Musculoskeletal diseases continue to produce major disability around the world. Advances in therapy – particularly for the inflammatory diseases – have the potential to eradicate the inflammation and thus prevent joint destruction. Surgical advances include minimally invasive and computer-assisted robotic surgery, and advances in arthroscopic surgery. The development of new musculoskeletal tissues – tendons, cartilage and bone using nanotechnology and stem cells – has the potential to revolutionise the way we approach these chronic destructive diseases as well as major trauma. With the rapid increase in these conditions with an ageing population, new models of care will need to be developed to ensure that the right care is delivered at the right time by the most appropriately trained health professional and at a reasonable cost. The Bone and Joint Decade has played a significant role in focussing researchers, clinicians and health educators on these diseases and also in drawing them to the attention of Governments around the globe. While there is still much to be done, the journey has commenced and will continue into the future with education, research and service delivery into these important conditions being further enhanced.
Introduction
The Bone and Joint Decade was established to draw attention to the major problems of musculoskeletal diseases and trauma around the globe and to stimulate education and research leading to better care and clinical outcomes for patients with musculoskeletal diseases. Target conditions for the decade included
- •
joint disease
- •
osteoporosis
- •
back pain and spine conditions
- •
childhood musculoskeletal conditions
- •
road traffic trauma
Although we are well aware of the burden of musculoskeletal conditions, we forget that every minute of every day a child is killed or seriously injured on the worlds roads. Many of these deaths and injuries are preventable and this has been a major focus of this decade.
From a medical perspective, this decade has seen great advances in the management of inflammatory forms of arthritis driven in part by the wider availability of the biologic agents which have increased in range and number. Biologics are also showing benefit in a greater number of diseases such as ankylosing spondylitis, psoriatic arthritis and connective tissue diseases .
Osteoarthritis is increasing with the ageing population and is the major reason for mobility restriction. Despite significant efforts over the past decade to develop markers for early detection, there is still no clear way of identifying which patients will progress rapidly . Treatment remains symptomatic with a combination of pharmaceutical and physiotherapy approaches along with general issues such as maintaining ideal body weight.
Although non-steriodal anti-inflammatory drugs are still the mainstay of treatment for many painful musculoskeletal conditions, there is growing concern about the evidence that all non-steroidal anti-inflammatory drugs (NSAIDs) are associated with an increase in the risk of cardiovascular disease . Musculoskeletal pain is still the most common symptom that afflicts humankind and its management needs to be improved significantly .
New osteoporotic agents have also been developed but the standard therapies such as the bisphonates have come under some shadow because of side effects such as bone destruction .
All of these advances combine to provide patients with musculoskeletal disease with a more positive message in 2010 than at the beginning of the decade in the year 2000 . So, how has this occurred and how will it be maintained?
The establishment of National Action Networks in nearly 62 countries around the globe has surely raised the profile of these conditions nationally and internationally. Unfortunately, one of our major sponsors – the World Health Organisation (WHO) – has still not recognised musculoskeletal conditions as a priority area despite the overwhelming evidence of their impact on the burden of the disease .
Milestones in the Bone and Joint Decade
This table summarises the major activities of the decade.
- •
1998 Inaugural Consensus Meeting held in Lund, Sweden to establish goals and objectives of the Bone and Joint Decade (BJD).
- •
1999 United Nations endorses BJD 2000–2010.
- •
2000 BJD formally launched at WHO in Geneva.
- •
2000 The first BJD world Network Meeting held in Oman and repeated each year
- –
2002 Brazil
- –
2003 Germany
- –
2004 China
- –
2005 Canada
- –
2006 South Africa
- –
2007 Australia
- –
2008 India
- –
2009 USA
- –
2010 Sweden
- –
- •
2003 Global Technical report published by WHO: The Burden of Musculoskeletal Conditions at the Start of the New Millenium – WHO.
- •
2003 Release of a report – Musculoskeletal Problems and Functional Limitation – from an expert European group and funded by European Union (EU).
- •
2003 US Surgeon General publishes its first ever report on Bone Health and Osteoporosis.
- •
2004 Global Road Safety, spearheaded by the BJD, is declared by WHO as its theme for World Health Day.
- •
2004 UN General Assembly meets to promote global road safety, endorses the World Road Traffic Injury and calls for a UN Road Safety Charter.
