FDA public workshop: Orthopaedic sensing, measuring, and advanced reporting technology (SMART) devices

Traditional orthopaedic devices do not communicate with physicians or patients post-operatively. After implantation, follow-up of traditional orthopaedic devices is generally limited to episodic monitoring. However, the orthopaedic community may be shifting towards incorporation of smart technology. Smart technology in orthopaedics is a term that encompasses a wide range of potential applications. Smart orthopaedic implants offer the possibility of gathering data and exchanging it with an external reader. They incorporate technology that enables automated sensing, measuring, processing, and reporting of patient or device parameters at or near the implant. While including advanced technology in orthopaedic devices has the potential to benefit patients, physicians, and the scientific community, it may also increase the patient risks associated with the implants. Understanding the benefit-risk profile of new smart orthopaedic devices is critical to ensuring their safety and effectiveness. The 2018 FDA public workshop on orthopaedic sensing, measuring, and advanced reporting technology (SMART) devices was held on April 30, 2018, at the FDA White Oak Campus in Silver Spring, MD with the goal of fostering a collaborative dialogue amongst the orthopaedic community. Workshop attendees discussed four key areas related to smart orthopaedic devices: engineering and technology considerations, clinical and patient perspectives, cybersecurity, and regulatory considerations. The workshop presentations and associated discussions highlighted the need for the orthopaedic community to collectively craft a responsible path for incorporating smart technology in musculoskeletal disease care.

A comprehensive overview of osteoporotic fracture treatment

Osteoporosis is a worldwide epidemic, affecting more than 75 million people in the United States, Europe, and Japan. At a consensus conference in 1990, European and American leaders defined osteoporosis as a disease characterized by low bone mass, microarchitectural deterioration of bone tissue, and a resulting increase in fracture risk. In 2000, the National Institutes of Health modified this definition, describing osteoporosis as a skeletal disorder characterized by compromised bone strength and a predisposition for increased fracture risk. It was emphasized that bone strength, which is a more comprehensive concept than bone mass, integrates the concepts of both bone density and bone quality. As orthopaedic surgeons, recognizing osteoporosis and its healthcare implications is critical to optimize the musculoskeletal health of patients of all ages and both sexes.

Infectious, inflammatory, and metabolic diseases affecting the athlete's spine

Sports and weight-bearing activities can have a positive effect on bone health in the growing, mature, or aging athlete. However, certain athletic activities and training regimens may place the athlete at increased risk for stress fractures in the spine. In addition, some athletes have an underlying susceptibility to fracture due to either systemic or focal abnormalities. It is important to identify and treat these athletes in order to prevent stress fractures and reduce the risk of osteoporosis in late adulthood. Therefore, the pre-participation physical examination offers a unique opportunity to screen athletes for metabolic bone disease through the history and physical examination. Positive findings warrant a thorough workup including a metabolic bone laboratory panel, and possibly a DEXA scan, which includes a lateral spine view.

Characterization of low bone mass in young patients with thalassemia by DXA, pQCT and markers of bone turnover

Previous reports using dual x-ray absorptiometry (DXA) suggest that up to 70% of adults with thalassemia major (Thal) have low bone mass. However, few studies have controlled for body size and pubertal delay, variables known to affect bone mass in this population. In this study, bone mineral content and areal density (BMC, aBMD) of the spine and whole body were assessed by DXA, and volumetric BMD and cortical geometries of the distal tibia by peripheral quantitative computed tomography (pQCT) in subjects with Thal (n = 25, 11 male, 10 to 30 years) and local controls (n=34, 15 male, 7 to 30 years). Z-scores for bone outcomes were calculated from reference data from a large sample of healthy children and young adults. Fasting blood and urine were collected, pubertal status determined by self-assessment and dietary intake and physical activity assessed by written questionnaires. Subjects with Thal were similar in age, but had lower height, weight and lean mass index Z-scores (all p < 0.001) compared to controls. DXA aBMD was significantly lower in Thal compared to controls at all sites. Adult Thal subjects (> 18 years, n = 11) had lower tibial trabecular vBMD (p = 0.03), cortical area, cortical BMC, cortical thickness, periosteal circumference and section modulus Z-scores (all p < 0.01) compared to controls. Cortical area, cortical BMC, cortical thickness, and periosteal circumference Z-scores (p = 0.02) were significantly lower in young Thal (≤ 18 years, n = 14) compared to controls. In separate multivariate models, tibial cortical area, BMC, and thickness and spine aBMD and whole body BMC Z-scores remained lower in Thal compared to controls after adjustment for gender, lean mass and/or growth deficits (all p < 0.01). Tanner stage was not predictive in these models. Osteocalcin, a marker of bone formation, was significantly reduced in Thal compared to controls after adjusting for age, puberty and whole body BMC (p=0.029). In summary, we have found evidence of skeletal deficits that cannot be dismissed as an artifact of small bone size or delayed maturity alone. Given that reduced bone density and strength are associated with increased risk of fracture, therapies focused on increasing bone formation and bone size in younger patients are worthy of further evaluation.

