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Elderly hip fracture patients require emergent surgery and often have comorbidities that make optimizing their recoveries challenging and critically important.
Philipp Leucht, M.D., Ph.D., Associate Professor of Orthopedic Surgery and Cell Biology at NYU Langone Health, has worked to improve outcomes for this high-risk patient population by addressing all aspects of their care. He also runs an NIH-funded research lab that’s focused on the cellular and molecular mechanisms that govern skeletal development and fracture healing, the effect of mechanical stimulation of bone regeneration and stem cell-based tissue engineering strategies to enhance bone regeneration.
During a recent study, Dr. Leucht and his colleagues randomized 186 hip fracture patients to receive an intraoperative injection of bupivacaine, morphine sulfate and ketorolac or no injection of pain medication.
Patients who received the cocktail of local anesthetics and analgesics reported less post-op pain, nausea and drowsiness. Importantly, they were also able to ambulate longer distances in the initial days following surgery, an important factor in improved rehabilitation and outcomes.
Controlling post-op pain without the use of opioids also helped to prevent delirium and lowered the risk of the patients becoming addicted to the powerful narcotics.
Dr. Leucht presented the findings at the 2023 American Academy of Orthopaedic Surgeons (AAOS) annual meeting in Las Vegas. That’s where we caught up with him to discuss ways to improve fracture repairs, why orthobiologics are key to advancing trauma care and what his research lab is doing to help bones heal.
What led you to investigate the care of hip fracture patients?
Dr. Leucht: This patient population is particularly challenging due to their age and the traumatic nature of their injuries. We have found that the sooner patients start walking after surgery, the fewer complications they experience. However, pain is often a limiting factor in the process. To address this issue, we standardized the pain protocol for all trauma patients and implemented a perioperative multimodal injection to help patients manage pain immediately after surgery and in the long term.
Patients who received the injection had better short- and long-term outcomes. Our study showed that patients in the treatment group experienced less pain immediately after surgery, as well as in the postoperative period, and required 33% fewer narcotics within the first 24 to 48 hours compared to the control group.
Orthopedic companies should consider including perioperative pain management in their product portfolio. They could offer a platform that includes fixation implants and pre-mixed pain medication. During the stress of surgery, surgeons might forget to administer pain medication. Having pain medication readily available — in the same kit or tray as an implant — could eliminate this issue and improve outcomes.
The reduction of post-op pain also resulted in improved ambulation outcomes. Why is that important?
Dr. Leucht: Patients in the treatment group walked significantly further than the control group. Specifically, the control group walked an average of 70 feet on day one and 40 feet on days two and three. The treatment group walked an average of 90 feet on day one, 115 feet on day two and 90 feet on day three. That’s a huge difference and an amazing result, because early ambulation is associated with improved outcomes.
The treatment group experienced significantly fewer major cardiovascular and pulmonary complications, with a four-fold decrease compared to the control group. This reduction in major complications is a significant outcome, as it surpasses the benefit of simply reducing pain and improving mobility.
That’s significant because there has been no improvement in mortality rates for hip fracture care over the past 30 years, despite advances in surgery. The potential to reduce intra-hospital mortality by simply getting patients out of bed is promising.
What is needed to advance the field of fracture repair?
Dr. Leucht: While there have been minor modifications in the implant space, I do not foresee any drastic improvements in the immediate future. Therefore, we need to focus on fracture augmentation, and I believe orthobiologics are the next step. Shortening the time to fracture union would limit the amount of pain patients feel and allow them to return to work earlier, resulting in significant socio-economic benefits. Options for fracture repair are currently limited in the biologics space, but it’s slowly expanding, and over the next few years the most effective solutions will become widely used.
What role do growth factors and skeleton stem cells play in the bone healing process?
Dr. Leucht: Fracture repair is a complex process that is often oversimplified in the orthopedic community as an injury involving a bone that will reform and heal. In reality, fracture healing involves a sophisticated interplay of various growth factors that are exposed to different cell types and vary at every stage of the healing process.
This makes it difficult to design or translate growth factors into biologics. For example, BMP-2 plays multiple roles in fracture healing, and its effects differ depending on when it’s administered. Administering BMP-2 during surgery may cause an initial inflammatory response because the bone cells aren’t yet present. It’s essential to find the right growth factor and delivery method to ensure that it’s present at the right time and placed in the fracture for effective healing.
Ideally, a growth factor cocktail would be administered at specific time intervals and locations within the injury site to achieve maximum effectiveness. But the maximum effect might not be necessary — a small amount of growth factor could be sufficient to kickstart the healing process, allowing the body to complete the rest of the repair.
Some biologics already promote the early stages of repair, such as angiogenesis, stem cell division and blood vessel formation. Stem cells present in a well-perfused fracture environment will deposit bone and initiate their healing process. This approach is more likely to be used in the future.
What research are you conducting in your lab pertaining to the development of orthobiologics?
Dr. Leucht: I’m excited by the potential of using stem cells for bone regeneration. Stem cells possess the ability to perform the same functions as biologics. Although surgeons must tailor their use of biologics to match the various stages of fracture repair, stem cells can respond appropriately to cues at repair sites and secrete growth factors to attract other stem cells that divide and deposit bone.
The challenge is understanding how to increase the number of stem cells at the repair site, because insufficient numbers are typically the reason for poor bone regeneration. If we can boost the number of stem cells, they will initiate the healing process if the right environment and signals are in place.
Elderly hip fracture patients require emergent surgery and often have comorbidities that make optimizing their recoveries challenging and critically important.
Philipp Leucht, M.D., Ph.D., Associate Professor of Orthopedic Surgery and Cell Biology at NYU Langone Health, has worked to improve outcomes for this high-risk patient population by...