- •
2004 UN Stakeholders Forum on Global Road safety held at UN.
- •
2005 European Action towards better Musculoskeletal Health supported by the European Commission is published.
- •
2006 UN endorses Global Road Safety week.
- •
2007 1st United Nations Global Road Safety Week held.
- •
2007 Middle East and north African Consensus on Osteoporosis Guidelines signed.
- •
2008 BJD designated as a WHO Collaborating Centre for Evidence-based Health Care in Musculoskeletal Disorders.
- •
2009 WHO and BJD jointly organise World Trauma Forum in Rio de Janeiro.
- •
2010 UN declares Decade of Action on Road Safety – an initiative started by the BJD at the beginning of this decade.
The main principle of the Bone and Joint Decade has been that of collaboration – without that fundamental approach it would not have been possible to achieve these goals. The global initiative of the BJD has survived because of the distinctive national strategies and actions which have involved
- •
multidisciplinary team work with engagement of orthopaedics, rheumatology, traumatology and the myriad of health professionals who deliver care to those with musculoskeletal conditions,
- •
collaboration between patients and health-care professionals – the importance of the ‘patient voice’ cannot be underestimated and has been driven through the engagement of patients and the community through the National Action Networks (NANs) and
- •
alliances between governments, non-government organisations (NGOs) and industry.
The BJD will continue as the Bone and Joint Decades and has already outlined an active programme of activities to further the mission of facing the global challenges of musculoskeletal care in all its many facets.
One particular challenge will be to continue to research the evidence base in musculoskeletal science and to translate these exciting advances in basic and clinical science into policy and practice . Some of these advances will challenge the status quo and the way we have done things in the past. Perhaps one of the areas where this is most challenging is that of the workforce. We need to deliver health services to an increasingly aged population with chronic musculoskeletal disease. This will have to be done increasingly with ‘teams’ of health professionals rather than by individuals and using a broader range of appropriately trained health professionals . To prepare this future workforce we are going to have to think laterally in relation to scope of practice, roles and incentives but not waiver from using evidence of best practice and research to inform policy decisions. We must remember that the key to any sustainable health system is keeping the three pillars of research, learning and health-care delivery as closely aligned as possible because that is how we will improve patient care in the long-term.
Milestones in the Bone and Joint Decade
This table summarises the major activities of the decade.
- •
1998 Inaugural Consensus Meeting held in Lund, Sweden to establish goals and objectives of the Bone and Joint Decade (BJD).
- •
1999 United Nations endorses BJD 2000–2010.
- •
2000 BJD formally launched at WHO in Geneva.
- •
2000 The first BJD world Network Meeting held in Oman and repeated each year
- –
2002 Brazil
- –
2003 Germany
- –
2004 China
- –
2005 Canada
- –
2006 South Africa
- –
2007 Australia
- –
2008 India
- –
2009 USA
- –
2010 Sweden
- –
- •
2003 Global Technical report published by WHO: The Burden of Musculoskeletal Conditions at the Start of the New Millenium – WHO.
- •
2003 Release of a report – Musculoskeletal Problems and Functional Limitation – from an expert European group and funded by European Union (EU).
- •
2003 US Surgeon General publishes its first ever report on Bone Health and Osteoporosis.
- •
2004 Global Road Safety, spearheaded by the BJD, is declared by WHO as its theme for World Health Day.
- •
2004 UN General Assembly meets to promote global road safety, endorses the World Road Traffic Injury and calls for a UN Road Safety Charter.
- •
2004 UN Stakeholders Forum on Global Road safety held at UN.
- •
2005 European Action towards better Musculoskeletal Health supported by the European Commission is published.
- •
2006 UN endorses Global Road Safety week.
- •
2007 1st United Nations Global Road Safety Week held.
- •
2007 Middle East and north African Consensus on Osteoporosis Guidelines signed.
- •
2008 BJD designated as a WHO Collaborating Centre for Evidence-based Health Care in Musculoskeletal Disorders.
- •
2009 WHO and BJD jointly organise World Trauma Forum in Rio de Janeiro.
- •
2010 UN declares Decade of Action on Road Safety – an initiative started by the BJD at the beginning of this decade.
The main principle of the Bone and Joint Decade has been that of collaboration – without that fundamental approach it would not have been possible to achieve these goals. The global initiative of the BJD has survived because of the distinctive national strategies and actions which have involved
- •
multidisciplinary team work with engagement of orthopaedics, rheumatology, traumatology and the myriad of health professionals who deliver care to those with musculoskeletal conditions,
- •
collaboration between patients and health-care professionals – the importance of the ‘patient voice’ cannot be underestimated and has been driven through the engagement of patients and the community through the National Action Networks (NANs) and
- •
alliances between governments, non-government organisations (NGOs) and industry.
