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The paralysed man who can ride a bike

A man who was paralysed from the chest down after a knife attack in 2010 can now ride an adapted tricycle.  In 2014, surgeons in Poland announced they had reversed Darek Fidyka’s paralysis using cells taken from his nose to repair his spinal cord.  The former fireman says he has noticed a gradual return of feeling and muscle control below his injury.

Continued...

The surgical team are now launching a search for two more paralysed patients who they will try to help walk again.  Mr Fidyka told me: “I can tell that sensation is coming back and I am getting stronger. A year ago I would not have been able to ride a tricycle. Now I can feel each muscle and each press of the foot on the pedals.”

The BBC’s Panorama program told the remarkable story of Darek Fidyka and the 40-year research programme involving scientists in Britain and Poland.  The medical team are now launching the worldwide search as they are looking for patients with an uncommon type of injury, where the spinal cord has been completely severed, which can happen after a knife injury.  The head of the project, surgeon Dr Pawel Tabakow said: “If we can bridge the gap between two spinal cord stumps then there will be no doubt that our technique works and this will be historic – if we succeed we will have found a cure for paralysis.

“Then we will be able to help other patients with the most common type of injury, caused by a crush or compression.”

The Wroclaw Walk Again Project will be conducted in Poland, but patients anywhere in the world aged 16-65 will be able to apply via the team’s website, which will be officially launched on 8th March in Wroclaw.  All the treatment will be free, but to be eligible patients must have no feeling or voluntary muscle function below the injury and they must be prepared to spend around three years in Poland.  They will undergo extensive physiotherapy before and especially after the transplant surgery.

The medical team are expecting to be inundated with applications in the months ahead.  They will make an initial shortlist based on patient scans and medical notes and then invite a few potential volunteers for assessment in Poland.  Those selected will undergo the same pioneering surgery that was performed on Darek Fidyka.

Analysis

Scientists have spent decades searching for a means of enabling the paralysed to walk again. Motorised exoskeletons, which are strapped on the body, bypassing the injury, are now available commercially. Electrical stimulation techniques use implants to enable patients to flex their lower limbs. But neither method involves repairing the damaged spinal cord.  The approach in Poland aims to reconnect the brain with the lower limbs along the neural superhighway that is the spinal cord, enabling both motor control commands to travel down the body and sensation to travel up.

Darek Fidyka’s spinal cord had been almost completely severed as a result of a knife attack, apart from a thin thread of external connective tissue and prior to the transplant, he had no feeling or control below his injury.  Now he has had to re-learn how to control his muscles and interpret sensations. He said: “I realise how important the brain is while cycling, and that thinking is more tiring than the exercise itself.”  But the results from one patient, however impressive, would never be sufficient evidence on which to base a new approach to spinal cord injury.  The forthcoming trial in Poland will be crucial if the wider scientific community is to be convinced that a patient’s own cells can be used to regenerate their spinal cord.  It is also worth stressing that the patients selected will have to show enormous determination if they are to see the full benefits of the treatment.

In the first of two operations, surgeons will remove one of the patient’s olfactory bulbs, which sit above the nasal cavity at the base of the brain, and process the sense of smell.  The bulb contains specialist cells known as olfactory ensheathing cells (OECs) which act as a pathway that enables nerve fibres in the olfactory system to continually renew.  In a second operation the patient’s OECs will be injected above and below the injury and strips of tissue laid across the gap in the cord.  The team believe the OECs will enable nerve fibres to regenerate across the cord and so repair the damage.  An independent team of assessors led by neurophysiologists from Imperial College London will also be closely involved in monitoring the research.  Peter Ellaway, emeritus professor of physiology, at Imperial said: “I’m excited because this is a novel treatment with a lot of promise.”  But he cautioned that even if it works it would take some years to refine and so would not be immediately available for patients.

The treatment in Poland will cost £250,000 per patient and is being funded by a small British charity, the Nicholls Spinal Injury Foundation. It was founded by chef David Nicholls after his 18-year-old son Daniel was paralysed from the neck down in a swimming accident.  Mr Nicholls said: “I know how important progress is to people living with spinal cord injury and am optimistic that success with the next two patients will result in an announcement that paralysis is curable.”  NSIF and the UK Stem Cell Foundation both support the research of Prof Geoff Raisman, chair of neural regeneration at University College London (UCL), who has pioneered the use of OECs to repair the damaged spinal cord and leads the British side of the Walk Again project.

