onto the LN-Ti surface was conducted by dip coating in an aqueous silver ionic solution and subsequently converted to silver nanoparticles (AgNPs) by using a low power laser-assisted photocatalytic reduction process. Structural and surface morphology analysis via XRD and SEM revealed a uniform distribution of Ag and the formation of an AgTi-alloy interface on the Ti surface. The antibacterial efficacy of the LN-Ti with laser immobilized silver (LN-Ti/LI-Ag) was tested against both gram-positive (Staphylococcus aureus) and gram-negative (Escherichia coli) bacteria. The LN-Ti/LI-Ag surface was observed to have efficient and stable antimicrobial properties for over 6 days. In addition, it was found that the LN-Ti/LI-Ag maintained a cytocompatibility and bone cell mineralization property similar to the LN-Ti surface. The differential toxicity of the LN-Ti/LI-Ag between bacterial and cellular species qualifies this approach as a promising candidate for novel rapid surface modification of biomedical metal implants.

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Novel Imaging Technique Reveals Excellent Biologic Fixation in Cementless Knee Replacement

Newswise — Cementless knee replacement, an alternative approach to the traditional surgery in which bone cement is used, is gaining interest among orthopedic surgeons. Using a novel MRI technique, researchers at Hospital for Special Surgery (HSS) found that a cementless implant demonstrated excellent biologic fixation, and even improved fixation of implant components in some areas in the joint, compared to the standard cemented implant.

HSS hip and knee surgeon Geoffrey Westrich, MD, and colleagues in the HSS Radiology Department used an advanced imaging technique known as “multi-acquisition variable-resonance image combination selective MRI” to assess fixation in patients who had a cementless knee replacement compared to those whose implant was affixed with bone cement.

“The purpose of our study was to quantify and compare the ﬁxation of uncemented versus cemented knee replacement components,” said Dr. Westrich, lead investigator. “At an average patient follow-up of 16 months, our study demonstrated robust ﬁxation of the cementless knee replacement components, with results comparable to the cemented total knee replacements. And while there was no clinically significant difference regarding overall fixation in the knee, there were some component areas in which cementless fixation appeared to be superior.” The study was published in the October edition of the journal Arthroplasty Today.

The HSS researchers performed MRIs in 20 patients who had a cementless knee replacement. A matched control group of 20 patients with a cemented knee replacement was also evaluated. The images were reviewed by a fellowship-trained musculoskeletal radiologist specializing in the interpretation of joint replacement MRI, including more than 20 years of experience in assessing bony ﬁxation of knee replacement components.

In a traditional knee replacement, implant components are secured in the joint using bone cement. It’s a tried-and-true technique that has worked well for decades. But eventually, over time, the cement may start to loosen from the bone and/or the implant. This loosening is the leading cause of revision surgery, in which a patient needs a second knee replacement.

“With the cementless prosthesis, the components are press fit into place for biologic fixation, which basically means that the bone will grow into the implant,” explains Dr. Westrich, who believes a well-designed cementless implant will make loosening over time less likely. This could enable a total knee replacement to last much longer, a particular concern for younger patients.

“Overall, traditional knee replacement offers excellent outcomes and longevity,” he says. “However, younger patients generally put more demands on their joint, causing more wear and tear and potential loosening. The cemented knee implant used in a traditional joint replacement usually lasts 15 to 20 years.”

Cementless implants have been used successfully in total hip replacement surgery for many years. It has been much more challenging to develop a cementless prosthesis that would work well in the knee because of its particular anatomy, Dr. Westrich explains.

“Early generation cementless implants had numerous design ﬂaws resulting in loosening and poor survivorship compared to cemented knee replacements,” he says. “More contemporary cementless knee components such as those used in our study utilize highly porous surfaces to promote biologic ﬁxation of the prosthesis. This should improve outcomes.”

Candidates for the cementless procedure are generally patients under age 70 with good bone quality to promote biologic fixation. In addition to younger patients, Dr. Westrich notes that the cementless implant may prove to be a good option for very overweight patients who tend to put more stress on their joint replacement.

