December 2018

With great sadness, the medical world learned of the death of Steve Katz who was the Director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS).  A dermatologist by training, Steve was an outstanding scientist in the field of immunology and a vibrant force for basic, clinical and translational research.  He was a mentor to a generation of academic dermatologists and, when he became the Director of NIAMS, he became enmeshed in the multiple disciplines that NIAMS represents including orthopedics, rheumatology and bone biology. 
 
Steve was a strong advocate of the Bone and Joint Decade, its US arm, the US Bone and Joint Decade (USBJD) and its successor, the US Bone and Joint Initiative (USBJI). Shortly after President Bush opened the National Bone and Joint Decade in our country, Steve chaired a meeting to bring together representatives of the major professional societies and patient advocacy organizations in the field of musculoskeletal medicine.  The goal of the meeting was to determine US priorities for the Decade. One of first priorities was the establishment of the Young Investigator Initiative (YII) to increase the pipeline of researchers.  As Steve said, “Well founded research will get funded” and this has remained the credo of the YII ever since.
 
Another program that Steve helped develop was Project 100 the goal of which has been to increase education on musculoskeletal medicine at medical schools, currently focused on those pursuing careers in primary care.  This program is another important achievement of the USBJD and USBJI and a reflection of Steve’s vision for a multidisciplinary organization that could have a major impact on patient care.  Always an activist and enthusiastic, Steve closely followed the progress of the USBJD and USBJI, regularly met with our leadership, and provided expert opinion. 
 
While Steve held a very important position, he was always approachable, eager to talk to you, not just about research or the happenings in academia, but also about you and your family.  I always enjoyed my visits with Steve at meetings of the American College of Rheumatology.  He had a lively way, always jovial with a warm smile, happy to hear about news of my children.  While I saw Steve only about once a year, I considered him a good friend and could rely upon him for guidance and advice.
 
In the last few years, NIAMS took on a very bold project with the Accelerating Medicines Partnership (AMP) Initiative.  The AMP is a public-private venture to spur the application of powerful new technology to understand at the molecular level events crucial for arthritis and other musculoskeletal diseases.   In some ways, AMP is a moon launch for our field, a big challenge that comes with real risk.  With his good friend Francis Collins, the Director of the NIH, Steve made AMP a reality.  AMP is a great achievement and just one of the many programs that Steve nurtured and advanced.  AMP is just one part of a wonderful legacy.
 
All involved in scientific research on musculoskeletal disease and the care of patients with the broad range of these conditions have lost a great champion, ally and friend with Steve’s death.  We were fortunate to have him as part of our community during this exciting and sometimes turbulent era and distraught that his time with us ended so suddenly.  Everyone who is part of the USBJI extends to Steve’s family our deepest sympathy and condolences at this sad time. 
 
Words written by David Pisetsky, MD, PhD, USBJI President 2015-2017

Reflections by USBJD/USBJI Past Presidents

"While others have acknowledged the intellect, leadership abilities and scientific prowess of Steve Katz, I would like to extol his humanity. Steve's vision and aspirations were all about using science as a vehicle to ease human suffering by preventing disease and restoring health. Through my numerous professional interactions with Dr. Katz while I served on the NIAMS Advisory Council  and while I attended frequent advocacy events in Washington, DC, his passion for using science to improve the human condition was always evident. One of my fondest memories of Steve is the kindness he showed my daughter (see attached photo) when she joined a delegation of researchers and patients advocating for increased NIH funding on Capitol Hill. He recognized the importance of inspiring future generations to follow his path. The musculoskeletal research community has lost one of its most passionate and effective advocates -- Dr. Steven Katz will be sorely missed." - Josh Jacobs, MD, USBJD President 2009-2011

"I am deeply saddened to learn that Dr. Steven Katz passed away on Thursday, December 20, 2018.  I had the honor of working with him on a number of projects and will miss him.  One of his attributes that impressed me the most was his ability to assemble a highly functional working team.  From small group discussions to managing an entire NIH Institute, Steve was always able to put together the right people to get the job done.  His team at NIAMS is a perfect example of his leadership skills and is the reason why musculoskeletal science in the United States has thrived over the past few decades.  Traits such as his concern for young investigators, commitment to high quality research, intellect and outgoingness will be very difficult to replace.  We are all so lucky to have had him leading our cause.” - J. Edward Puzas, PhD, USBJD President, 2007-2009
 

