Lessons in Orthopaedic Leadership: An AOA Podcast
Lessons in Orthopaedic Leadership: An AOA Podcast
Exploring Cutting-Edge Implant Technologies with Arun Aneja, MD, PhD
Unlock the future of orthopaedic surgery as Arun Aneja, MD, PhD, a trailblazer in trauma surgery, unveils groundbreaking advancements in surgical implants. Explore how technology is reshaping the field with fourth-generation intramedullary nails and antibiotic-coated implants that promise to treat complex fractures and minimize complications. Discover the innovative biphasic plates designed to adapt dynamically to the healing needs of fractures, offering a glimpse into a more personalized approach to patient care. Dr. Aneja's pioneering insights reveal the transformative potential of these technologies, redefining the landscape of orthopaedic trauma surgery, one innovation at a time.
Delve into crucial topics such as antibiotic stewardship in orthopaedic procedures, where Dr. Aneja emphasizes the importance of responsible usage to combat resistance. Learn about the cutting-edge attachment of antibiotics to implants for sustained release and the use of growth factors to enhance bone healing. Consider the balance between the benefits of emergent technologies and their financial implications on healthcare systems. This episode serves as an enlightening journey through the latest orthopaedic innovations, offering listeners a detailed look into the exciting trajectory of trauma surgery and its future implications.
Welcome to the AOA Future in Orthopedic Surgery podcast series.
Speaker 2:Welcome to the AOA Future in Orthopedic Surgery podcast series. This AOA podcast series will focus on the future in orthopedic surgery and the impact on leaders in our profession. These podcasts will focus on the vast spectrum of change that will occur as the future reveals itself. We will consider changes as they occur in the domains of culture, employment, technology, scope of practice, compensation and other areas. My name is Doug Lundy, host for this podcast series. Joining us today is Dr Arun Aneja.
Speaker 2:Dr Aneja is a board-certified orthopedic trauma surgeon specializing in orthopedic trauma. He's originally from Greenville, north Carolina, where he obtained his undergraduate medical school degrees at the University of North Carolina. At Chapel Hill, he then obtained a PhD in clinical health sciences and then his orthopedic surgical residency at the University of Mississippi. Dr Inesia's doctoral research focused on the use of mesenchymal stem cells in fracture care for patients with osteoporosis. He completed his oncology fellowship at the University of Chicago and then his orthopedic trauma fellowship at Wake Forest University. For the eight years prior to coming to Mass General, dr Inesia had been teaching as an associate professor of orthopedic trauma at the University of Kentucky. He currently serves as the director of orthopedic trauma research at Mass General as a nationally recognized leader in orthopedic trauma surgery. So, dr Anasia, welcome to the podcast, sir.
Speaker 3:Well, thank you for having me. This is quite the honor.
Speaker 2:First of all, you've got a very diverse and unique educational background, not only with your PhD, but also with your fellowships in oncology and in trauma, I get this is probably not a whole lot. You're afraid of man.
Speaker 3:Oh no, Always a healthy balance and healthy skepticism and fear every single surgical case.
Speaker 2:Well, well said, but you certainly are trained adequately to address those. But today, and as you and I talked, we're going to be talking about changes in technology, specifically in the lines of surgical implants, and you've spoken on this before, specifically within the AOA and other contexts. So, sir, as the future continues to change and you and I are both orthopedic trauma surgeons, so hopefully the audience will forgive us if we tend to talk about what you and I like to talk about, the best or the most when do you see implants going in the future in terms of surgical implants?
