Orthopedics is a branch of surgery that deals with disorders and conditions that involve the musculoskeletal system. Orthopedic surgeons use surgical and non-surgical agents to treat musculoskeletal trauma, spinal diseases, sports injuries, degenerative diseases, infections, tumors, and congenital disorders.
The quality of human life can be dramatically improved with the use of biomaterials . Rapidly advancing technologies are allowing new and improved biomaterials to be developed with unprecedented performance behaviour.
There has been significant improvement in technologies to reconstruct musculoskeletal defects as a result of trauma or disease . During the last few decades, there has been widespread use of bone-banked, processed skeletal allografts to reconstruct large deficits of bone and cartilage with outcomes at intermediate follow-up providing 85% satisfactory results. However, there still is a significant incidence of nonunions and graft failures, which usually require additional surgical intervention and result in additional morbidity. Additionally, the cost and availability of graft materials and some immunological issues still have not been completely resolved. Although great strides have been made to improve materials and surgical techniques, the failure rate in these younger patients still approaches 10% in long-term follow-ups. The ultimate goal of any treatment that addresses musculoskeletal tissue loss is the restoration of the morphology and function of the lost tissue. The recent emergence of a new discipline, defined as tissue engineering, combines aspects of cell biology, engineering, materials science, and surgery with the outcome goal to regenerate functional skeletal tissues as opposed to replacing them. Repair and regeneration of skeletal tissues are fundamentally different processes. In many situations, scar, which is the result of rapid repair, can function satisfactorily, such as in the early phases of bone restoration. By contrast, regeneration is a relatively slow process that ultimately results in a duplication of the tissue that has been lost. Regeneration is rarely seen in adults but is evident in very young children. Such regeneration appears to recapitulate some of the key steps that occur in embryonic development. Our approach to musculoskeletal tissue regeneration is to use principles of tissue engineering that are based upon the premise that there are important constituents that distinguish the fetal environment from that in adults and by mimicking aspects of these fetal microenvironments, we can engineer the restoration of adult tissue. The basic component of any tissue engineering strategy is the use, either in combination or separately, of cells, biomatrices or scaffolds/delivery vehicles, and signaling molecules that provide the biological cues for the progression of cellular differentiation and its site-specific functional modulation. Significant issues remain for each component that must be addressed to develop successful and realistic tissue engineering treatment strategies. Central to our strategies is the need for cells. Significant issues that remain include the source of these cells, the number and density, and, most important, their age, phenotypic character, and developmental potency. We have put forth the hypothesis that mesenchymal stem or progenitor cells possess the appropriate developmental potential, are responsive to local cueing, and are capable of ultimately differentiating into the appropriate required phenotype. By contrast, adult differentiated cells are generally less responsive to mechanical and biological cues and may not be available in the appropriate quantities to achieve the desired tissue density.
Tooth is a biological organ originating from ectomesenchymal cells composed of enamel, dentin, and viable pulp tissue which is altogether called as tooth organ . These tissues usually arise from the interaction of oral epithelium and mesenchyme of cranial neural crest.
As a highly specialized and dynamic tissue, bone is
characterized by its mineralized matrix, rigidity and hardness
with certain degree of elasticity . Bone provides support and
protection to internal organs and also aids in locomotion.
Ligaments are specialized connective tissues whose
biomechanical properties allow them to adapt to and carry out
the complex functions required of the body . While ligaments
were once thought to be inert, it is now recognized that they are in
fact responsive to many local and systemic factors which influence
their performance within the organism. Injury to a ligament
results in a drastic change in its structure and physiology and may
resolve by the formation of scar tissue, which is biologically and
biomechanically inferior to the ligament it replaces. T1 weighted
images are particularly useful at demonstrating the normal
anatomy . Ligaments will appear black against the adjacent
fat which will be white. In case of injury, T2 weighted images will
show edema in the soft tissues and if fat suppression is used then
this can easily be differentiated from fatty structures. Therefore,
T2 weighted images with fat suppression, or perhaps more
sensitively, Fast STIR images should be employed. Because the
anatomy of the lateral complex is variable, the choice of imaging
planes is difficult. True axial images are particularly useful for
looking at both the anterior and posterior tibiofibular ligaments.
The anterior talofibular ligament will also be seen on most axial
images although arguably an oblique axial running along the
plane of this ligament may be more precise. Much more difficult is
the calcaneofibular ligament. This is unfortunate as it is the most
structurally important and therefore where we would like to image
most accurately. The calcaneofibular ligament runs in oblique
plane from the calcaneus running anteriorly and superiorly to the
fibula. The angle varies with individuals and the shape of the hind
foot. It is very difficult to judge the inclination of the best imaging
plane to produce a true axial of this ligament. It is common that
axial images will show the ligament on multiple slices, and it is
difficult to follow its integrity even with MIP reconstructions.
Alternative strategies are to place the foot in an equinus position,
which elevates the calcaneus, making the calcaneofibular ligament
a more horizontal structure. In this position a true axial is more
likely to show the calcaneofibular ligament in its full length, but
this may be a difficult position for the patient to achieve and hold,
particularly if the ankle is painful. Therefore, it may be easier to
examine the foot in a neutral position and incline the imaging
plane with the anterior margin more cranial. The difficulty is how
to assess the degree of angulation that would be required for an
individual. Careful palpation of the ankle and judgement of the
imaging plane by the examining technician or radiographer may
assist. True 3D volume imaging of this region has an advantage
that reconstructions can be made in different planes. However, 3D
volume is most effectively achieved using gradient echo imaging
and the contrast between the ligament and the adjacent structure
is not as effective as it is on spin echo imaging. Therefore, 3D
volume images are more difficult to interpret.
