11 Points on Technology & Treatment Revolutionizing Sports MedicineWritten by Laura Dyrda | Thursday, 29 December 2011 17:48
Top sports medicine physicians and specialists discuss the most important technology and techniques revolutionizing their practices today and where sports medicine is headed in the future.
1. Meniscal injuries: arthroscopic surgery helps now, but biologics are the future. Meniscal tears are one of the most common injuries among athletes and traditionally demanded long recovery periods. However, surgeons today are able to use an arthroscope to repair a meniscal tear without disrupting the patient's anatomy, which shortens the recovery process. "We can place stitches in the meniscus so it can heal itself in a reliable fashion, without making the large incisions like we used to," says Clinton Bell, MD, a sports medicine specialist at Methodist Health System in Dallas.
Surgeons are now finding that even relatively little meniscal damage can put patients in a lot of pain. Robert Marx, MD, an orthopedic sports medicine physician at Hospital for Special Surgery in New York City, recently published an article in the journal Arthroscopy and Related Surgery about small meniscal capsular separation among young female athletes. For a long time, surgeons ordered MRIs for these athletes, which came back negative because the detachment was so minor. However, after treating injuries in several girls who had persisting symptoms for more than six months, he decided to operate.
"I did arthroscopy on a couple of these patients and found a subtle detachment of the medial meniscus," says Dr. Marx. "I fixed it surgically by suturing the meniscus back to the capsule. Although the injury was small and subtle in some cases it was clearly causing the pain because after recovering from the procedure, the patients were pain free."
Kevin R. Stone, MD, founder of The Stone Clinic and chairman of the Stone Research Foundation in San Francisco, takes a different approach to treating unicompartmental knee injuries: meniscus transplantation. His practice recently opened the first dedicated meniscal transplant center in the country, which allows surgeons to treat the damaged compartment of the knee without performing a full artificial knee replacement.
"These patients are highly active patients who have damage to one compartment of their knee but don’t want to undergo artificial knee replacement," says Dr. Stone. "By replacing the meniscus and combining the meniscus replacement with an articular cartilage paste graft we can diminish the pain and permit return to full sports in most patients treated so far. The new meniscus transplantation center has changed my practice quite a bit."
2. Biologic solutions: platelet-rich plasma for now, stem cells to come. Sports medicine physicians around the country have incorporated platelet-rich plasma injections into their practice, either as standalone treatment for partial ligament tears or as growth-enhancer during larger repairs. PRP burst onto the scene a few years ago and showed a great deal of healing promise, but recent studies shed doubt on its actual healing ability and no long-term data is available. Outcomes depend on the variations in each person's blood and whether the equipment spins a higher or lower platelet concentration.
"Everyone is trying to explore the biologic treatment of injuries and eventually biologic treatment of injury prevention," says Neal ElAttrache, MD, a sports medicine physician with Kerlan-Jobe Orthopaedic Clinic in Los Angeles and team physician for the Los Angeles Dodgers. "There is a big interest in studying the effects of enhancing the body's ability to heal itself using the patient's own blood and bone marrow to regenerate damaged tissue."
Jimmy D. Bowen, MD, an orthopedic sports medicine physician with Advanced Orthopedic Specialists based in Cape Girardeau, Mo., has been performing PRP injections in his practice for more than three years. Coupled with a musculoskeletal ultrasound for injection guidance, he has seen excellent results from PRP. "One of my first patients who used PRP as part of our trial to test effectiveness was a former basketball player who had a partial tear in the patellar tendon," says Dr. Bowen. "We were able to place the PRP in the area of the tear and within three months he was able to return to playing basketball, which he couldn't do for six months before the injection."
In his practice, Dr. Bowen also performs PRP injections for patients with partial tears in the hip abductor muscle tendons, Achilles tendons and rotator cuffs. Dr. Bowen says the injections have helped of his patients with partial tears from throwing injuries, including one athlete who had a tear in the ulnar collateral ligament. "In my practice, I've seen great results for patients with partial tears who don't want to undergo surgery," he says. "We have the athletes start activity very quickly after the injection so they can return to full activity in three to six weeks."
