August 2003 Bulletin

Directions for future research—Unified Research Agenda:

• Explore the genetic, biological and mechanical factors that influence the progression of arthritis. B, C

• Examine the molecular basis of osteoarthritis, biological repair processes and bioengineering approaches to tissue regeneration with special emphasis on cartilage repair. B, C, T

• Study the interaction of materials and wear and, specifically, the interaction of the material with the host, emphasizing early detection methodologies, prevention and medical intervention. C T

• Examine the effect on tissues of debris particles and investigate possible molecular markers of loosening and osteolysis. B, C

• Explore the effectiveness of alternative therapies in reducing symptoms of osteoarthritis. C, T

• Study the short- and long-term effects of alternative bearing surfaces. C

• Evaluate new coatings and methods of implant fixation, including use of bioactive materials. B, C

• Explore the benefits of chondral transplantation in preventing degeneration of joints. C

• Study joint kinematics around the hip, ankle, elbow, shoulder, wrist and knee in normal, arthritic and reconstructed states with the development of high-speed computational methodologies to stimulate natural and artificial joint performance. C

• Explore the role of novel imaging technologies on joint arthroplasty, including RSA, DEXA, surgical navigation, minimally invasive and robotic surgery. C, T

• Expand the use of finite element analysis (FEA) to predict implant performance, identify fundamental mechanisms of failure and predict performance failure of mechanical devices. C, T

• Apply basic principles for the mechanics of materials to individual connective tissue cells to define the cell response to mechanical stimuli and the cellular pathways involved on the transduction of mechanical inputs. B,C

• Implement new strategies to minimize technical complications, such as dislocation in total hip replacement and arthrofibrosis in total knee replacement, and medical complications, such as infection, venous thrombosis and embolism. C, T

• Develop new arthroplasties such as ankles, first metacarpal-phalangeal and wrist. B, C, T

• Study the relationship between quality and volume in total joint arthroplasty. H

• Study the apparent underutilization of total joint arthroplasty in some geographic areas and among some ethnic groups. H

Spinal disorders

• Improve the ability to diagnose spinal disorders, including the ability to localize the source of pain, evaluate motion segment instability and evaluate the role of muscles and connective tissue on back pain. C, T

• Implement randomized controlled trials for surgical and nonsurgical treatment of back disorders. C

• Reduce poor acute outcomes and improve long-term outcomes from surgical treatment.C, T

• Explore new treatment methods and technologies for degenerative disc disease, including the use of artificial disc and nucleus and the use of growth factors and/or gene therapy to reverse the process of disc degeneration. T

• Study the etiology of spinal deformities such as idiopathic scoliosis with emphasis on screening programs and treatment alternatives. C

• Improve the treatment of spinal column injuries, including methods of fixation, and enhance the treatment of neurologic injury associated with spinal trauma. C, T

• Understand the basic biological processes associated with spinal disorders, including the biological basis for fusion enhancement and the biological treatment of degenerative disc disease. B

• Study the biomechanics of spinal degeneration, motion segment and clinical instability. C

• Improve the treatment of both primary and metastatic spinal column tumors. C, T

• Study etiology of lower back and neck pain with goal of using novel medical interventions as well as treatment alternatives that may be useful in alleviating pain in the future. C, T

• Better define and clarify what role ergonomic injuries play in causing spine disorders and how ergonomic modifications can reduce and prevent such disorders. C, T, H

Soft tissue injuries

• Increase the understanding of the causes of peripheral nerve compression and develop alternatives to surgical treatment. C, T

• Increase our understanding of Charcot arthropathy and diabetic foot insensitivity complications. B, C

• Expand the role of prefabricated engineered tissue in free tissue transfer and identify the links, if any, between factors that regulate microcirculation and those that mediate pain perception. C, T

• Develop improved methods of nerve repair and regeneration. B, T

• Investigate the molecular signals that control repair and growth in cells of the musculoskeletal system. B

• Develop synthetic replacements for muscle, ligament, tendon and cartilage using tissue engineering techniques and/or gene therapy. C, T

• Explore the knowledge of the interaction of the immune system and its role in transplantation of bone and ligaments. B, C, T

• Study the relative influences of osseous anatomy, ligamentous laxity and sex hormones on musculoskeletal disorders. B, C