Prof Raisman said: “Darek’s latest progress demonstrates the extraordinary power of (neuro) plasticity. But it depends on the patient’s own efforts. It is like a baby learning to walk. We cannot teach it how. The progress comes from inside.”  Darek underwent his transplant in April 2012, and he still spends five hours a day undergoing physiotherapy.  He can now walk slowly using crutches or a small walking frame, but usually relies on a wheelchair as it is simply quicker and less tiring.  The return of sensation below his injury has brought other benefits like bladder control and the return of sexual function.

Darek was happy to discuss sex and explained that the reawakening of the erogenous zones was a crucial part of his recovery.  He said: “The return of sexual satisfaction – which travels along the spinal cord to the brain – is very important psychologically and is another part of my growing sense of independence.”

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Doctors urge schools to ban tackling in rugby

More than 70 doctors and academics are calling for a ban on tackling in rugby matches played in UK and Irish schools.  In an open letter to ministers, they say injuries from this “high-impact collision sport” can have lifelong consequences for children.  They argue two thirds of injuries in youth rugby and most concussions are down to tackles and urge schools to move to touch and non-contact rugby.  Supporters say rugby builds character and other forms are less challenging.  The concerns have been raised as a seven-year programme headed by the Rugby Football Union is on target to introduce rugby to a million children in state schools across England.  The RFU’s programme, which began in 2012 and is running until 2019, has so far reached 400 schools, with 350 to follow.

‘Fractures and dislocations’

But, in their letter to ministers, chief medical officers and children’s commissioners in England, Scotland, Wales, Northern Ireland and the Republic of Ireland, doctors say the risks for players aged under 18 are high.  They say many secondary schools in the UK deliver contact rugby as a compulsory part of the physical education curriculum from the age of 11.  “The majority of all injuries occur during contact or collision, such as the tackle and the scrum,” the letter says.

“These injuries, which include fractures, ligamentous tears, dislocated shoulders, spinal injuries and head injuries can have short-term, lifelong and life-ending consequences for children.”  The doctors say concussion is a common injury, and they highlight a link between “repeat concussions and cognitive impairment and an association with depression, memory loss and diminished verbal abilities”.  One of the signatories of the open letter is Prof Allyson Pollock, from Queen Mary University of London, who has long campaigned about the dangers of rugby.

She said evidence collected over 12 years showed rugby players up to the age of 18 or 19 had a 28% chance of getting injured over a season of 15 matches.  “If you’re thinking of a million children playing every year with this risk of injury you’re looking at 300,000 extra injuries a year, including up to 100,000 concussions,” she said.  She added that 90% of injuries resulted in more than seven days lost from school.  There are various forms of touch or tag rugby, in which tackles are replaced by touching a player or removing a tag from their clothing. Aspects of rugby such as scrums and rucks are also excluded from these forms of the game.

Jonny Cross, a PE teacher at Congleton High School in Cheshire – where rugby is compulsory from the age of 11 – says the sport provides a challenge.  Mr Cross says children wear gum-shields and are taught how to maintain the proper posture in scrums to avoid injury, a technique known as “tower of power”.  “Contact rugby helps build character. They are putting their body on the line in a match. The risk factor is part of it,” he says.  “They enjoy the contact element. There is a ‘boy factor’ – it’s partly about developing masculinity. They would be more likely to be bored by touch rugby.  “I would say that some students need it. It provides a challenge, where challenge is being taken out of everyday life.”  Mr Cross says children wear gum-shields and are taught how to maintain the proper posture in scrums to avoid injury, a technique known as “tower of power”.  “Contact rugby helps build character. They are putting their body on the line in a match. The risk factor is part of it,” he says.  “They enjoy the contact element. There is a ‘boy factor’ – it’s partly about developing masculinity. They would be more likely to be bored by touch rugby.  “I would say that some students need it. It provides a challenge, where challenge is being taken out of everyday life.”  The RFU and the Welsh Rugby Union both said they took player safety “extremely seriously” but that rugby was a “fantastic sport for children” which offered many benefits for society.