Elderly hip fracture patients require emergent surgery and often have comorbidities that make optimizing their recoveries challenging and critically important.
Philipp Leucht, M.D., Ph.D., Associate Professor of Orthopedic Surgery and Cell Biology at NYU Langone Health, has worked to improve outcomes for this high-risk patient population by addressing all aspects of their care. He also runs an NIH-funded research lab that’s focused on the cellular and molecular mechanisms that govern skeletal development and fracture healing, the effect of mechanical stimulation of bone regeneration and stem cell-based tissue engineering strategies to enhance bone regeneration.
During a recent study, Dr. Leucht and his colleagues randomized 186 hip fracture patients to receive an intraoperative injection of bupivacaine, morphine sulfate and ketorolac or no injection of pain medication.
Patients who received the cocktail of local anesthetics and analgesics reported less post-op pain, nausea and drowsiness. Importantly, they were also able to ambulate longer distances in the initial days following surgery, an important factor in improved rehabilitation and outcomes.
Controlling post-op pain without the use of opioids also helped to prevent delirium and lowered the risk of the patients becoming addicted to the powerful narcotics.
Dr. Leucht presented the findings at the 2023 American Academy of Orthopaedic Surgeons (AAOS) annual meeting in Las Vegas. That’s where we caught up with him to discuss ways to improve fracture repairs, why orthobiologics are key to advancing trauma care and what his research lab is doing to help bones heal.
What led you to investigate the care of hip fracture patients?
Dr. Leucht: This patient population is particularly challenging due to their age and the traumatic nature of their injuries. We have found that the sooner patients start walking after surgery, the fewer complications they experience. However, pain is often a limiting factor in the process. To address this issue, we standardized the pain protocol for all trauma patients and implemented a perioperative multimodal injection to help patients manage pain immediately after surgery and in the long term.
Patients who received the injection had better short- and long-term outcomes. Our study showed that patients in the treatment group experienced less pain immediately after surgery, as well as in the postoperative period, and required 33% fewer narcotics within the first 24 to 48 hours compared to the control group.
Orthopedic companies should consider including perioperative pain management in their product portfolio. They could offer a platform that includes fixation implants and pre-mixed pain medication. During the stress of surgery, surgeons might forget to administer pain medication. Having pain medication readily available — in the same kit or tray as an implant — could eliminate this issue and improve outcomes.
The reduction of post-op pain also resulted in improved ambulation outcomes. Why is that important?
Dr. Leucht: Patients in the treatment group walked significantly further than the control group. Specifically, the control group walked an average of 70 feet on day one and 40 feet on days two and three. The treatment group walked an average of 90 feet on day one, 115 feet on day two and 90 feet on day three. That’s a huge difference and an amazing result, because early ambulation is associated with improved outcomes.
The treatment group experienced significantly fewer major cardiovascular and pulmonary complications, with a four-fold decrease compared to the control group. This reduction in major complications is a significant outcome, as it surpasses the benefit of simply reducing pain and improving mobility.
That’s significant because there has been no improvement in mortality rates for hip fracture care over the past 30 years, despite advances in surgery. The potential to reduce intra-hospital mortality by simply getting patients out of bed is promising.
What is needed to advance the field of fracture repair?
Dr. Leucht: While there have been minor modifications in the implant space, I do not foresee any drastic improvements in the immediate future. Therefore, we need to focus on fracture augmentation, and I believe orthobiologics are the next step. Shortening the time to fracture union would limit the amount of pain patients feel and allow them to return to work earlier, resulting in significant socio-economic benefits. Options for fracture repair are currently limited in the biologics space, but it’s slowly expanding, and over the next few years the most effective solutions will become widely used.
What role do growth factors and skeleton stem cells play in the bone healing process?
Dr. Leucht: Fracture repair is a complex process that is often oversimplified in the orthopedic community as an injury involving a bone that will reform and heal. In reality, fracture healing involves a sophisticated interplay of various growth factors that are exposed to different cell types and vary at every stage of the healing process.
This makes it difficult to design or translate growth factors into biologics. For example, BMP-2 plays multiple roles in fracture healing, and its effects differ depending on when it’s administered. Administering BMP-2 during surgery may cause an initial inflammatory response because the bone cells aren’t yet present. It’s essential to find the right growth factor and delivery method to ensure that it’s present at the right time and placed in the fracture for effective healing.
Ideally, a growth factor cocktail would be administered at specific time intervals and locations within the injury site to achieve maximum effectiveness. But the maximum effect might not be necessary — a small amount of growth factor could be sufficient to kickstart the healing process, allowing the body to complete the rest of the repair.
Some biologics already promote the early stages of repair, such as angiogenesis, stem cell division and blood vessel formation. Stem cells present in a well-perfused fracture environment will deposit bone and initiate their healing process. This approach is more likely to be used in the future.
What research are you conducting in your lab pertaining to the development of orthobiologics?
Dr. Leucht: I’m excited by the potential of using stem cells for bone regeneration. Stem cells possess the ability to perform the same functions as biologics. Although surgeons must tailor their use of biologics to match the various stages of fracture repair, stem cells can respond appropriately to cues at repair sites and secrete growth factors to attract other stem cells that divide and deposit bone.
The challenge is understanding how to increase the number of stem cells at the repair site, because insufficient numbers are typically the reason for poor bone regeneration. If we can boost the number of stem cells, they will initiate the healing process if the right environment and signals are in place.
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Dan Cook is a senior editor with more than 18 years of experience in medical publishing and an extensive background in covering orthopedics and outpatient surgery. He joined ORTHOWORLD to develop content focused on important industry trends, top thought leaders and innovative technologies.