The BJD will continue as the Bone and Joint Decades and has already outlined an active programme of activities to further the mission of facing the global challenges of musculoskeletal care in all its many facets.
One particular challenge will be to continue to research the evidence base in musculoskeletal science and to translate these exciting advances in basic and clinical science into policy and practice . Some of these advances will challenge the status quo and the way we have done things in the past. Perhaps one of the areas where this is most challenging is that of the workforce. We need to deliver health services to an increasingly aged population with chronic musculoskeletal disease. This will have to be done increasingly with ‘teams’ of health professionals rather than by individuals and using a broader range of appropriately trained health professionals . To prepare this future workforce we are going to have to think laterally in relation to scope of practice, roles and incentives but not waiver from using evidence of best practice and research to inform policy decisions. We must remember that the key to any sustainable health system is keeping the three pillars of research, learning and health-care delivery as closely aligned as possible because that is how we will improve patient care in the long-term.
Surgical advances
Minimally invasive surgery
Minimally invasive surgery has been the operative signature of the 21st century. The desire to reduce the morbidity of surgery, postoperative pain and length of in-hospital stay has resulted in many innovative ways to perform elective and acute orthopaedic procedures. Examples where minimally invasive surgery has been most successfully deployed include hip and knee replacement surgery, shoulder stabilisation procedures, decompression of rotator cuff impingement , trauma surgery and spinal discectomy , to name a few.
To achieve surgical exposure through substantially smaller incisions has required innovation in the (1) design and number of incisions, for example, where the acetabulum and the femoral canal are approached for total joint replacement through two separate and smaller incisions as compared to one large incision; (2) choices of surgical approaches to different anatomic regions, for example, total knee replacement being performed by an approach that avoids laying open the knee joint which traditionally requires cutting into the quadriceps tendon by passing under vastus medialis obliquus and shifting the quadriceps out of the way; and (3) the use of intra-operative radiological or computer guidance to accurately locate important landmarks hidden by small incisions such as with hip and knee surgery .
The benefits of minimally invasive surgery have included a significant reduction in length of stay where authors have reported day- or overnight stay-only experiences for hip and knee joint replacement surgery . The use of arthroscopic shoulder decompression or stabilisation procedures has seen a multi-day procedure reduced to day-only surgery.
The pursuit of smaller incisions, however, has encountered challenges and criticism in certain circumstances . Errors in placement of prosthetic components during joint replacement surgery, significant soft-tissue contusions and damage to vital structures such as nerves and arteries have been reported. Smaller incisions have driven a greater awareness of the importance of surgical and surface anatomy and, therefore, a need for appropriate training prior to surgeons undertaking such procedures.
Computer-assisted surgery
Computer-assisted surgery (CAS) has been promoted since the early to mid-1990s. However, it was not till the 2000s that the maturity of the systems allowed greater uptake of the technology . CAS has also facilitated minimally invasive surgery. Using different methods of acquiring information, computers are deployed intra-operatively to accurately portray bone anatomy and to guide the placement and orientation of surgical instruments and prostheses. The purpose of CAS is to enhance the accuracy of surgery where it is needed with the aim of reducing surgical morbidity and increasing implant longevity where appropriate.
Anatomic information required for CAS is acquired either preoperatively from specially prepared computed tomography (CT) data (Dicom) of the region, or intra-operatively from orthogonal X-rays obtained by a special iso-centric fluoroscope, or from infra-red mapping and matching of anatomic points which does not require ionising radiation. Such data are inputed into a computer which when combined with information regarding the type of procedure, instruments and prostheses to be used and the real-time capture of instrument positioning during the operation allows a graphical representation of the procedure to be displayed on a screen. The surgeon uses this information to accurately position cutting tools to prepare the bone surfaces to receive the implants. The correct position and orientation of the implants and the alignment of the operated limb can then be confirmed on the computer screen.