The Scottish Rugby Union said it was “committed to player welfare at every level of the game” but pointed out that every sport carried “an element of risk”.

Southern hemisphere

South African schools allow tackling, as do schools in Australia – although there has been a recent push to make children wear protective headgear, but this is not compulsory.  In New Zealand, tackling is permitted, but in some schools it is banned in lunchtime games that are not being supervised.  Former England rugby player Matt Perry said: “I took a risk when I started rugby at seven and I’m afraid at school level if that tackle is taken out we’ve lost one of the great games and one of the great cultural games.”  Former England international Brian Moore dismissed the evidence in the letter as “flawed” and “partial”.  Obesity would kill more children than rugby, he said.  “If you want to ban things, you’ve got to do it on the right basis.”

The Association for Physical Education said contact versions of the game should be introduced and managed only by “suitably experienced staff” following recognised guidelines.  “Parents should be aware of what sports are taught in the schools they choose to send their children to – if rugby is taught, then parents send their children to the school in the knowledge that they are likely to be asked to play rugby at some level,” it added.

A spokesman for the Department for Education in England said: “Team sports, such as rugby, play an important role in developing character.  “We expect schools to be aware of the risks associated with sporting activities and to provide a safe environment for pupils.”

2.3.2016 BBC News

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Rise in hip replacements for under 60s

The number of hip replacement operations on people aged under 60 has risen 76% in the last decade, NHS figures for England reveal.  In 2004-05 there were 10,145 hip replacements for people aged 59 and below, with 17,883 in 2014-15.  The Royal College of Surgeons says this is partly because doctors are now more confident that replacement joints will be more durable than in the past.  Patients are also said to be less willing to wait.

As a proportion of all hip replacements carried out, the rise among under 60s is small, but the Royal College of Surgeons says it is still noteworthy.  Demand for new hips across all ages has risen – there were 89,919 of the operations in 2004-05 and 122,154 in 2014-15.

Stephen Cannon, vice-president of the RCS, says as hip replacement techniques and prosthetics have improved, so have the numbers of younger patients undergoing this type of surgery.  “It’s no longer seen as a last resort.  “As surgeons, we now have more confidence about the wear rate of these prosthetics which allows us to be less restrictive on an age basis.”

‘Less arduous’

He said surgeons used to advise patients with hip pain to wait until they were 60 or 65 to have a replacement because the old-fashioned replacements had a shelf-life of about 15 years, meaning the operation might need redoing once in a lifetime – when the patient had turned 80.

“If you look at newer prosthetics, you could do the first operation at 55 and it is going to last for 20 years or more, so you would still only need one revision in a lifetime.”  He said another factor might be patient demand.  “Certainly, in my experience, patients do not get fobbed off. They don’t want to wait for an operation. They say, ‘I can’t play a round of golf or tennis and I want to.'”  Mr Cannon said concerns over the safety of a the metal-on-metal hip replacement in 2010 did not appear to have affected demand.  He said hip operations had become less arduous. Patients can be back on their feet with crutches on the same day or the day after surgery, and out of hospital within three days post-op. “They’re off crutches altogether by six weeks.”

‘Perfect storm’

Most hip replacements are done if the joint becomes damaged from arthritis or an injury. Many of the conditions treated with a hip replacement are age-related so hip replacements are usually carried out in older adults.  Mr Cannon says it’s not clear if conditions such as osteoarthritis are becoming more common and affecting people at younger ages, but it is worth exploring.  And with an ageing population, he says demand for hip operations could soon outstrip supply.  “The ageing population is a perfect storm. We are not there quite yet, but we might be in 10 years from now. It’s a continuing trend.”

A spokesman for the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man said: “The increase in numbers of under-60s undergoing primary hip surgery is entirely in line with the overall increase in provision of the operation.  “The orthopaedic sector must continue to work to get the first time surgery as right for the patient as possible – especially where younger patients are concerned as they are most likely to need at least one revision surgery in their lifetime.  “It is, of course, heartening and very encouraging that hip and knee implants are lasting ten years or more, with risk of revision lower than 5%.  “Joint replacement surgery offers significant benefits – getting patients back to their chosen lifestyle sooner, free from pain and with improved mobility.”