"Despite Dr. Katz's important position and numerous accomplishments, he was always very approachable and connected easily with people.  I felt out of my league when meeting with him; yet, he always thoughtfully considered my ideas and was willing to discuss the pros and cons of any idea and made me feel part of the NIAMS community.  I appreciate the support that he always demonstrated.  He will be sorely missed. Despite Dr. Katz's important position and numerous accomplishments, he was always very approachable and connected easily with people.  I felt out of my league when meeting with him; yet, he always thoughtfully considered my ideas and was willing to discuss the pros and cons of any idea and made me feel part of the NIAMS community.  I appreciate the support that he always demonstrated.  He will be sorely missed. " - Kim Templeton. MD, USBJI President 2011-2013

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I am a pediatric hand surgeon at Nationwide Children’s Hospital, in Columbus, Ohio, and feel privileged to have had the opportunity to participate in the United States Bone and Joint Initiative (USBJI) Young Investigator Initiative (YII) Grant Mentoring and Career Development Program.I just began my fourth year of clinical practice and honestly am surprised at how quickly the time has passed.I was busy clinically right from the start, and have been involved with multiple committees and administrative activities.I have a tremendous interest in quality improvement, and have worked on enhancing pediatric musculoskeletal safety and quality through local and national work.One of my favorite activities is the American Academy of Orthopaedic Surgeons (AAOS) Evidence-Based Quality and Value Committee, which oversees the development of our orthopaedic Clinical Practice Guidelines (CPGs) and Appropriate Use Criteria (AUCs).I am also fortunate to serve as the committee’s liaison to the AAOS Patient Safety Committee.I was recently selected to serve as co-Director of the Clinical Quality Improvement Fellowship at Nationwide Children’s Hospital.This area of quality and safe patient care will continue to be important to me throughout my career.

In general, I find research activities are the easiest to ‘push aside’, as there always seem to be more pressing clinical issues.Although I have published several articles during the first three years of my clinical practice, the publications are all quite diverse.The Young Investigator Initiative Grant Mentoring and Career Development Program has made me realize that I must not only focus my research but also must carve out dedicated time for research, and not allow the other ‘duties’ to interfere with that protected time.

One research area of interest for me is the relationship of vitamin D levels and bone health in the pediatric population.I discovered that many of my fracture patients who had delayed healing or fracture nonunions had low levels of vitamin D upon testing.There have been studies evaluating the prevalence of vitamin D insufficiency and deficiency in otherwise healthy children, but there are fewer reports on associations with fracture risk and delayed healing in the pediatric population.For example, if pediatric patients present with 2 or more low energy fractures over their short lifetimes, should I worry about their underlying vitamin D levels? When should I obtain laboratory work-up? It is not without financial burden to order these expensive labs, and with rapidly rising healthcare expenditures, we should have a greater understanding of when to evaluate these children.I am currently applying for K funding to pursue some of these questions.I had the great fortune of finding a research mentor through the USBJI/YII) program, and he is working with me to improve and enhance my grant application.

The program was instrumental in re-focusing my career.Furthermore, it was important to receive research mentorship, which until this time had been lacking.I look forward to the opportunity to contribute to our knowledge and improve bone health in our pediatric population.

The next Call for Applications Deadline for submissions, January 15, 2018 - Workshop April 26-28, 2018. Visit: www.usbji.org/programs/yii/call-for-applications for more information.

Technology and medicine continue to advance at a rapid pace and often intersect with regards to recent advancements. Staying up to date with these advancements can be a daunting task for physicians with busy practices. Members of the American Association of Hip and Knee Surgeons (AAHKS) Digital Health and Social Media Committee identified a number of topics which are on the forefront of digital technology as it currently pertains to relevant topics in total joint arthroplasty, orthopaedics and medicine in general.

Committee members drafted five white papers as the initial installment of these topics. The papers were recently posted on the AAHKS website and disseminated at the 2018 AAHKS Annual Meeting. The topics include:  Virtual Reality in Orthopaedics, Patient Engagement Platforms, 3D Printing in Orthopaedics, Holograms in Medicine and Mixed Reality. There will be future white papers on more topics released in the near future. Read the AAHKS Digital Health white papers.

AAHKS was formed in 1991 with a mission to advance hip and knee patient care through education and advocacy. The Digital Health and Social Media Committee is responsible for the development and testing of new technology and web-based programs as well as oversight of the social media platforms of AAHKS.

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The American Orthopaedic Association (AOA) recently became a partner with Project ECHO® (Extension for Community Healthcare Outcomes). Beginning in spring 2019, the AOA and its Own the Bone program will be launching the nation’s first orthopaedic-focused teleECHO program. Participating clinicians will convene via monthly videoconferencing sessions to enhance knowledge and skills through expert-led lectures and interactive case presentations.
 