• Understand the role of physical activity in the development of tendon, ligament and muscle. C, T

• Develop a better understanding of the particular fitness requirements for different genders, for different age groups and for individuals with different physical disabilites. C, T, H

• Develop a better understanding of the impact of inactivity with respect to common pathologic mechanisms in musculoskeletal and neurological diseases or disorders. C

• Study pathomechanics of joint injury focusing on prevention and the development of more effective protective devices for particular sports and jobs where risks of physical impairment exist. C, T

• Develop training and conditioning programs that improve muscle reaction time, protective muscle stiffness and performance. C, T

• Analyze the forces in normal tissues and the healing of soft tissues during in vivo activities. Develop new designs, based on this analysis, for improved repair and reconstruction procedures as well as for scientifically based rehabilitation protocols. B, T

• Identify the signaling pathways involved with muscle, tendon and ligament injury, repair and hypertrophy. B

Major limb trauma

• Improve injury prevention, including passenger safety, in motor vehicle collisions. H

• Develop additional agents, delivery systems for molecular compounds and biophysical stimuli to accelerate normal healing. B, C, T

• Elucidate causes for delayed union and nonunion and develop biologic mediators to reinitiate fracture repair. B, C, T

• Continue to improve trauma systems triage and delivery. C, H

• Elucidate the system effects of skeletal triage and delivery. H

• Elucidate the indications for nonoperative fracture care and improve management of specific skeletal injuries using techniques such as minimally invasive surgery. C, T

• Continue to improve implants used for fracture stabilization. C, T

• Improve outcome rates for fracture. Address improvements in the diagnosis and management of compartment syndromes and treatment of skeletal infection using local measures and systemic adjuncts. C, T

• Improve rehabilitation with workplace and activity re-entry including assessment of benefits of physical and occupational therapy protocols. T, H

Osteoporosis and bone quality

• Explore the factors that contribute to the development of peak bone mass. B, C, T

• Focus educational efforts on the maintenance of bone mass throughout life and secondary prevention such as medical therapies and physical activity training. C, T

• Explore the use of emerging technology such as vertebroplasty and kyphoplasty in the treatment of vertebral compression fractures. C, T

• Improve injury prevention programs for the elderly. T

• Improve the management of fractures once they have occurred, including fracture fixation methods, improved inpatient management and localized as well as systemic bone augmentation. C, T, H

• Identify predictive models for determining fracture risk. C, T ,H

• Determine gene and matrix factors that affect bone mechanical strength and optimal fracture healing. B

• Develop appropriate cost-effective methods to evaluate causes of secondary osteoporosis at the time of the hip fracture. C, T, H

• Identify essential services needed to optimize the outcomes, particularly in the context of the heterogeneous hip fracture population. T, H

• Identify the parameters to be used to determine appropriate length of stay in the acute and rehabilitative settings. Develop criteria to determine transfer to acute or sub-acute rehabilitation centers, skilled nursing facility or discharge to home. These criteria should include milestones that determine when utilization of these alternate care settings have been optimized and no further benerfits can be anticipated. H

• Develop improved treatment protocols for metastatic tumors to the musculoskeletal system, especially bone. C, T

Childhood musculoskeletal conditions

• Identify and define the action of the genes that regulate skeletal formation, growth and development. B

• Elucidate the mechanisms by which these genes are regulated. B

• Discover the actions and interactions of cell-regulatory proteins and their target cells in normal and abnormal conditions. B

• Investigate the developmental biology of the musculoskeletal system with emphasis on bone and joint development and mechanism of regeneration. B

• Develop more physiologic interventions for the correction of skeletal deformities and neuromuscular conditions including cerebral palsy and muscular dystrophies. B, C, T

• Design and conduct clinical trials to determine optimal therapeutic approaches to these conditions as new treatments are developed. C, T

• Understand the molecular heterogeneity of bone and soft tissue tumors in terms of characterization and response to therapy. B, C, T

• Investigate the role of genetics in bone tumors with emphasis on molecular staging, therapeutic targets, models development and use of gene chip (microarray) analysis. B, C, T

• Improve the use of bone allografts and prosthetic reconstruction in limb salvage for bone tumors. C, T

• Improve childhood injury programs. C, H

• Develop rapid diagnostic tools for musculoskeletal infection. C

Types of research