“While our study found that early ﬁxation of cementless total knee components are comparable, if not superior, to cemented total knee replacement, further study with a larger number of patients over a lengthier time period is needed to assess long-term durability and fixation.”

Disclosure: Research support received from Stryker Corporation.

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Preparing for Joint Replacement Surgery

Contact friends and family for support. You may need help bathing, using the toilet, cooking meals, doing laundry or housework, shopping, going to your doctor’s office, and exercising for several weeks. Contact family members or friends ahead of time to make the necessary arrangements. If you don’t have someone to help you at home, ask your doctor about home caregivers. There are various support networks that can provide emotional support and, in many areas, there are also businesses that offer in-home support.

Get your home ready for your recovery. Store frequently used items such as cleaning supplies, food, remote controls, medications, and reading materials in easy-to-reach locations. Avoid very high or very low shelves as these may require you to use a step stool or kneel.

Plan for meals. Make and freeze meals or stock up on frozen dinners before surgery so that meal preparation is easier and requires less effort. You should plan on making enough meals for at least one week.

Check the safety of your home to prevent falls or tripping. Move long electrical and telephone cords against the wall, remove rugs, and place a non-skid mat in your bathtub. You may want to prepare a bed on the ground level of your home so you can avoid climbing stairs. Have an elevated chair or high-seated chair with arms in every room if possible.

A little time spent getting your home ready before your surgery can make a big difference in your recovery. Some ideas to get started, include:

Stock up on toilet paper, shampoo, toothpaste, medications, and other personal items

Put a chair in your shower

Get a hand-held shower head

Get a raised toilet seat

Get a shower sponge with a long handle

Put handrails in the shower and next to the toilet

Install nightlights throughout the house

Wash all your towels, linens, and dirty clothes

Place loose clothing and pajamas in upper drawers or closets

Reachers and grabbers will come in handy

To keep your hands free for balance, consider using a walker basket, hip-pouch, small backpack, or an apron with large pockets to hold things you’ll want nearby

Rent/buy/borrow plenty of books, movies, music, and puzzles

Call your local post office to request that mail be left at your front door instead of in your mailbox

Originally Appeared Here

The Challenge of Knee OA and the Potential of Manual Therapy

Knee osteoarthritis is a major public health problem that primarily
affects the elderly. Almost 10 percent of the United States population
suffers from symptomatic knee osteoarthritis by the age of 60. In fact,
OA is prevalent worldwide, especially with an increasingly aging
society. It is one of the leading causes of pain and dysfunction in the
joints among the aging population. Despite this, there are no approved
interventions that ameliorate structural progression of this disorder. Continue reading on digital

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Knee Osteonecrosis Latest Facts: Causes, Diagnosis, Risk Factors, Symptoms, Prognosis, and Treatment

Blood supply to every organ and tissue in the body is very vital for optimal functioning. Loss of blood supply to any body part or organ leads to a gradual death (necrosis) of that part or organ and can be very dangerous. Loss of blood supply to the brain results in stroke; loss of blood supply to the heart results in a heart attack; loss of blood supply to a bone tissue leads to bone death (osteonecrosis).

Knee Bones

Knee osteonecrosis means knee bone death. It occurs mostly in older people, with women being more affected than men. Three types of osteonecrosis affect the knee: spontaneous osteonecrosis of the knee (SONK), secondary, and post-arthroscopic.

Read Also: PRP Is No More Effective for Knee Osteoarthritis than Placebo

Anatomy of the knee

The knee is one of the two major hinge joints in the body, with the elbow being the other. It is responsible for movement and very vital for weight-bearing. The joint at the knee is the largest and most complex joint in the body. It is made up of three bones the lower end of the femur (thigh bone), the upper end of the tibia (shin bone), and the patella (kneecap). Knee osteonecrosis commonly occurs in the medial femoral condyle (inside of the knee), however, the lateral femoral epicondyle (outside of the knee) or tibial plateau (the flat top of the tibia) may also be likely areas of occurrence.