PRP injections can be advantageous, if they are able to heal the patient, because there is a shorter recovery time than surgical repair. However, Dr. Bowen doesn't think PRP is the end of the road for biological development in orthopedic treatment. "In the future, I see us moving away from PRP and more toward stem cell injections," he says.
The transition to using stem cells in joint procedures has been slow. One of the issues with developing biologic healing is moral and legal objection to using embryonic stem cells for research in the United States. "There are some things we aren't able to do in the United States that surgeons do successfully overseas," says Dr. ElAttrache. "We have limitations with regards to stem cells, but more centers in this country are finding ways to use mesenchymal stem cells in their studies."
3. ACL reconstruction: moving closer to anatomical repair. Although there is a high success rate in the literature for the single-bundle anterior cruciate ligament repair, there is also a high post-surgery attrition rate for athletes because the single bundle limits rotational ability. The procedure also impacts the ACL's stability, which is crucial for any level of athletics. As a result, new technology and advancement in surgical technique make anatomically correct procedures possible.
Some surgeons have learned a double-bundle technique, which strengthens rotational and front-back stability. Athletes who receive double-bundle ACL reconstruction are able to perform cutting and pivoting motions at a reduced risk of re-injury. Unfortunately, the significant learning curve associated with the double-bundle procedure makes it inaccessible to many surgeons.
However, traditional single- or double-bundle procedures aren't their only options. Adnan Cutuk, MD, and Scott Kaar, MD, both orthopedic surgeons at Saint Louis University Hospital, perform a variation on the single-bundle procedure where they drill the femoral tunnel through the medial portal, as most surgeons do, but use flexible remers instead of rigid remers to achieve a more natural knee.
"Using the flexible remers allows us to get a longer tunnel and closer to the native footprint of the ACL on the femoral side," says Dr. Cutuk. "This technique is relatively easy to master and can provide significant improvement for even general orthopedic surgeons who are performing a few ACL reconstructions per year."
As outcomes literature on this technique spreads, Dr. Cutuk predicts the procedure will become more pervasive. "As the data becomes available, the natural progression will be for everyone to adopt this new technique," he says. "For the time being, it is a technique that a lot of surgeons who are leaders in the field have adopted. Over time, the information we receive at meetings and discussions will persuade others to learn the technique as well."
4. Computer technology: redefining the way we understand how our body moves. Over the past few years, there has been an explosion of digital and computer technology being applied to medicine as it relates to the body's biomechanics. This technology allows sports medicine physicians to see how injuries occur and could be crucial to preventing injuries in the future. Some of the biggest advancements in this technology include multiplane ultrasound and fluoroscopy as well as digital videotape technology.
"If we have a person who is involved in a throwing sport, we can use new high speed digital video technology and multiplane ultrasound and fluoroscopy to observe how the complex motions of the shoulder during that motion," says Dr. ElAttrache. "Right now, we don't have a clear understanding of what the mechanics are with all he moving parts. Some of the new technology is helping us understand and diagnose what the pathologic motions are that cause the injury."
Studying biomechanics can help surgeons see how different movement stresses joints to the point where an athlete is at high risk for ligament or tissue tears and injuries. Athletes who have injury to one knee are also more likely to re-injure that knee or injure their other knee than athletes who have no injuries at all.
"Even after a perfect reconstruction, athletes' mechanics often put them at risk of re-injury," says Dr. ElAttrache. "There are studies where we are looking at the dynamics of the pelvic balance and gluteal function as well as the timing of muscle use whenever you land from a jump. We are using really modern technology to study these functions. It's very exciting to be able to improve our results, decrease recurrent injury and prevent injuries in the first place."
5. Surgical technique: safer methods of damaged tissue removal and regeneration on the horizon. One of the developments Dr. ElAttrache is most excited about today is the application of safer methods to remove injured tissue during a less invasive surgery. He is studying ultrasound waves to remove injured and damaged tissue, which can have better outcomes for the patient.