Speaker 3:Yeah, I think there's many different directions to go. If you look at, what we're doing in orthopedic trauma is we're starting to treat more and more fractures with endosteal implants as opposed to periosteal implants. So there's an explosion in the intramuscular nail market. You also see that. You know we're now currently in the fourth generation of intramuscular nails initially. You know we're now currently in the fourth generation of intermeasure nails, initially, you know, prior to the Kushner nails, prior to the Cloverleaf nails. You know the earlier generations. We are now starting to treat much more extreme fractures, much more distal fractures than just diafseal fractures. We're starting to treat metafseal and articular fractures and so there's just been an explosion and I think they described it as a fourth generation inch and measure nailing, where we're now starting to see nails that have some sort of fixed angle, whether it's capture, whether it's some sort of polymer, whether it's interlocking within the threads of the interlocking hole or whether it's some sort of coating within the nail. That's kind of become popular overseas and hopefully would get adopted in the United States.
Speaker 3:So I think the explosion in orthopedic trauma recently has been predominant in the intramedial nail sector. That's one area, particularly with coating as well as ability to have a better stability and ability to treat more and more extreme fractures. The other area that's been really taking off is in if you want to talk about the more so the periosteal plates, is the whole concept of the strain theory, having these biphasic plates, having these plates that somehow modulate their strain within so that at times when you need the implant to be very stiff, it can sort of modulate that strain. That can kind of give you that and as the fracture starts healing, whether you need more flexibility or whether you need more stiffness, these biphasic plates are starting to take off. So those are the two sort of areas that I really see. Non-unions are problems, infections are problems. Treating fractures with endosteal implants always advantage. So the nail sectors, I think is really worth scrolling.
Speaker 2:So you brought up the coated implants. That in and of itself is an absolutely amazing thing. Where do you see coated implants going? What are we coating them with and why are we doing it?
Speaker 3:to have just with their non-union rates. So, believe it or not, overseas, in Europe, you know antibiotic coated nails are already being made and used, right, they don't have as tight FDA regulations, so they're one of the largest vendors. Synthes already has a genomized and coated nail that's well approved and used in Europe. However, that never got approved in the United States, whether it's FDA or whatever. But I see within the near future that there is going, instead of us having to do off-label, you know assembly of antibiotic coated nails that we do in our back table with the cement gun and you know the heat.
Speaker 3:Stable tubing, tigon tubing, whichever tubing you decide to use stable tubing, tigon tubing, whichever tubing you decide to use I anticipate in the near future you will have major, large vendors produce antibiotic coated nails. In addition, you know, is it possible that certain nails might also have BMPs attached to it? Yeah, that's also something that's been looked into. I don't know of any vendor that's specifically making that, but I think that there has been talk on that issue as well. But I see infection control as one of the biggest things.
Speaker 2:I was talking with Dan Barry. I heard him give a talk at a meeting I was attending and believe that infected total joint arthroplasty was the big frontier in total joints that still nothing had progressed along with. Let's hop back to the antibiotic-coated nails. What about the risks of developing resistance overtreating? I mean, I get what you're saying. However, let me play devil's advocate for a minute. There's a fair number of tibia fractures, femoral fractures, that never get infected. Are we causing any additional problems by coating these with antibiotics versus just treating the ones that would have been infected?
Speaker 3:You know this is a great question, but if you see the wave of practice, currently the whole topic of local antibiotic delivery has taken off. You know whether it's the, the Vanco trial or whatnot, but reality is we're using local antibiotics a lot more frequently than we were, you know, and so this whole concept of resistance is a very key issue. I don't see this sort of going away. I see us still continuing to use it despite the evidence. Right, like vancomycin resistant enterococcal VRE is like a huge concern, right, but we still use vanco, right. What do we do? We combine it. Well, let's combine. Let's do synergism. Let's combine it with another antibiotic that works a different mechanism. So that way I have less concern about resistance. Right now I'm giving two antibiotics that work different mechanisms. So I'm adding bank with tilbomycin and I'm hoping that now the likelihood of getting resistance is going to be less. The likelihood of eradicating the bacteria is going to be much higher. But it's definitely a valid concern. I don't see it playing out quite yet in that sense, in the sense that we're still going to continue using local antibiotics.