The knee is vulnerable to injury; according to the database from the National Institutes of Health, it is the most commonly injured joint by adolescent athletes. Among older people, it is prone to knee osteonecrosis, which if not given medical attention early, can progress to osteoarthritis.

Epidemiology

The most common form of knee osteonecrosis is spontaneous osteonecrosis of the knee, SONK. It is mostly observed in people who are over age 50. On the other hand, secondary osteonecrosis has been observed to be more common in the younger population and it is linked to some medical conditions like sickle cell disease (SCD), consumption of alcohol, corticosteroids, and tobacco, and myeloproliferative disorders. The last form, post-arthroscopic osteonecrosis, is a rare type. Reports show that it affected 4% of patients who had arthroscopic knee surgery, particularly meniscectomy.

Causes of knee osteonecrosis

When there is a lack of blood supply to bone tissues, it leads to the death of bone cells, which results in an eventual collapse of the bone. This is the case in osteonecrosis. Knee osteonecrosis can result in a collapse of the articular cartilage covering the bone ends, and this can lead to arthritis.

Read Also: TOKA a New Customized 3D-Printed Plate for the Treatment of Knee Osteoarthritis

Risk factors

The cause of the lack of blood supply is still unknown, but studies have linked the following risk factors to the development of knee osteonecrosis:

Knee injury

Aside from pain and swelling, knee injuries like dislocation or fracture can also result in damaged blood vessels. Dislocation involves bone ends; fracture involves any bone part; either way, both injuries can affect the blood vessels supplying the bone, thereby, reducing the flow of blood to the dislocated/fractured bone. This is why immediate medical attention is needed. Sometimes, an x-ray or MRI scan may be done to have a deeper view of the bone.

Oral corticosteroid medications

It is not exactly known why oral steroid medications cause osteonecrosis, but research shows that there is a connection between them. This is disturbing because many diseases such as asthma and rheumatoid arthritis are treated with these medications.

Medical conditions

Some medical conditions such as obesity, SCD, and lupus are associated with the secondary form of knee osteonecrosis. HIV patients are also diagnosed with it this is because the medications for HIV treatment are also linked to the disease.

Excessive consumption of alcohol

Alcohol causes weight gain because it stops the body from burning fat. Drinking too much alcohol increases the buildup of fat in the body, and this can consequently lead to deposits of fat tissues that can block blood vessels and obstruct blood flow to the vessels.

Transplants

Studies show that osteonecrosis can occur after organ transplants, especially kidney transplants.

Read Also: Duke University Researchers Create a Gel That Could Replace the Cartilage in the Knees

Symptoms of knee osteonecrosis

The most common symptom associated with osteonecrosis of the knee is pain on the inside of the knee. The pain can be triggered by a specific activity or a minor injury and can become intense at night.

Other symptoms include: swelling over the front and inside of the knee, increased sensitivity to touch in the area, and limited movement of the knee due to pain.

Diagnosis of knee osteonecrosis

A good diagnosis of knee osteonecrosis begins with a thorough history taking.

Here, your doctor will talk about your medical history, ask you to describe your symptoms and then proceed to examine your knee.

While examining your knee, your doctor looks out for swelling within your joints, tenderness, redness, and joint instability.

You may be asked to move your knee to observe the range of motion at your knee joint.

Your doctor also looks out for any sign of injury to the muscles, ligaments, and tendons around your knee.

After a physical examination of your knee, your doctor then goes on to confirm the diagnosis by taking an imaging study of your knee either with an X-ray study, magnetic resonance imaging (MRI) scan, or a bone scan. An imaging study is vital as it helps to take a deeper look at your bones and other aspects of your knee joint to identify the stage of knee osteonecrosis you have.