BBC News 3.3.2016

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New understanding of bones could lead to stronger materials, osteoporosis treatment

Researchers at Cornell University have discovered that bone does something better than most man-made materials: it bounces back after it breaks. In an article published in the Proceedings of the National Academy of Sciences this week Cornell scientists report that cancellous bone the spongy foam-like type of bone found near joints and in the vertebrae that is involved in most osteoporosis related fractures displays unique material properties that allow it to recover shape after it breaks.

When most things break, they fall apart and lose their mechanical function. To help make car and aircraft parts last longer, engineers apply surface treatments that harden the surfaces to prevent cracks from starting.

“Cancellous bone does the opposite, it has softer surfaces with a more brittle interior,” says Christopher Hernandez, Associate Professor of Mechanical and Aerospace Engineering and Biomedical Engineering and principal investigator on the project. The combination of softer surfaces and brittle interior allows cancellous bone to direct cracks to locations where they are less detrimental, allowing the structure to recover its shape — bounce back — after it breaks.

“That’s totally not what we expected from an engineering standpoint,” says Ashley Torres, a graduate student in biomedical engineering who was one of two individuals to lead the study. “But it allows the material able to continue to function after failure.”

The discovery provides a compelling answer to the long-standing question as to why bones have foam-like regions. “We used to think that we had cancellous bone for the same reasons that we use foams in engineering, to absorb energy or make the structure more lightweight, but it turns out that cancellous bone does something different, the way cancellous bone breaks actually makes it heal better,” says Hernandez.

“In the future, this could help in the design of new materials that can take advantage of this ‘function after failure,'” says Jonathan Matheny the other graduate student leading the project. Material heterogeneity in structures, the group proposes, could help mitigate the effects of small structural flaws that are inevitable in manufacturing. Additionally, Matheny said these findings have implications for medicine, “to help us identify people at risk for an osteoporosis-related fracture and prescribe drug treatment.”

MNT 1 March 2016

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New study of patients receiving physical therapy following total knee replacement raises new concerns over referral for profit

A new study concludes that patients who undergo total knee replacement (TKR) surgery and are referred to a physical therapist (PT) not affiliated with their surgeon’s practice have fewer visits and more individualized, one-on-one care. Conversely, the research showed that those who received physiotherapy services from a clinic owned by their physician had twice as many visits and were provided a less-intensive approach.

The study, e-published ahead of print in the scientific journal Health Services Research, examined whether the course of physical therapy treatments received by patients who undergo TKR surgery differs depending on whether the orthopedic surgeon (OS) has a financial stake in physical therapy services, often called physician self-referral. The authors reviewed 3,771 TKR episodes. Of those, 709 (18.8%) met criteria as self-referring. Of the remaining 3,062 episodes deemed non-self-referring (NSR), 2,215 (72.3%) were cases in which the OS who performed the TKR did not have an ownership interest in physical therapy services. For the remaining 847 NSR episodes, the OS had an ownership interest in physical therapy services, but the patient received services elsewhere.

Key findings included:

  • The duration of episodes of care provided by a physician-owned physical therapy practice were a week longer.
  • TKR patients who were treated in a clinic owned by their OS received an average of 8.3 more (or twice as many) PT visits than those who were treated in a clinic in which their OS had no financial stake.
  • When there is no financial incentive for the OS owner, the episodes of care were virtually identical to those received in a non-physician-owned clinic, making clear the link between financial profit and course of care.
  • Patients who received care in a non-physician-owned clinic tended to receive more one-on-one care than those who were self-referred to their physician’s own physical therapy services. Patients who were self-referred for treatment received less intensive interventions and more group care, an approach that requires more visits and potentially extends recovery time.

“When there is referral-for-profit, and from this data as related to group therapy and an extended number of visits, it stands to reason there is increased risk that the patient’s individual needs are of secondary importance to revenue. This has long been the concern here at the American Physical Therapy Association (APTA), and it is why we have fought so hard, alongside our partners in the Alliance for Integrity in Medicare Coalition, against physician-owned physical therapy services (POPTS),” said APTA President Sharon Dunn, PT, PhD, OCS. “This study provides further evidence that when the bottom line takes precedence in health care the patient loses. A patient’s welfare and recovery should always be the primary focus of treatment.”

