SANTA ANA, Calif. - Joints creak. Hips give out. Backaches become unendurable.

Who ya gonna call?

Not a superstar doctor. Instead, a reliable orthopedic expert.

Orthopedic surgeons don't get the glory that goes to heart surgeons and brain surgeons, but people depend on them when age or injury make movement painful.

Innovations, as befit such a craftsmanlike medical specialty, tend to come in dibs and drabs, not in dramatic breakthroughs.

"Innovations have been incremental changes - and not necessarily improvements," veteran orthopedic surgeon Dr. Harry Skinner told the American Society of Mechanical Engineers at a conference about medical devices last month in Irvine, Calif.

His talk, which focused on joint repairs, was followed a week later by a corporate presentation to the Southern California Biomedical Council on products for fixing deteriorating spines.

Together, the talks summarized the state of the orthopedic art and highlighted the work of several local innovators.

In an orthopedic market that's expected to reach $20 billion within a few years, no local company comes close to dominating the field like artificial-joint makers Zimmer of Indiana or Stryker of Michigan.

About 15 small entrepreneurial companies make new varieties of orthopedic devices in Los Angeles and Orange Counties, said Ahmed Enany, president of the SoCalBio trade group.

In Orange County, spinal devices are a particular specialty.

FRACTURES

Treatment for broken bones has improved just a bit in the past 20 years, said Skinner, who is a medical textbook author and plain-talking veteran of 12 years as chairman of the Department of Orthopedic Surgery at the University of California-Irvine School of Medicine. He moved to St. Jude Medical Center in Fullerton last year after UCI replaced him with a new department head.

"Twenty years ago we had bone plates" to hold fractured bones in place, he said. "Now we have individualized fracture plates. "

"That's an incremental advance. It isn't a home run."

The top innovations, he said, are "locking plates" for repairing fractures.

The surgeon can attach screws into those plates to hold fragmented bones in place, eliminating the need to rely for support on screws attached to the bone itself.

SPINE

Several orthopedic companies focus on spinal repair devices, including Interventional Spine of Irvine, Allez Spine of Irvine, and VertiFlex of San Clemente.

Interventional Spine makes two implants that doctors can attach via minimally invasive surgery to strengthen the lower spine.

The company's Perpos system, which is on sale in Europe and the United States, uses screws to compress part of the backbone in connection with a spinal fusion procedure. The related PercuDyn system also strengthens the spine but allows more movement. It's used in Europe, and the company this week won approval from the Food and Drug Administration to start clinical trials in the United States.

Allez Spine, which is owned by doctors, makes the Laguna Polyaxial Pedicle Screw System, which can immobilize injured or deteriorated portions of the spine with a rod attached to vertebrae by titanium screws. Allez has been hit with a patent-infringement lawsuit from large spinal-device companies Medtronic and Johnson & Johnson, as well as criticism from industry groups and regulators that its doctor-owners have financial incentives to use Allez products that might not be in their patients' interest.

VertiFlex makes implants such as the Silverbolt and the Dynabolt for minimally invasive spinal fusion and for strengthening the spine while allowing mobility.

BONE INFECTIONS

Orthopedic infections are tough to get rid of, Skinner said. In contrast to infections in soft tissue, which antibiotics typically can clear up in two weeks, infections in bones and joints often require six weeks of antibiotics to eliminate.

"It's a huge expense," he said, costing $50,000 and occurring in roughly one of every 100 patients.

He criticized Medicare for its plan to stop reimbursing hospitals for the cost of treating infections that patients pick up while hospitalized.

"It's not rational," he said. "I'm going to have post-operative infections as long as patients come to me with bacteria, and every one of us has bacteria – in the gut and elsewhere."

To cut down on infections, he proposed bacterial-repellent surfaces on prostheses, better methods of closing up surgery sites, and more automated intravenous systems for antibiotics.

SHOULDERS

Without the day-in, day-out pressures that hips and knees undergo, shoulders less frequently need to be replaced. The number of shoulder replacements is about one-twentieth the number of knee replacements.

A recent innovation in that field is so-called "reverse shoulder replacement surgery," which is used for patients with severely malfunctioning joints. Unlike a natural shoulder joint, which consists of a ball at the end of the arm bone and a socket on the shoulder bone, the reverse-design implant has a socket on the arm bone and a ball on the shoulder bone.

In Orange County, Calif., the procedure is done at St. Jude in Fullerton and St. Joseph Medical Center in Orange, Skinner said.

HIPS AND KNEES

Knee replacements are tops in the orthopedic world, with about 529,000 performed annually in the United States at an overall cost of $3.2 billion.

Hip replacements are also popular, totaling 250,000 a year and costing $1.8 billion.

As the population grows older, the need for such operations will increase.

For example, surgeons will perform an estimated 2.5 million knee replacements annually by the year 2028, Skinner said.

Despite their popularity, joint replacements haven't improved much in recent years, Skinner said.

Companies have introduced longer-lived polyethylene plastic-on-ceramic joints as an alternative to the polyethylene plastic-on-metal cobalt chrome joints that Skinner called the "gold standard."

The ceramic joints are expected to have roughly a 25-year life, compared with about 15 years for metal joints, but they have drawbacks.

"Ceramic is kind of like dinnerware. It fractures catastrophically," Skinner said.

Some patients also report problems with ceramic hips that squeak, including a man who complained that his wife would always laugh at the squeaks his hip made when they made love, Skinner said.

Other innovations include the use of magnetized materials to keep joint components separated, ceramic-on-ceramic joints, and metal-on-metal joints.

Overall, the innovations mostly amount to "changes, but not improvements," he said.

"Device manufacturers, like Ford and Chevy, need a new model every year to maintain profits."