The uptake of CAS has been the greatest in knee replacement surgery where CAS has demonstrated a reduction in the variability of limb alignment after total knee replacement highlighting its usefulness for more accurate surgery. Studies examining the impact of CAS in knee replacement surgery have reported better function and patient satisfaction in patients with better aligned knees . Whether this translates to greater longevity will require long-term longitudinal studies and data capture on joint replacement registries.
Other examples where CAS has been used include total hip replacement surgery, high tibial osteotomy, positioning of pedicular screws for spinal surgery and for guidance of internal fixation of fractures.
Arthroscopic surgery
Arthroscopic surgery is not new. However, the use of this technique has been expanded to address conditions previously left untreated or treated by open surgery. The purpose of arthroscopic surgery is to reduce patient morbidity and to enhance early mobilisation and discharge from hospital.
Hip arthroscopy has been popularised in the 2000s with a focus on treating several hip conditions including labral pathology, deformities of the neck of the femur, intra-articular loose bodies and hip synovitis. Arthroscopic surgery of the hip has reduced the requirement for elective dislocation of the hip for many of these procedures.
Shoulder arthroscopy is another emerging technique, which has found great efficacy for managing shoulder instability and rotator cuff impingement . These are two procedures where arthroscopy has revolutionised the rehabilitation and requirement for inpatient stay. Because fewer normal structures have to be divided and repaired as part of arthroscopic surgery, the usual precautionary delays in rehabilitation can be avoided.
Wrist arthroscopy for managing carpal tunnel syndrome and injuries to the ligamentous structures of the wrist has also become popular with many of these procedures now permitting day-only surgery and rapid return to function and activity.
Trauma surgery
As with other types of surgery, trauma surgery has also seen a growing popularity in the use of minimally invasive and image-guided techniques. The aims of such surgery are to minimise further trauma to already traumatised tissue, to reduce further physiologic insult on a multi-trauma patient and to promote early rehabilitation. Specialised low profile or miniaturised implants have been designed to allow percutaneous implantation and when combined with image-guided reduction and fixation of the fractures, patients today are exposed to far less surgical morbidity and quicker recovery.
One area where significant improvements have been seen is in the area of cross bolting of intramedullary devices such as those used for fractures of the femur, tibia and humerus. Previously, long periods of radiation exposure would be required to guide the positioning and implantation of large bolts that cross through the bone and intramedullary device pinning both together. These days, the use of non-ionising electro-magnetic targeting instruments allow rapid and accurate placement of cross bolts without exposing patients to radiation.
With advances in the understanding of bone cell biology, growth factors known to stimulate bone metabolism are now being employed for managing fracture nonunions.
Tumour surgery
The management of musculoskeletal tumours has seen a tremendous improvement in survival and outcomes because of advances in imaging, diagnosis, radiotherapy, chemotherapy and surgery. The multidisciplinary approach to treatment based in specialised centres now sees survival of bone and soft-tissue sarcomas exceeding 75% at 5 years. More importantly, where previously amputation was de rigeur , now limb-sparing surgery for arm or leg tumours is the standard of care. Techniques that utilise biologic, prosthetic or a combination of both now sees limb-sparing surgery being offered to over 90% of patients with limb tumours.
In the last decade, the identification of unique genetic aberrations linked with specific cellular disturbances has allowed the growth of targeted molecular therapy . Specially designed molecules that target the known mechanisms arising from genetic abnormalities have been shown to inhibit tumour growth and metastasis. The use of imatinib, a tyrosine kinase inhibitor, has resulted in significant control of gastro intestinal stromal tumours (gist), while denusomab, an inihibitor of RANK ligand, a necessary component of the dynamic interaction between osteoblast and osteoclast that controls the recruitment of osteoclasts, has seen a remarkable response to treatment of giant cell tumour of bone. Other investigatory molecules include pigment–epitheliuum-derived growth factor (PEDF), which is the most potent physiologic inhibitor of angiogenesis that has been shown to exert a potent inhibitory affect on osteosarcoma .
Related posts:
Looking back at the start of the bone and joint decade what have we learnt?
Taking advances from bench to bedside during the last decade
Improving musculoskeletal health: Global issues
The need to address the burden of musculoskeletal conditions
Advancements in the Management of Spine Disorders
High-energy trauma
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