Beyond the clinical implications, authors believe their study adds more weight to the argument against the in-office ancillary services (IOAS) exception to the Stark laws – federal legislation that prohibits most self-referral practices in Medicare. IOAS allows physicians to self-refer for several “common sense” or same-day treatments; unfortunately, it also creates loopholes for services that are rarely provided on the same day, including physical therapy, anatomic pathology, advanced imaging, and radiation therapy. Authors write that most research on these exceptions has reached the same conclusion as their own study: “that self-referral results in increased use of services and higher health care expenditures.”

The study was funded by the Foundation for Physical Therapy and was authored by Jean M. Mitchell, PhD, James D. Reschovsky, PhD, and Elizabeth Anne Reicherter, PT, DPT, PhD. Reicherter, who is currently employed by APTA, was with the Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD, when the study was conducted.

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Study finds freezing nerves prior to knee replacement improves outcomes

The first study of its kind has found that freezing nerves before knee replacement surgery combined with traditional pain management approaches significantly improves patient outcomes. The results of the preliminary retrospective study led by Vinod Dasa, MD, Associate Professor of Clinical Orthopaedics at LSU Health New Orleans School of Medicine, were published online Feb. 10, 2016, in the journal, The Knee, as an Article in Press.

The study, a retrospective chart review, investigated the cases of 100 patients with advanced osteoarthritis requiring total knee replacement in Dr. Dasa’s LSU Health New Orleans orthopaedic practice. Half of them were treated with standard multiple pain management options, before cryoneurolysis (nerve freezing) was introduced to the practice. The first 50 patients to undergo cryneurolysis in addition to multimodal pain management comprised the treatment group, which was compared to the control group who had standard therapy alone. The treatment and control groups were similar in terms of gender, age and body mass index. The only difference is that the treatment group received cryoneurolysis via an FDA-approved handheld device five days prior to surgery. The KOOS (Knee Injury and Osteoarthritis Outcome Score), PROMS (Patient-reported Outcomes Measurement Information System), WOMAC (Western Ontario and McMaster Universities Arthritis Index) and Oxford Knee Score were used to measure outcomes.

“Patients in the treatment group had significantly shorter hospital stays, were prescribed significantly fewer opioids during the first 12 weeks post-operatively and had significantly fewer knee symptoms,” notes Dr. Vinod Dasa, Associate Professor of Clinical Orthopaedics at LSU Health New Orleans School of Medicine.

The ability to decrease hospital length of stay following total knee replacement should substantially reduce costs for hospitals and payers. In the present study, only 6% of patients treated with cryoneurolysis prior to surgery stayed in the hospital for two or more days compared to 67% of patients who did not receive this treatment. Similarly, almost half of patients treated with cryoneurolysis were discharged on the same day of surgery compared with only 14% in the control group. The shorter length of stay of the patients in the treatment group may be due to better local control of pain and a reduced need for nerve blocks that can impair motor function, as well as reduced use of opioids for pain control, which allows patients to walk and function well enough to go home sooner.

Approximately 600,000 knee replacements are performed each year, and this number is expected to increase in coming years. Although knee replacements usually are very successful in the long term, patients often experience a significant amount of pain during the immediate post-operative period, which can be a major hindrance to effective rehabilitation and restoration of function following surgery.

MNT 12 February 2016

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Muscle Strengthening Aids New Knees

A new study suggests that a carefully focused program of muscle strengthening can make an important difference in how well patients recover after knee replacement.  Patients who underwent six weeks of progressive muscle strengthening aimed at the quadriceps did much better than patients given conventional treatment. The study appears in the February issue of Arthritis Care & Research.  Almost 500,000 knee replacements are done in the United States each year, and patients often report that they still have problems doing things like walking and climbing.  For the study, more than 200 patients were divided into groups and given different treatments about four weeks after surgery.  One received conventional treatment. Another was also given quadriceps strengthening, while a third was given the strengthening and electrical stimulation to make the muscles contract.

