Overcoming obstacles in musculoskeletal medicine

Demand for total joint replacement (TJR) surgeries will far outstrip supply in the coming years, significantly diminishing the quality of patient care, and methicillin-resistant Staphylococcus aureus (MRSA) infection threatens to become a "21st-century plague,"according to speakers at the recent American Academy of Orthopaedic Surgeons (AAOS) annual meeting held in San Francisco.The breakthrough potential of stem cells, tissue engineering, and gene therapy in musculoskeletal medicine was another key area of discussion.

TJR dilemma. TJR surgeries have increased dramatically in the past 10 years and are expected to increase even more with the growth and aging of the population. A predicted 572,000 total hip replacements and 3.4 million total knee replacements will be performed in 2030, representing greater than 100% and 500% increases over the numbers performed in 2005, respectively, according to a new study. However, the supply of orthopedic surgeons is expected to increase only 2% between 2000 and 2020, and in a 2005 survey of more than 23,000 AAOS members, only 7% identified themselves as primary surgical specialists for the adult hip and knee. Leading orthopedic surgeons called for creation of an American joint replacement registry and changes in the physician reimbursement system to help close the gap and avoid a quality-of-care crisis in the years ahead.

MRSA becoming "bulletproof." In 2005, there were 94,360 invasive MRSA infections in the United States, according to a 2007 CDC report; 18,650 persons died as a result and 85% of the cases were health care–associated. The incidence of this serious infection, which may be community- or hospital-acquired, has become a worldwide phenomenon and is increasing significantly. Orthopedic surgeons expressed concern that S aureus bacteria are becoming increasingly resistant to current treatment approaches and cited improved prevention efforts as a key to addressing the musculoskeletal infections problem.

Stem cells show promise. The use of stem cells is developing rapidly, offering new hope to patients who have musculoskeletal conditions, according to the AAOS. Adult stem cells, readily available from a number of sources, are being used for fracture repair and bony defects. In the near future, physicians may be able to harvest a body's stem cells and direct them to the damaged and degenerative cartilage that is causing arthritis pain, possibly restoring and regenerating the cartilage to a normal state. Orthopedic research scientists are working on stem cell therapies to improve tissue healing, muscle regeneration, cartilage repair and bone growth, and musculoskeletal diseases and conditions (eg, osteoarthritis, osteoporosis, and osteosarcomas). Stem cells could eventually eliminate the need for joint replacement, and patients with orthopedic trauma may benefit from future cellharvesting techniques.

Nagging concerns. Other areas of discussion included the following:

• There are numerous sex (genetic) and gender (environmental) differences between women and men that require greater consideration from physicians in protecting women's musculoskeletal health (eg, anterior cruciate ligament [ACL] injuries). Orthopedic surgeons are calling for more research, better training and prevention techniques, and increased patient education.

• Increased exposure to sports activities has resulted in an increased risk of injuries in young athletes. With new approaches to treatment, however, physicians now can manage many shoulder, ACL, and elbow injuries more effectively.

• Plantar fasciitis is a common problem in which physicians often cannot pinpoint what triggered the pain. Treatment options now include nonoperative therapy (eg, exercises and massage), partial plantar fasciectomy, and shockwave therapy.

For more information on these and other musculoskeletal topics discussed at the AAOS annual meeting, visit the AAOS Web site at www.aaos.org. Or, contact the organization at AAOS Headquarters, 6300 North River Road, Rosemont, IL 60018-4262; telephone: (847) 823-7186.