Speaker 3:Hopefully we will use local antibiotics that aren't the big guns, right. Hopefully we're not always jumping to vancomycin you know meropenem like the one of the largest guns. Fortunately, you know I don't know about heat stability, but we aren't mixing that with antibiotic, right? Nobody's sprinkling meropenem in the wound, right Like that's one of our biggest guns. And I think if you start doing that, I anticipate you're going to be getting phone calls from the infectious disease doctors.
Speaker 3:I've definitely had times where I've wanted certain antifungals in my antibiotic implants and I've definitely gotten calls from the pharmacist at the academic center and be like hey, why do you need this? And so I, and that there's enough stewardship within these large academic center where there's some sort of regulatory oversight. As of now, I still see certain antibiotics that we're allowed to use, but if we use some of the ones that are the bigger guns per se, I could see that as being a huge problem. But I think tobramycin will be used, I think genomycin will be used, I think vancomycin, even despite BRE and other things, is still going to be used.
Speaker 2:How do the antibiotics? How do they attach the antibiotics to the nail? I've heard of nanotubes, some of the things. Do you know? How does that work?
Speaker 3:Yeah. So I think that's a great question. You know it has to be in some sort of manner that provides the best sustained delivery. So, whether you know, whatever core site that gets fabricated has to have some bioavailability data to show that, hey, you're going to see this peak of antibiotic at 48 hours, but you're going to get constant elution that is good for bactericidal activity for as good as two weeks. The last thing you want is you just want to rush of antibiotics and then you know it's no longer effective, and that's how I think you might lead to more resistance happening. So, from what I've seen not the ones that have been approved, the one in Europe, it's usually sort of four size particles that are attached and manufactured to the actual nail itself.
Speaker 2:So you have also talked about the growth factors attached to the nails. How does that work, and what growth factors are you aware that are being considered?
Speaker 3:Yeah, I think there's a lot of debate on this right Like so I could see BMP2s, bmp7, op1. Way that we're going is we're now starting to realize it's not a single bone morphogenic protein. Rather, there's nothing as good as Autograph right, the whole constellation of factors. So I don't know if it's going to be a single bone morphogenic protein or a single growth factor. I think whatever it's going to be, it's likely going to be a constellation and again it's going to have to demonstrate some sort of peak elution property that is super advantageous. I don't know any nail on the market in the United States that has done that quite yet, but whatever the way it goes in the future, they would have to show really good elution properties and it'd be something that is not individualistic in the sense of a single bone morphogenetic protein, but rather a constellation, and it's got to be as good, if not somewhat resemblance of autographed.
Speaker 2:So let's continue on our non-union theme here. As you and I are well aware, sometimes supraconolar distal femoral fractures of different types are prone to go to non-union, and the implants that we currently utilize are often accused of being too stiff. So we've heard of far distal locking and all the other modifications that you can do to the plating techniques to increase or decrease the rigidity of the construct. Can you tell us more about these biphasic plates? How does that work and how do you modulate the stiffness of the plate?
Speaker 3:Yeah, I know. So this is a great question in the sense that what I've seen so far is at certain industry development centers there have actually been implants that have strain gauges which can actually record data about the plate of the implant that's being used and deliver it to the iPhone or some sort of computer device. So it gives you an idea of like, hey, at early fracture healing, this is the amount of strain that needed. At later fracture healing, this is the amount of strain that is much more optimal for consolidation healing.
Speaker 3:The biphase plates is something that's just been recently introduced. I am still kind of fully trying to understand it. You know it is on the market in Europe but it hasn't made its way all the way to the United States and it's very much in its experimental developmental stages. I know it's won several incubator awards. But to be honest with you, I know that somehow and I don't know exactly it definitely doesn't have an internal strain gauge built in, but it somehow it modulates strain. So that way they know, at a certain time point where you want flexibility to get that micromotion and callus formation, it can induce it, that micromotion, and callus formation.