While the electrical stimulation did not appear to make a difference, the muscle strengthening appeared to bring the patients back to a level of functioning almost normal for their age.  One of the authors, Lynn Snyder-Mackler of the University of Delaware, said in an e-mail message that knee replacement patients and their doctors should not underestimate the ability “to really improve their function.”

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Patient and Doctor

Caring for Hips and Knees to Avoid Artificial Joints

PROTECT your joints now, or pay later.

That’s the message of today’s column, which could be headlined Joint Economics.

If you are one of the more than 400,000 people a year who have already had one or more hips or knees replaced — or someone who already has no choice but to consider joining their ranks — we offer our sympathies or encouragement or even congratulations, depending on how you are faring. But this column is for people who are not yet destined to necessarily become part of those statistics.

Although the human body has an amazing capacity to repair itself, our joints are surprisingly fragile.  When the cartilage that cushions bones wears away, it does not grow back. Thinning cartilage contributes to osteoarthritis, also known as degenerative arthritis, a painful and often debilitating condition.

Over time, arthritic joints can become so sore and inflamed that they need to be replaced with mechanical substitutes. A result: more pain, at least in the short term, and big medical bills.  Fortunately, you can act to protect your joints now, to reduce your chances of needing to replace them later.  And protect you should. The cost for a new hip or knee — the joints most commonly replaced — is $30,000 to $40,000. If you have insurance, your total out-of-pocket costs will be much less, but may still be $3,000 to $4,000. And don’t forget to factor in all those days of work you will miss before you get your new prosthetic.

Creaky joints are a growing national problem. The population is getting older, more people are overweight, and an increasing number of children and young adults are playing serious sports and getting seriously injured — all factors that contribute to osteoarthritis.

“Arthritis used to show up in people during their late 40s and 50s, now we’re seeing it earlier, like in the 30s and 40s,” said Dr. Patience White, a rheumatologist and the chief public health officer at the Arthritis Foundation.

The total national bill for hip replacements in 2007 was $19 billion, and $26 billion for knees, according to the federal Agency for Healthcare Research and Quality. Those figures are expected to rise significantly in the coming decade, Dr. White said. So protecting your joints will do more than save wear and tear on you and your budget. You could also be doing your part to curtail the national health care bill.  If your joints are still intact, or just beginning to creak, here are some ways to keep osteoarthritis at bay.

CONTROL YOUR WEIGHT The more you weigh, the more pressure on your joints, which can lead to joint damage. When you walk, each knee bears a force equivalent to three to six times the body’s weight. If you weigh a mere 120 pounds, your knees are taking a 360-pound, or more, beating with every step.

Studies have found a connection between being overweight and developing osteoarthritis of the knees, and to a lesser extent the hips. One recent review found that 27 percent of hip replacements and 69 percent of knee replacements might be attributed to obesity.  For reasons not well understood, weight is more of risk factor for women than men.

“A woman’s risk for developing O.A. is linearly related to her weight,” Dr. David Felson, a rheumatologist and arthritis prevention specialist at Boston University School of Medicine, said, referring to osteoarthritis.

“Men who are moderately overweight are not as at high a risk as a woman of the same weight,” Dr. Felson said.

But a woman can substantially lower her risk by shedding pounds. One study in which Dr. Felson was a co-author found that when a woman lost 10 pounds, her risk of arthritis of the knee dropped by half.

GO LOW-IMPACT Although no definitive link has been found between osteoarthritis of the knee and running (or any other sport), sports medicine doctors discourage their patients from running on hard pavement, playing tennis on concrete or activities like skiing over lots of moguls.

“Impact sports put too much stress on the joints, particularly the knees,” said Dr. Donald M. Kastenbaum vice chairman of orthopedic surgery at Beth Israel Medical Center in Manhattan. “These activities may lead to O.A. and they definitely can escalate the progression of the condition.”

If you run regularly, try to do so on a track or treadmill and consider swapping one run a week for something low-impact like swimming, biking, lifting weights or tai chi.

AVOID INJURY Easier said than done, of course. But major injuries, typically the type that require surgery, greatly increase your risk for osteoarthritis.  According to one big study, 10 to 20 years after a person injures the anterior cruciate ligament or menisci of the knee, that person has a 50% chance of having arthritis of the knee.

