June 2003 Bulletin

Washington Report

AAOS testifies before Congressional subcommittee

Urges increased funding for NIAMS

AAOS Research Council Chair Joshua J.
Jacobs, MD (right), and orthopaedic patient
Jerry Holiber (left)urged the House Appropriations
Committee to increase NIAMS funding.

On May 7, Joshua J. Jacobs, MD, the Crown Family Professor of Orthopaedic Surgery at Rush Medical College in Chicago and Chair of the AAOS Council on Research and Scientific Affairs, testified before the Subcommittee on Labor, Health and Human Services and Education of the House Appropriations Committee, to urge Congress to provide increased funding for the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Dr. Jacobs was accompanied by orthopaedic patient Jerry Holiber, who, in 1983, received one of the first porous-coated cementless hip implants, which has lasted more than 20 years.

Both urged Congress to provide $538.25 million in FY 2004 funding for the NIAMS, a 10 percent increase over FY 2003 levels. President Bush has proposed only a 2 percent increase.

Burden of disease

This year, the Centers for Disease Control and Prevention (CDC) issued a report, "Targeting Arthritis: the Leading Cause of Disability, 2003." Of the top 10 disabilities in the United States identified by the CDC, three are musculoskeletal diseases and conditions. These three comprise nearly 40 percent of all disabilities in this country with arthritis or rheumatism leading the list (17.5 percent). Back or spine problems were second with 16.5 percent and in sixth position was limb/extremity stiffness at 4.2 percent.

Dr. Jacobs stated, "The burden of musculoskeletal disease on society demands a strong and committed response by Congress. Yet, despite the chronic nature and the high burden of disease of musculoskeletal conditions, funding for orthopaedic research has not yet reached the goals of the doubling effort that was undertaken five years ago for the National Institutes of Health (NIH).

"Since 1989, I have been a research investigator on six NIAMS grants, and the principal investigator on two more studies. Today, I am involved in three ongoing research efforts, including studies on osteoarthritis, on systemic implications of total joint replacement and on the identification of bioreactivity markers in patients with total hip replacement. These multi-year studies hold great promise for improving patient care.

"As we look to the future and as the population ages, there will be more demands for orthopaedic services, such as hip and knee replacements. In the future, arthritis or a spinal cord injury may not be life-long ailments. Some musculoskeletal diseases may be cured by regenerating bones, cartilage or nerve cells. These therapies may be possible, but only if we now make musculoskeletal research funding a top priority."

Dr. Jacobs, who is a practicing orthopaedic surgeon specializing in joint replacement, spoke about the progress as well as the remaining challenges relating to health of the musculoskeletal system. He described the case of Mr. Holiber, a retired employee with the U.S. Department of Transportation. "This technology, unknown prior to the 1980s, employs a porous coating bonded to the implant surface," Dr. Jacobs explained. "Bone grows into this porous coating, creating durable biologic fixation. This advance has stood the test of time and currently well over 90 percent of the socket components of total hip replacements use this technology.

"Mr. Holiber’s success story is representative of the advancements in orthopaedic surgery made possible by systematic progressive research. It also helps to highlight the challenges ahead as we continue our research into total joint replacements to search for better approaches to make the implants more durable with the goal of producing orthopaedic implants that can last a lifetime," Dr. Jacobs added. "This is particularly important as joint replacement surgery is increasingly required in younger patients with higher levels of functional demand, as our elderly population becomes more and more active and as the baby boomer population ages."

Patient tells his story

Orthopaedic patient Jerry Holiber told members of the subcommittee that receiving a joint replacement changed his life for the better. "Several years before my total hip replacement, I was involved in an automobile accident," he explained. "My condition grew worse, and by 1983, I could barely walk and was in constant pain.

"At the time of my accident, I was told that the approach to joint replacement was to delay surgery as long as possible, especially in active patients such as myself. This was due to the fact that implants would not last long, and would have to be revised and replaced. Also, for the 20 years prior to my surgery, implant components were cemented into place, and this type of fixation was often the weakest link between the artificial implant and the body.

"Fortunately, my orthopaedic surgeon, Dr. Charlie Engh of Virginia, was pioneering a new experimental procedure, the porous-coated cementless hip implant. Twenty years after this total hip implant, I am pain-free and play tennis regularly. In fact, I cancelled a match to testify before you today. Remarkably, this original implant has lasted 20 years.

"Hopefully, this implant will last another 20 years. It is my understanding that today, there is research on many other breakthrough technologies in joint replacement, which hold great promise, just as the porous-coated cementless hip implant did in the 1980s."

Future directions in musculoskeletal research

Dr. Jacobs noted that the AAOS Committee on Research has just completed an almost four-year project to help the orthopaedic community identify future directions in musculoskeletal research that hold the most promise for improving patient care. These critical and immediate areas for future research include:

Genetic research/Tissue engineering. Tissue engineering can be defined as any effort to repair, augment, replace or regenerate a specific tissue in a specific anatomic location. Tissues of particular interest and value to the field of orthopaedic surgery include bone, cartilage, tendon, ligament, meniscus, intervertebral disc, fat, muscle and nerve. Promising future areas of research include the biology of fracture healing, regeneration of the peripheral nerve and the treatment of brachial plexus injury and biological repair processes and bioengineering approaches to tissue regeneration in the treatment of arthritis.

Cell biology/Basic cellular research. Today researchers in cartilage biology and orthopaedics are using cellular, molecular and genetic approaches to analyze cartilage development, growth, diseases and aging, as well as applying the emerging technologies of mesenchymal adult stem cell-based tissue engineering to functional cartilage replacement. This research may be especially important in the treatment of degenerative spinal disc disease.

Genetic research/Biomarkers. The sequencing of the human genome has fundamentally changed the way scientists view disease, and it will enable clinicians to treat patients in ways that were not possible in the past. Particular areas of concern include identifying the subset of genes that encompass the musculoskeletal genome and defining the action of the genes that regulate skeletal formation, growth and development. Research in this area could include investigating the greater prevalence and triggers of arthritis in women and identifying the genetic markers in the treatment of sarcoma patients.

Biomechanics/Biophysics (kinematics and modeling). There are many challenging and unanswered questions in the fields of cellular and molecular biophysics. The clinical specialty of orthopaedics is built largely on the therapeutic manipulation of the physical environment of skeletal tissues to allow and potentially stimulate repair. Current research is being directed at how repairing skeletal tissues respond to physical cues and what translational opportunities exits. Active investigations are underway to understand the therapeutic potential of mechanical strain, electrical fields and ultrasound in stimulating skeletal repair. This area also holds great promise for innovative approaches to treating patients.

Other major research areas of interest include biomaterials (fixation frames and injury repair), the epidemiology of injury and its prevention, the impact of aging, infections and pain research including drug efficacy.

Call to action

"If Americans are to be relieved from the personal, societal and financial burdens of musculoskeletal conditions, improved treatments and eventual cures must be found," said Dr. Jacobs in conclusion. "These innovations require an investment in both basic science and clinical research. Yet, despite the chronic nature of musculoskeletal conditions, funding for orthopaedic research has not yet reached the goals of the doubling effort that was undertaken five years ago for the NIH.

"We urge the subcommittee to consider the need for research on the causes of musculoskeletal diseases and disorders, the validation of new technologies being used to assess disease processes and the examination of new interventions and appropriate treatments."

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