The AOA’s Own the Bone® program is a national post-fracture, systems-based, multidisciplinary fragility fracture prevention program seeking to change provider and patient behavior in order to reduce the incidence of future fractures and positively impact bone health treatment.
 
Paul A. Anderson, MD, FAOA, who chairs the Own the Bone steering committee, is pleased to begin growing and sharing knowledge among orthopaedic providers, including surgeons, specialist physicians, physician assistants, nurse practitioners, and nurses. “Project ECHO has an impressive track record of facilitating the expansion of knowledge within the medical community. The structure of teleECHO programs is particularly helpful, because all participants – experts and attendees – are viewed as teachers and learners. Our program’s team of experts are eager to begin this interactive process, and we are excited to offer this terrific learning opportunity to a broad network of clinicians at Own the Bone institutions. The field of bone health often changes rapidly, and Project ECHO will allow the Own the Bone community to interact and keep abreast of these developments in a timely manner. Expert consultation will be available to aid important advances in bone health care through Project ECHO.”
 
Project ECHO® makes specialized healthcare knowledge available to the masses by gathering local clinicians together with expert specialist teams in the setting of virtual teleECHO sessions. Expert panels present brief lessons, and participating clinicians are given the opportunity to discuss actual patient case studies without identifiable information.
 
Project ECHO began in 2003, at the University of New Mexico Health Sciences Center thanks to the efforts of hepatologist, Sanjeev Arora, MD, who figured out a novel strategy to meet the needs of thousands of untreated patients with hepatitis C who lived in rural areas with no nearby specialists. He created a technology-based learning platform that empowered primary care providers to treat hepatitis C in their own communities without the need to refer them to far-away specialists.
 

The AOA’s Own the Bone program now joins the global ECHO community, which currently consists of over 250 replicating centers, or “hubs,” and 12 “superhubs” (a center that can train and support other replicating centers) in 34 countries, offering more than 150 ECHO topic areas, with a goal of touching 1 billion lives by 2025. The AOA is the second specialty society to launch a teleECHO program, following upon the work of Itasca, IL-based American Academy of Pediatrics.
 
For those interested in learning more about the Own the Bone ECHO, please visit www.ownthebone.org/ECHO or contact Ben Grace, MPH at grace@aoassn.org

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The National Association of Orthopaedic Nurses (NAON) announces their Best Practice Guidelines (BPGs) for Total Hip Replacement and Total Knee Replacement and their Patient Education Manuals.

The purpose of the BPGs are to collate the currently available literature to provide best practice information aimed at the continuum of nursing care for the patient undergoing a total hip replacement or a total knee replacement. Authored by experts who work in Joint Commission Disease Specific Certified settings, these guidelines offer an assessment of the benefits and harms of various care and practice options for the total knee replacement patient or the total hip replacement patient. Each BPG will assist and empower nurses to manage the acute care requirements of either patient effectively. Ultimately, adoption of recommended practices offers the potential for an enhanced patient experience and recovery.

Both BPGs are available for purchase and immediate download through the NAON online store. The BPGs can be purchased by NAON members for $25 each and non-members for $65 each.

NAON's Patient Education manuals are a free resource intended for the patient and caregiver audience. They present information that can be shared with individuals or groups. The manuals reflect current evidence and recommendations related to health literacy and adult learning, as well as learner-friendly formatting and visuals. Each manual is downloadable in its entirety, with space throughout for notes and comments to individualize the education according to specific patient needs. Click here to view the latest Patient Education Manuals.
 
If you have any questions please e-mail NAON Headquarters at naon@orthonurse.org

Gerald F. Harris, PhD
Professor, Department of Biomedical Engineering
Marquette University Milwaukee WI
Director of Research
Shriners Hospital for Children Chicago IL





Peter A. Smith, MD
Pediatric Orthopedic Surgeon,
Director Osteogenesis Imperfecta Clinic
Shriners Hospital for Children, Chicago, Illinois
Professor, Orthopedic Surgery
Rush University Medical Center, Chicago, IL



 
Work done at Shriners Hospital for Children in Chicago and Marquette University in Milwaukee has focused on ways to better understand the risk of fracture in children with a genetic condition called Osteogenesis Imperfecta or “OI” in which the bones are brittle, subject to deformity and fracture, Figure 1.  This condition describes a group of diseases affecting the bones and connective tissue.  It affects approximately 1 in 10,000 people with the most common forms linked to mutations in procollagen which gives bone strength.  The bones of the legs, especially the femur and tibia, are common sites of concern in these children. To judge the necessity for surgical intervention, the surgeon must subjectively predict whether the quality of bone and any deformities are likely to cause fracture during common activities of daily life. These clinical decisions, however, could be enhanced with additional objective information.