Those rates are even higher when the injury happens in your 30s or 40s, Dr. Felson said. “As you move into middle age, it’s crucial to avoid sports that predispose you to injury,” he said.  Weekend warriors, who sit at a desk Monday through Friday, and then run or play basketball for five hours straight on the weekend, are at a high risk for injury, and thus for osteoarthritis.

GET FIT It makes sense. The better toned your muscles are, the less likely you are to injure yourself (unless you are also playing football every Saturday morning).  And “building muscles up around joints acts like a shock absorber, spreading stress across the joint,” said Dr. Laith M. Jazrawi, chief of the sports medicine division at NYU Hospital for Joint Diseases. Pilates, moderate weight lifting, vinyasa yoga and swimming are all nonimpact forms of exercise that firm up your muscles without jeopardizing your cartilage.

No definitive link exists between increased flexibility and lower, or higher, rates of osteoarthritis. But some doctors interviewed said they believed that by regularly stretching your muscles you are less likely to injure your joints. It can’t hurt to judiciously stretch your muscles after a workout. And even if it won’t protect your joints from deterioration, it will certainly make your muscles feel better.

BE SKEPTICAL Don’t waste your money on specialized nutrients. Shark cartilage, glucosamine and chondroitin — popular supplements marketed for healthy joints — can be expensive and probably are of limited benefit, many specialists say.

“There’s some evidence to suggest glucosamine and chondroitin sulfate may be helpful in O.A. once it has started, but overall the results are inconclusive,” Dr. Jazrawi said. As for shark cartilage, there is no evidence to suggest that it has any benefit for treating the symptoms or the disease, he said. Joints are like car parts. With proper care and maintenance, they last longer.

New York Times

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Getting a New Knee or Hip? Do It Right the First Time

THERE is nothing like a new hip or knee to put the spring back in your step. Patients receiving joint implants often are able to resume many of the physical activities they love, even those as vigorous as tennis and hiking. No wonder, then, that joint replacement is growing in popularity.

In the United States in 2007, surgeons performed about 806,000 hip and knee implants (the joints most commonly replaced), double the number performed a decade earlier. Though these procedures have become routine, they are not fail-safe.  Implants must sometimes be replaced, said Dr. Henrik Malchau, an orthopedic surgeon at Massachusetts General Hospital in Boston. A study published in 2007 found that 7 percent of hips implanted in Medicare patients had to be replaced within seven and a half years.

The percentage may sound low, but the finding suggests that thousands of hip patients eventually require a second operation, said Dr. Malchau. Those patients must endure additional recoveries, often painful, and increased medical expenses.  The failure rate should be lower, many experts agree. Sweden, for instance, has a failure rate estimated to be a third of that in the United States.

Sweden also has a national joint replacement registry, a database of information from which surgeons can learn how and why certain procedures go awry. A registry also helps surgeons learn quickly whether a specific type of implant is particularly problematic. “Every country that has developed a registry has been able to reduce failure rates significantly,” said Dr. Daniel Berry, chief of orthopedic surgery at the Mayo Clinic in Rochester, Minn.

A newly formed American Joint Replacement Registry will begin gathering data from hospitals in the next 12 to 18 months.  Meanwhile, if you are considering replacing a deteriorating knee or hip, here are some ways to raise the chances of success and avoid a second operation.

EXPERIENCE COUNTS Choose — or request a referral to — an experienced surgeon at a busy hospital. “The most important variable is the technical job done by the surgeon,” said Dr. Donald C. Fithian, an orthopedic surgeon and the former director of Kaiser Permanente’s joint replacement registry.  Ask for recommendations from friends who have had successful implants and from doctors you know and trust. When you meet with the surgeon, ask how many replacements he or she does each year.

VOLUME MATTERS A study published in The Journal of Bone and Joint Surgery in 2004 found that patients receiving knee replacements from doctors who performed more than 50 of the procedures a year had fewer complications than patients whose surgeons did 12 procedures or fewer a year.  The researchers documented a similar trend when it came to hospital volume. Patients at hospitals that performed more than 200 knee replacements a year fared better than patients at hospitals that performed 25 or fewer.