"Through a little opening in the skin no bigger than a hole for a needle, you can insert a little ultrasound wand, put it where the damaged tissue is and remove injured tissue with sound waves," says Dr. ElAttrache. "We are also working on ways to place stem cells or plasma elements on the surgical site through the same needle. The stem cells or plasma elements promote regeneration of normal tissue after removal."
The advancements in surgical technique for tissue removal and biologic regeneration are possible because minimally invasive instruments can support the procedures. Dr. ElAttrache sees this continuing as a big trend over the next few years. "We will be able to do more and more with extremely minimal invasion," he says.
6. Hip surgery: focusing on hip impingement correction. Hip impingement is a common condition among high-level athletes. The severity of the disorder depends on the rotation of the acetabulum — whether it is tilted, the amount of coverage on the socket, the rotation and the amount of bone on the femoral head in junction with the femur, says Dr. Kaar.
"People can get chronic labral tears from bony impingement of the hip," he says. "In the 1990s, we were doing open procedures for hip impingement. Now there is a proliferation of arthroscopic procedures."
The transition from open to arthroscopic procedures has the same advantages for hip impingement as it does with other minimally invasive orthopedic procedures: there is less morbidity, shorter rehabilitation and the surgeon doesn't have to dislocate the hip as they do in the open procedure.
7. Pain injections: ultrasound guidance is growing fast. Ultrasound technology has been around for decades, but its use in the musculoskeletal and pain management specialties is just beginning to spread. Most sports medicine physicians learned to administer blind injections to a troubled joint in their residencies, becoming more successful with experience. However, once ultrasound technology was adapted for joint injections, physicians were able to administer the injection to the right spot on a more regular basis — which is supported by literature published in the American Journal of Sports Medicine.
"Since we can use ultrasound for directing injections, there is less ambiguity about where the needle is placed for injections, including PRP," says Dr. Bowen. "At my practice, we're not doing blind injections where you administer the injection based professional experience and intuition. Studies have shown we aren't always in the right place as often as we think we are without ultrasound guidance."
Charles Garten, MD, an orthopedic sports medicine physician with Myers Sports Medicine and Orthopaedic Center and former team physician for the Atlanta Falcons and Atlanta Thrashers, has also been using musculoskeletal ultrasound in his practice for the past five years, but he couples this technology with the Navigator Delivery System. The Navigator DS is designed to make the delivery of injections more efficient by automating the preparation of the medicine for the injection. As a result, contaminated needles are never an issue. The Navigator DS also has practice management advantages.
"From a record management standpoint, the Navigator DS interfaces with the ultrasound and captures the image of what you are injecting," says Dr. Garten. "The image is then uploaded to your electronic medical record, so you are able to capture that data for the patient record."
In some cases, ultrasound is also used for diagnosing soft tissue injuries such as partial tears. The equipment is portable, which means it can be taken from one exam room to another and used on the sidelines at sporting events. Ultrasound is also advantageous because you can view the anatomy in action to assess the biomechanics of the problem.
"The ultrasound is a great adjunct to your clinical exam," says Dr. Bowen. "The technology is advancing to the point where there are ultrasounds dedicated to just musculoskeletal structures. The needle visualization technology is also better, and the technology is becoming less expensive for physician offices to purchase."
8. Robotic technology: making joint replacements more precise. New computer-guidance and robotic technology is on the market for partial knee and hip replacement procedures. The computer software takes a three-dimensional CT scan of the patient's anatomy and allows the surgeon to preplan procedures. The plans are then translated to the robot, which guides surgeons in the operating rooms.
"The robotic guidance has been a big plus because we are able to treat some of the isolated problems in the knee, such as patellofemoral arthritis, with better precision," says Scott Grewe, MD, an orthopedic surgeon with Orthopedics Northwest in Tigard, Ore., and Legacy Meridian Park Medical Center, where he performs, MAKOplasty, a robotic-guidance procedure. Legacy Meridian Park Medical Center is currently the only hospital in Oregon to employ the MAKOplasty technology. "It has taken out some of the variable for partial knee reconstructive procedures. If you have medial compartment arthritis, you want the alignment of the leg to be precise so bearing weight doesn't wear out the implant or the opposite normal compartment."