Read Also: Still No Effective Cures for Osteoarthritis but There Is Some Hope

Staging of knee osteonecrosis

There are four stages to knee osteonecrosis development:

Stage I: At this stage, the patient experiences symptoms that become intense and last for six to eight weeks. To be sure of the diagnosis, the doctor uses a positive bone scan, not just x-rays to get a better view of the knee. At this point, surgery is not required for treatment, instead, the doctor administers medication for pain relief and other methods that focuses on reduced weight-bearing.

Stage II: From Stage I to this stage takes several months. At this stage, x-rays can confirm the diagnosis, because the medial femoral condyle which is normally rounded now becomes flattened and can be visible with x-rays. Other forms of imaging studies such as MRI, CT, or bone scan can also confirm the diagnosis.

Stage III: From Stage I to this stage takes about three to six months, x-rays alone can confirm the diagnosis. The articular cartilage that covers the bones starts to come off the bone since the bone itself is gradually dying. Surgical procedures may be required to treat the patient at this point.

Stage IV: At this stage, the disease becomes very critical as the articular cartilage is now destroyed and the joint space becomes narrow; severe osteoarthritis develops; joint replacement surgery becomes necessary.

Prognosis of knee osteonecrosis

When knee osteonecrosis is diagnosed early (at stage I), a simple pain relief medication may be all that is needed to treat it. The doctor may also advise lower mobility of the affected knee. At advanced stages, surgery may be done to prevent increased damage to the whole joint.

Treatment of knee osteonecrosis

The treatment option for knee osteonecrosis depends on some factors which include the stage of the disease, the portion of bone that is affected, and the cause of the disease. Based on these factors, treatment can be non-surgical or surgical.

Read Also: Scientists Repair Bones Successfully by Combining Gene Therapy and Bioprinting

Non-surgical treatment option

If the disease is at an early stage and only a small area of the knee is affected, surgery may not be necessary. The doctor may suggest any of the following non-surgical treatment procedures:

Use of medications:

The doctor may prescribe some nonsteroidal inflammatory drugs (NSAIDs) like ibuprofen and naproxen to relieve the pain and swelling in the knee. If the patient is a young person, the doctor may suggest bisphosphonates for treatment.

Reduced weight bearing:

For some patients, just simply taking weight off their knees may be all that is needed to slow the damage and allow for healing. The patient may need to start using crutches for some time to reduce the weight on their knees.

Exercise:

The patient may be asked to engage in certain physical activities that aid in strengthening the thigh muscles and allow for a range of movement in the affected joint. To avoid stress on the joint, water exercise may also be recommended for the patient.

Modification in certain activities:

The doctor may advise the patient to stop certain activities that lead to pain.

Surgical treatment options

Your doctor may recommend surgery if there seems to be no improvement after the non-surgical treatment options, or if the portion of the bone affected is quite large. Some surgical procedures that may be recommended include:

Total knee replacement:

Your doctor may opt for this procedure if the disease has progressed to stage IV, where the bone has been destroyed. The procedure involves a replacement of the destroyed bones and cartilages with metal or plastic joint surfaces to restore the knee function.

Osteotomy:

In this procedure, the surgeon removes a portion of either the tibia or femur or will insert a wedge of bone graft/synthetic bone to help take the weight off the damaged portion of the knee. This is vital because taking weight off the affected area of the joint will relieve the patient of pain and promote healing.

Other surgical procedures your doctor may recommend osteochondral bone (bone and cartilage) grafting, core compression, arthroscopic debridement and microfracture, and autologous chondrocyte implantation (ACI).

Read Also: Inflammatory Joint Diseases: Actions and Foods You Should Consider to Relieve Joints Inflammation Naturally

Conclusion

As much as knee osteonecrosis is likely to occur in people who are over age 50, it can be avoided and effectively treated when we are armed with the knowledge of what it is and how to diagnose and easily manage it.

References

https://orthoinfo.aaos.org/en/diseases–conditions/osteonecrosis-of-the-knee

https://www.sciencedirect.com/science/article/pii/S2665913121000327

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