Speaker 2:It can induce it so many times, especially now with the finite amount of money in healthcare. One could argue that these technologies, although they're incredibly cool, are an additional expense to the system. So can you talk at all about the value basis of healthcare in terms of what is the additional cost of these implants and the development of these implants worth the overall spend? Are we treating enough adequate disease with the amount of money that we're spending with this, or are these just cool gadgets that we like to use?
Speaker 3:Yeah, that's a good problem to notice, right, Like I mean these newer technology, guess what R&D is going into it? Big companies are going to be wanting to push and pedal it because they cost a lot more. And what does that mean? That means your patients are going to get charged a lot more. So, yes, is it worth paying for all these bells and whistles? Probably not.
Speaker 3:So another area of explosion that's been happening is now you're starting to get, you know, pre-contoured plates for the medial distal femur. You're getting pre-contoured plates for the posterior tibia. You know, like, does that, do these areas really need it, or can you just do cheaper or much more utilitarian use with off-label use? So I 100% agree. I do think we're saturating the market and I definitely think this is something that the industry sector is kind of pushing and doesn't need to be done. Probably not. You can. You know fractures can be definitely treated with standard implants, right? That's something I think of almost every day, because I know there's a charge master sheet that the hospital is using and so even if the vendor tells you oh, this is only $100, $200 more, I know the patient's getting charged a lot more. So you're a hundred percent right, the value. Cost is probably not worth all these bells and whistles, and so there's oversaturation.
Speaker 2:And you're at Mass General where a bunch of this research is going on. Don't tell us anything that you're not supposed to tell us. But where can you tell us about what y'all are doing over in Boston to make things better for the rest of us?
Speaker 3:Yeah, so. So maybe not so much in the trauma line, but one thing that Mass General has been prolific in is making the highly cross-linked polyethylene that's used in all the tibial trays and now in reverse shoulders and almost any sort of arthroplasty. So just highly cross-linked poly. I don't know what the status of patent is. I imagine patents run out after X amount of time, right? So industry definitely feels the pressure to add newer, cooler technology, more bells and whistles, so they can keep a new patent that can charge just as much, as opposed to selling something that's a lot less expensive and has more competitors now because the patents run out. So I know in the polyethylene space for arthroplasty they have been doing something similar to what we talked about is having polyethylene that has antimicrobial particles etched in so that it also elutes antibiotic in the arthroplasty setting, right, like so if you get a total knee, now you've got this highly crossing poly that's eluting antibiotics, you know, for X number of days. That's microcytal or bactericidal for, you know, preventing infection. So that's one thing that they're definitely working on.
Speaker 3:At the same time, if you notice, pain cocktails have really taken off in the arthroplasty literature and so, like you know, a lot of patients, after they get the total knees or total hips done, they get like a cocktail injection at the site. And so again, similar concept now that are also trying to, you know, have these sort of analgesic drugs attached to this polyethylene. That again gets eluded out. So now you're treating constellation. Not only are you treating and, you know, preventing infection, but this will also help with your pain. So, yes, this whole concept of local delivery of drugs, whether it's antibiotics, pain analgesic medication or whatever bone morphogenic proteins, I think that's something that's really appealing.
Speaker 2:Just local drug delivery very good, and you guys are working on that over there at Mass General.
Speaker 3:I think that's the new from what I heard from attending me going to the Harris Lab, which is the lab that developed it. That's where they're sort of heading.
Speaker 2:Very interesting. So where do you see perhaps 10 to 15 to 20 years from now? What's it going to be like in terms of when we pop the trays in the back table to do total joint arthroplasty or trauma surgery or whatever? Do you see any new standards of what it would look like then and how our children may go? Well, mom, dad, they did the best they could with what they had, but, as we know, that old titanium rod is not used anymore, do you have any insight as to where that'll be at that time? Dr Justin Marchegiani.