Figure 1. A child with mild/moderate OI and right femur deformity next to three femur models depicting deformity commonly seen in OI. Left model: no lateral bowing. Middle model: 5 mm/10° of lateral bowing. Right model: 15 mm/30° of lateral bowing.
 
Current work to objectively examine fracture risk in children with OI is focused in three areas: 1) determining bone quality, 2) understanding bone loads during gait and other activities, and 3) developing patient-specific models of the lower extremities (femur and tibia) that evaluate bone stress and fracture risk.

To characterize cortical bone material properties in the long bones of children with OI, bone samples that would otherwise be discarded are collected during fracture repair surgery.  The small bone samples are machined into tiny beams which are tested to determine their mechanical properties and failure behavior.  A special technique was developed to machine the bone specimens into small beams and a custom-designed jig was developed to accurately test them during loading.  Figure 2 illustrates the load device and diamond saw used to prepare bone specimens for testing.


Figure 2.  Illustration of the bone sample testing apparatus (left) and diamond saw (top center) used to machine tiny beams along the length (longitudinal) and perpendicular to the length (transverse) of the bone (top right).  The bending jig of the testing apparatus is shown in more detail (bottom center and right).

To better understand bone loads during gait and other activities, motion and load data as well as muscle activity data (electromyography or EMG) are collected.  Musculoskeletal models of the lower extremities calculate joint and muscle moments (torques) and forces.  This internal load data serves as input for models of the bones to examine fracture risk.

Models of the lower extremity bones (femur and tibia) are constructed using geometry from existing radiographs and other clinical data.  These models incorporate the bone material property data and activity load data from the earlier analyses.   The models are used to examine the effects of deformity, activity levels and muscle load scenarios (EMG) to determine the resulting stress distribution in the lower extremity bones, Figure 3.
 

Figure 3. Contour plots of stress distribution in the femur.  Colors represent stress levels (red = high, blue = low).  Model results from left to right: normal bone and muscle forces with no bowing, normal bone and muscle forces with 15 mm lateral bowing, OI type III bone with normal muscle forces and 15 mm lateral bowing, and OI type III with gluteus medius force increased 20% above normal and 15 mm lateral bowing.
 
In addition to aiding clinical decisions, these models allow further investigation of the effects of bone quality, activity level and geometry on strength and resistance to fracture.

Further information on OI studies performed at Shriners, Chicago and Marquette University can be found in the following references.

Fritz, J.M., Guan, Y., Wang, M., Smith, P.A. and Harris, G.F.: Muscle Force Sensitivity of a Finite Element Fracture Risk Assessment Model in Osteogenesis Imperfecta. Biomedical Sciences Instrumentation. 45:316–321, 2009.
Fritz, J.M., Guan, Y., Wang, M., Smith, P.A., and Harris, G.F.: A Fracture Risk Assessment Model of the Femur in Children with Osteogenesis Imperfecta (OI) During Gait.  Medical Engineering & Physics, 31(9):1043–1048, 2009.
Krzak, J.J., Graf, A., Flanagan, A., Caudill, A., Smith, P. and Harris, G.F.: Analysis of Push-Off Power during Locomotion in Children with Type 1 Osteogenesis Imperfecta. Journal of Experimental and Clinical Medicine. 3(5):195–199, 2011.
Albert C., Jameson J., Toth J.M., Smith P. and Harris G.F.: Bone Properties by Nanoindentation in Mild and Severe Osteogenesis Imperfecta. Clinical Biomechanics. 28(1):110–116, 2013.
Albert C., Jameson J. and Harris G.: Design and Validation of Bending Test Method for Characterization of Miniature Pediatric Cortical Bone Specimens. Journal of Engineering in Medicine, Part H. 227(2):105–113, 2013.
Albert, C., Jameson, J., Smith, P. and Harris, G.F.: Reduced Diaphyseal Strength associated with High Intracortical Vascular Porosity within Long Bones of Children with Osteogenesis Imperfect. Bone. 66:121–130, 2014.
Shaker J.L., Albert C., Fritz J. and Harris G.F.: Recent Developments in Osteogenesis Imperfecta. F1000Research 2015, 4(F1000 Faculty Rev): 681. doi: 10.12688/f1000research.6398.1)
Garman, C., Krzak, J., Caudill, A., Graf, A., Smith, P., Harris, G.: Gait Deviations in Children with Osteogenesis Imperfecta Type I. Journal of Pediatric Orthopaedics (JPO). Vol 98, (10), 6pgs, 2017.
Albert, C., Jameson, J., Tarima, S., Smith, P., Harris, G.F.: Macroscopic Anisotropic Bone Material Properties in Children with Severe Osteogenesis Imperfecta. Journal of Biomechanics. Vol. 64, 103–111, 2017.