ADJUST EXPECTATIONS Not everyone with joint pain will benefit from a joint replacement.  An implant can help reduce pain and improve mobility if the joint surface is damaged by arthritis, for instance. But a new joint will not help pain caused by inflammation of the surrounding soft tissue, said Dr. Berry, who is also vice president of the board of the American Academy of Orthopaedic Surgeons.  Some people with mildly arthritic joints, for instance, can manage well with the judicious use of medication. “Surgery comes with complications and risks, and should not be approached lightly,” Dr. Berry said.

Joint replacement is not a minor operation. If you have uncontrolled high blood pressure, chronic infection or another serious chronic condition, a joint replacement operation may be too risky a procedure for you. Seek advice from an experienced Orthopaedic Surgeon.

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New Models Of Implants Not Better, Study Finds

A new study suggests that the recent technology for artificial hips and knees did not perform any better than older, less expensive designs.

The study, which draws on data from Australia’s orthopedic registry, covered implants introduced from 2003 to 2007 and was published this week. The findings are significant for patients in the United States because many of the new designs, like so-called metal-on-metal hips, are widely used here. Those implants, which have both a ball and cup made of metal, are expected to fail prematurely in tens of thousands of patients rather than lasting 15 years or more as artificial joints are supposed to do.

The Australian study showed that not a single new artificial hip or knee introduced over a recent five-year period was any more durable than older ones. In fact, 30 percent of them fared worse. The Australian study concluded that both patients and taxpayer-financed health care programs were paying a high cost because surgeons were using newly designed implants, introduced with little test data, over existing designs that had track records.  ”Not only has the introduction of this technology been potentially detrimental to patient care, but the current approach may be an important driver of increased health care costs,” the review concluded.

Dr. Stephen E. Graves, the director of the Australian registry and a co-author of the study, said he believed that surgeons, hospitals and regulators should closely look at the review’s results. In the case of the all-metal hips, some experts say they believe that replacing them may cost companies, insurers and taxpayers billions of dollars.

”There needs to be a careful re-evaluation of current deficiencies in regulation,” Dr. Graves said in a recent e-mail.

The Australian review is part of a special issue of a medical journal, The Journal of Bone and Joint Surgery, devoted to studies that examine the benefits and the limitations of orthopedic registries. While America does not have a registry, the Food and Drug Administration is financing efforts to see whether data from sources like overseas databases and registries run by hospitals here can be used to better monitor device performance.  Many experts argue that such efforts are essential because 700,000 Americans undergo hip or knee replacement every year, and that number is expected to increase sharply as the population ages.  In a registry, information about a patient is entered into a database when he or she receives an implant. Then, when that patient undergoes surgery again to replace that device, more data is added. By looking at large numbers of patients followed in a registry, researchers can tell whether certain device models are failing prematurely at significantly higher rates.

But researchers in England, which has a registry, pointed out in another article in the same medical journal that a product-related disaster had likely already occurred before it was detected in a such a database. As a result, some experts say they believe that there must be greater scrutiny of implants either before or after they go on the market to detect problems earlier.  Another review in the same issue found that the results of published studies that accompany the introduction of new implants could bear little resemblance to registry findings about a device’s success once it went into broader use.  That problem occurs, the review by Australian researchers found, because surgeons involved in the original published reports are often involved in its development and may have a financial stake in them. In addition, such reviews tend to be short term.  Some surgeons say they believe that one type of all-metal implant known as a resurfacing device is permitting some patients to remain more active. However, data indicates that such benefits are limited to one group of patients, namely larger, middle-aged men.

This month, bipartisan legislation was introduced in the Senate that could force manufacturers to track the performance of implants like artificial hips after they have been approved for sale. Proponents of the bill acknowledge that the measure faces an uphill fight.  Both device producers and their allies in Congress have maintained that any additional F.D.A. regulations would slow the development and marketing of innovative products that benefit patients. For his part, Dr. Graves, the Australian official, said he believed that such arguments were misleading.

”The purpose of regulation is not to impede innovation but to ensure safety and effectiveness of medical devices,” he stated. ”This protects patients, but it also protects companies.”

New York Times December 23, 2011

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