Speaker 3:I hope we will continue to evolve and get better. If history has been any sort of representation of our future, you know, like the whole field of orthopedics has really advanced a lot, right, like I mean from World War II, like we talked about Kunchner nails, right, this whole concept of a slotted nail or that you kind of compress, you stick into the medial canal and let the nail expand, kind of compress, you stick into the medullary canal and let the nail expand. Then you come up with the idea of, hey, let's go and create some interlocking holes. So now that we have rotational as well as we can prevent shortening. And then you bring in the concept of reaming. We're definitely moving in the right direction. Right, like reaming, we find the biological value of that. We started using reamer irrigator aspirators, you know.
Speaker 3:So I think we're, I hope we're moving in the right direction. But it's going to be a fine balance. Like you mentioned, the whole idea is not to get oversaturated. You don't want to be the first one to jump on the bag when bandwagon and you definitely don't want to be the last right? So so I anticipate technology is going to keep innovating. There's going to be failures, but there will also be successes, and time and well-tested research is really going to help us sort of figure out which implants are better and which implants are of value, and which ones are worth innovating, which ones are worth not redesigning and failure.
Speaker 2:And it's interesting, the Harvard Business School, of course, is not very far from you all over there, of course, is not very far from you all over there, and you could. One could say that the future in implant design is the introduction in the advent of cheaper, more cost-effective implants. I mean, like, as our iphones become more and more technology, have more and more technology, the prices also tend to go down over time. So that could also be a certain way that technology could progress. But we keep talking about ranking the right, the ranking cost up. But it could go the other way as well.
Speaker 3:Yeah, without a doubt. You know, I mean, I don't have to tell anyone. You're like the expert on health care, you know the costs associated with it. But, like plastic example of sign nail right, sign nail is super cheap, right, but yet they haven't taken off in the United States, right, and overseas they're getting used all the time, but, yeah, does the pharmaceutical? Does the big vendors have some part in this? Yeah, probably. But yes, I do think that healthcare costs are immense and I do not think they're sustainable at the rate that we're going. So somewhere something's gonna give, so it's value. Cost analysis always gotta be on the top of your mind.
Speaker 2:But to your point on that, as leaders in surgery, it is incumbent on us to help focus not just another cool gadget that really doesn't solve a problem but we just think it's cool and want to do that, as opposed to, like I said before, of the issues of infection and total joint arthroplasty infection and trauma, trauma, nine unions and trauma to help push industry to actually spending money and doing cool things on areas that actually make a difference and not so much things that we just think are fun to use, right?
Speaker 3:Yeah, yeah. Now you have so many different companies, right, like earlier, we only had a couple of major companies. Now you got so many different vendors. Now a one foot and ankle company is now starting to come up with their trauma line, so they've got their own. So, yes, all these things need to be thought. It'd be ideal, it'd be great to get companies to work together, but that's not going to happen in a capitalistic market. But all great points.
Speaker 2:All right, parting shot, my friend. Any other additions to where you see things going in the future, anything that we should be looking for, anything fun and edgy in the future of implants.
Speaker 3:No, you know exciting times, but at the same time I kind of want to stress something that we've already talked about just as a healthy skepticism. You know, don't be the first one to jump on a bandwagon and don't be the last kind of really see how the literature plays out for certain implants. We've seen various implants that come into the market and have significant failure rates associated with it. So just stay tried and true to principles and I think that will guide you the best.
Speaker 2:It has been an absolute pleasure talking about the future of surgical implants with Dr Arun Aneja, who is an orthopedic trauma surgeon at Mass General. He's got his PhD as well in this and is certainly an expert in these areas and has a very interesting and intriguing viewpoint on these things. It's been fun to give a peek into the future on this and also talk to a fellow leader in orthopedic trauma surgery, Dr Aneja. Sir, thank you for being on the podcast.
Speaker 3:Dr Lundy, Thank you so much for having me. This has been extremely enjoyable, informative and I look forward to listening to this when it gets released.
Speaker 2:Yes, sir, and y'all look forward to future episodes in the future in orthopedic surgery podcast series.
Speaker 1:Orthopedic Surgery Podcast Series.