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Jonathan S. Kirschner, MD, RMSK, FAAPMR, who represents the American Academy of Physical Medicine and Rehabilitation on the USBJI Board, was interviewed recently by The Physiatrist about the new chapter he co-authored on Neuromuscular Disorders for the USBJI’s publication The Burden of Musculoskeletal Disease in the United States: Prevalence, Societal and Economic Cost (BMUS). Dr. Kirschner described in the interview what BMUS means for physiatry, its relevance and what it offers. He highlighted also the value to patients of these collaborative resources and activities by the USBJI involving multiple disciplines concerned with musculoskeletal health. To read the interview, click here.    

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) would like to mention two very important announcements.
 
First, the Institute’s current Long-Range Plan is slated to expire at the end of FY 2019, and we are in the process of developing our Strategic Plan for FY 2020-2024.  To gather input on topics that should be included, we discussed this activity with our Advisory Council during its September 2018 meeting, solicited public comments via a Request for Information, and held listening sessions to hear from investigators and other stakeholders.  We are now in the process of writing a new Strategic Plan and intend to make the draft available for public comment in 2019.  When complete, the plan will outline the Institute’s perspective on research needs and opportunities within NIAMS’ mission and will serve as a resource for all who are interested in NIAMS’ activities.  Because we will continue to devote the majority of our extramural budget toward funding the best investigator-initiated research ideas, the new plan will continue to encourage creative approaches for generating the scientific discoveries that will ultimately improve the health of the American public.
 
Second, the NIH Back Pain Consortium (BACPAC) Research Program, a component of the NIH HEAL (Helping to End Addiction Long-term^SM) Initiative, has recently published four Requests for Applications (RFAs):

• RFA-AR-19-026 - HEAL Initiative: Back Pain Consortium (BACPAC) Research Program: Mechanistic Research Centers (U19 Clinical Trial Optional)
• RFA-AR-19-027 - HEAL Initiative: Back Pain Consortium (BACPAC) Research Program Data Integration, Algorithm Development and Operations Management Center (U24 Clinical Trial Not Allowed)
• RFA-AR-19-028 - HEAL Initiative: Back Pain Consortium (BACPAC) Research Program Technology Research Sites (UH2/UH3 Clinical Trial Optional)
• RFA-AR-19-029 - HEAL Initiative: Back Pain Consortium (BACPAC) Research Program: Phase 2 Clinical Trials (UG3/UH3 Clinical Trial Required)

The NIH BACPAC Research Program initiative will support studies to dissect the components and mechanisms of chronic low back pain and integrate all new information to identify, prioritize and test new therapies targeted to specific mechanisms. This highly collaborative research program will be comprised of mechanistic research centers and technology sites that will conduct translational research and phase 2 clinical trials to deliver an integrated model of back pain, as well as patient-based algorithms to facilitate the identification of treatments tailored to the individual patient.

NIH BACPAC is part of the NIH HEAL (Helping to End Addiction Long-term^SM) Initiative, an aggressive, trans-agency effort to speed scientific solutions to stem the national opioid public health crisis.  Stay informed about NIH BACPAC by visiting the NIH BACPAC Research Program website and by following NIAMS on Twitter and Facebook. Inquiries may be sent to BACPAC-NIH@mail.nih.gov. 

Experts in Arthritis - www.ControlArthritis.org on Self Management and Treatment of Arthritis.


Experts in Arthritis  is for people with arthritis and people who care about them. Arthritis and other rheumatic conditions are the second most common musculoskeletal disease among adults in America. The program offers people with arthritis the opportunity to be better informed about current scientific evidence and management strategies in the treatment and care of osteoarthritis, rheumatoid arthritis, and juvenile arthritis. Other forms of arthritis are incorporated based on need.

Fit to a T - www.Fit2T.org on Fracture Prevention and Osteoporosis.


Fit to a T  educates men and women about fracture prevention, covering risk factors for fracture and osteoporosis, how to prevent bone loss, and how to avoid a fragility fracture, particularly secondary fractures. Fall prevention is an important component. 
 
The USBJI's Vision is that every American knows how to maximize musculoskeletal health throughout his or her lifetime. With your participation we could achieve that! Register your interest in organizing or presenting one or both these public education programs in your community. The materials are provided, at no cost, with ready-made PowerPoint Slides, handouts and organizational support. www.ControlArthritis.org and www.fit2t.org.

Images: The educational content of Experts in Arthritis and Fit to a T is captured on short whiteboard videos available online. These can be freely used in patient waiting rooms and shown in public settings.

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