A mechanically stable and bioactive substance would
dramatically change the practice of reconstructive fields, such as
orthopedic, plastic and oromaxillofacial surgery . Percutaneous
procedures with injectable, bioactive and resorbable cements
could replace invasive treatments of acute fractures, chronic
nonunions, and critical-sized bone defects. Management of
soft tissue defects that also require mechanical strength,
such as rotator cuff patches, anterior cruciate ligament (ACL)
reconstruction, and cartilage or meniscal repair could likewise
be performed with minimally invasive procedures and incur little
functional loss during recovery.
For this reason, there has been considerable research in
nanotechnology, which considers the biomaterial properties such
as chemistry, charge, wettability, and surface roughness. These
determine the extracellular protein interactions and mediate cell
interactions at the tissue/matrix interface, which are critical for
biocompatibility and longevity of the implant. In vitro research of
surface morphology has suggested the importance of nanometer
roughness. Up to four times the calcium-mineral deposition
occurs when osteoblasts were cultured for 28 days in the
presence of ceramics with grain sizes below 100 nm, compared
with conventional alumina surfaces. Even greater osteoblast
performance has been reported in grain sizes below 60 nm. This
has been correlated to osteoblast interactions with vitronectin,
which shares a linear dimension of approximately 60 nm. Multiple
techniques are now being explored, such as e-beam lithography,
polymer demising, chemical etching, cast-mold techniques
and spin casting to fine-tune surface characteristic for optimal
biologic interactions. In addition, three-dimensional (3D) printers
can construct 3D organic-inorganic composite matrices with
a defined internal architecture. These have also demonstrated
osteoblast ingrowth and proliferation in vivo.
Obviously, the use of the computer and associated software
has benefited the orthopedic surgeons in other aspects, such as
preoperative planning, preoperative 3D imaging, intraoperative
computer navigation in total joint and spine surgery, besides
trauma surgery, more recently, virtual intraoperative impingement
and stability testing in ACL reconstruction in the field of sports
The adoption of clinical pathways in patient care has grown
from the necessity of providing consistently high quality of care for an increasing demand for clinical services . Clinical pathways are structured multidisciplinary care plans that detail
the essential steps in the care of patients with specific clinical
problems. Clinical pathways provide hospitals with a consistent
template for patient care by creating a predetermined standardized
approach to care that should be adhered to by each member of
the healthcare team. Clinical pathways are especially suited to the
high volume and elective nature of much of orthopedic surgery.
In our specialty quality and efficiency must be optimized. To help
achieve this clinical pathways are used as standard protocols.
Each process, in a clinical pathway, is followed in order to ensure
that the desired end results are achieved. The pathway also
ensures that each patient is receiving optimum levels of care pre,
intra-, and postoperatively. Clinical pathways are evidence based
using the common international experience but must be adapted
to the culture of any given hospital. Clinical pathways are effective
because they standardize care, help develop measures for
prevention of patient discomfort and harm and provide ongoing
performance measures that promote effective and useful change
Adoption of clinical pathways can be met with skepticism
and resistance from any member of the multidisciplinary team
involved in patient care. Because clinical pathways standardize
care they reduce reliance on individual decision making or
traditional approaches to care. Every effort must be made in
adopting new clinical pathways to educate and inform the
multidisciplinary team of the evidentiary basis on which the
principles of the new pathway are based. Physician, nursing, and
administrative champions must work together to develop and
institute new pathways. The process should be communicated
in a completely transparent manner. The thought processes
involved should be clearly documented, and every member of
the patient care team must be trained and oriented to the new
process. Following implementation documentation of important
clinical indicators should be monitored and regular reports of
outcome must be communicated back to the hospital staff. The
pace of implementation must be geared to the tolerance of the
staff at each individual hospital. Often implementation should be
conservative with realistic expectations. As success is garnered
more progressive modifications to the pathway based on real
outcomes can be pursued. It is critical that the clinician champions
involved in this process be sensitive and realistic as well as willing
to devote their time and energy to the process.
At a time of groundbreaking medical advances in the diagnosis
and treatment of arthritis and musculoskeletal diseases, patient
education has become an essential component in providing
comprehensive care and in achieving positive clinical outcomes
. These advances, coupled with novel education delivery
systems such as the Internet, have created consumer demand for
information from patients, their families, and the general public.
Traumatological implants are used for the surgical treatment
of fractures, deformities, and tumor diseases of the bones. In
addition to products intended for the fixation of long bone
fractures, trauma implants for the shoulder, hand, pelvis and hip
are also produced. It should certainly be noted that innovations in
orthopedics and traumatology serve to complement and enhance
existing implants thereby improving the final outcome for
patients. The basis for making an implant is a doctor’s request for
making such an implant and a CT scan in order to precisely shape
the bone that needs to be replaced. Such implants are created in
close collaboration with the surgeon-operator with whom each
individual feature is analyzed and coordinated. After the doctor
agrees on the final design, the implant is produced by additive
manufacturing technology, popularly called 3D print technology,
which represents a revolution in the production of medical
implants because of its speed, accuracy, and economy.
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