Assessment of the risk of introduction of Anoplophora glabripennis (Coleoptera: Cerambycidae) in municipal solid waste from the quarantine area of New York City to landfills outside of the quarantine area: a pathway analysis of the risk of spread and establishment

The risk associated with spread of Asian longhorned beetle, Anoplophora glabripennis (Motschulsky), from infested areas in New York City to the wide array of landfills across the eastern United States contracted by the city since 1997 was unknown, but of great concern. Landfills, some as far as South Carolina, Virginia, and Ohio, occupied forest types and climates at high risk of Asian longhorned beetle establishment. The city proposed a separate waste wood collection known as the "311 System;" this was estimated to cost federal and state agencies $6.1 to $9.1 million per year, including the cost of processing and disposal of the wood. Pathway analysis was used to quantify the probability that Asian longhorned beetle present in wood waste collected at curbside would survive transport, compaction, and burial to form a mated pair. The study found that in seven alternate management scenarios, risks with most pathways are very low, especially given existing mitigations. Mitigations included chemical control, removal of infested trees, and burial of wood waste in managed landfills that involved multiple-layering, compaction, and capping of dumped waste with a 15-cm soil cover at the end of each day. Although the risk of business-as-usual collection and disposal practices was virtually nil, any changes of policy or practice such as illegal dumping or disposal at a single landfill increased the risk many thousandfold. By rigorously maintaining and monitoring existing mitigations, it was estimated that taxpayers would save $75 to $122 million dollars over the next decade.

Effect of relative humidity on viability of primary conidia of Zoophthora radicans

Four isolates of the entomopathogenic fungus Zoophthora radicans were compared in a laboratory study to evaluate the effect of relative humidity (RH) on duration of primary conidial viability. Primary conidia were showered onto agar-coated glass microscope slides within an enclosed chamber equilibrated to one of five test RH levels (60, 75, 80, 95, or 100%). Target RH levels were achieved by recirculating air through a glycerin/water solution, of controlled specific gravity, contained in a reservoir within the chamber. Conidial samples of each isolate incubated for 5, 10, 30, 60, 120, 180, or 240 min at each RH were removed and inspected using a technique of simultaneous vital fluorochrome staining to determine percentage conidial viability. At 60% RH, isolates did not differ significantly and average viability dropped to less than 10% within the first 60 min. At 75% RH, viability did not change significantly over 4 h. However, average viabilities at 75% RH differed significantly for the four isolates and ranged from 24 to 63%. At 80% RH, viability differed significantly among isolates and declined slowly over time, remaining above 80% for 2 h and above 50% for 4 h. At 95 and 100% RH, average viability was near 95% and did not vary significantly with time or isolate. These data can be used to assist selection of appropriate isolates for biological control.

RAPD-PCR for identification of Zoophthora radicans isolates in biological control of the potato leafhopper

Biological control studies require the ability to distinguish released pathogens from locally occurring isolates of the same species. We have developed a technique that differentiates genotypes using random amplified polymorphic DNA (RAPD) for the apomictic species Zoophthora radicans (Zygomycota: Entomophthorales), a pathogen of the potato leafhopper, Empoasca fabae (Homoptera: Cicadellidae). RAPD analysis was performed on Z. radicans isolates released in test plots in 1990 and 1991 for leafhopper control; isolates later recovered from the same plots and diverse other isolates were included in the analysis. RAPD fragment profiles of five recovered isolates proved very similar to those of the released isolates and different from all other isolates tested; they are probable descendants of the released isolates. One of the recovered isolates had RAPD profiles similar to isolates derived from aphids and probably represents a population endemic at the release site. In addition to verifying the successful establishment of our experimental releases, RAPD analysis revealed clear relationships among isolates derived from the same host taxon. We propose that this simple and relatively inexpensive method will be valuable in determining the establishment and spread of organisms released in biological control studies.