Traditionally, surgeons have taken x-rays to ensure appropriate implant placement. However, these images only allow for viewing the aligned knee in one position; the robotic technology allows for viewing the alignment while the knee is in motion during the preplan stage.
"You can see complete alignment with range of motion and what it would be like if you used a different size of implant or changed the position of the implant," says Dr. Grewe. "On the screen, you get a read out of the stress individual patients will place on the implant in a single position and how tight the knee joint is. Before, your assessment was much more subjective."
There are some barriers to access for this technology — it's expensive and requires additional surgeon training. There is also little clinical evidence to show the technology provides significant improvement in outcomes, despite the increased equipment cost. "When something new comes along, it needs a track record behind it because some of our new technology doesn't pan out," says Dr. Grewe. However, surgeons who use the technology often report, anecdotally, better surgical technique that could lead to a sturdier long-term outcome.
While the transition to robotic technology may be slow, Dr. Grewe sees this technology expanding to new applications. Software for guiding the robot during hip procedures was released earlier this year, and the software could grow to include other applications, such as shoulder surgery.
"When we are doing shoulder replacements, resecting the bone on the socket side is difficult because it's hard to access," says Dr. Grewe. "If it could be done through a small incision robotically, that would help make the procedure a more precise operation."
9. Spine surgery: minimally invasive techniques return players to the field. Athletes place a great deal of stress on their spinal cords, which can lead to fractures or other painful conditions. In the past, surgeons treated these conditions with disruptive open procedures and recovery was slow; there was little chance of returning to play. However, new technology has made it possible to perform minimally invasive surgical correction and return athletes to play within a year.
"Technology today allows us to get a solid fixation through a minimally invasive procedure," says Neel Anand, MD, director of orthopedic spine surgery at Cedars-Sinai Spine Center in Los Angeles. "When the fixation is set, we can have the athlete rehab and return to their normal activity."
One of the most high-profile athletes to undergo spine surgery this year, Indianapolis Colts quarterback Peyton Manning, is in the final stages of recovery after his anterior cervical discectomy and fusion. In the future, spine surgeons may be able to use stem cell therapy to alleviate the symptoms better, but most of these therapies haven't advanced to the point of clinical trials among humans.
10. Spinal injuries: quick and proper diagnoses make the difference. When athletes incur a spinal cord injury, they are able to receive a diagnosis and treatment much faster than they did in the past, which increases chances of recovery. From high school through professional sporting events, trained medical staff members stand on the sideline to orchestrate an initial assessment of the injury, and in serious cases athletes can be airlifted to a hospital. Once at the hospital, a CT scan is taken in the emergency room and results are almost instantaneous.
"We are recognizing more spinal injuries today than we did 10-15 years ago with both emergency and non-emergency sports-related spinal injuries," says Dr. Anand. "We can partially attribute this trend to the sophistication of our equipment and experience in working with professional athletes."
In the event of a spinal cord injury, there are some immediate treatments surgeons can administer, but technology hasn't developed to the point where the damage can be reversed. "The sooner you treat the spinal cord injury, the better chance you have for recovery," says Dr. Anand. "If you have a spinal cord injury, there is a lot of inflammation and extension of the injury zone. We want to reduce the injury zone, and treatment is moving that way. Down the road, I'm quite sure we will have the technology to use stem cell therapy in some fashion. The question is whether these treatments will be safe."
11. Concussion management and prevention: it starts with education. There has been a boom in concussion awareness among athletes as a result of studies showing the correlation between multiple concussions and severe neurological issues. Major professional athletic leagues have made changes in game regulations to prevent and better identify concussions over the past few years. For example, hockey players are no longer allowed to blindside an opposing player because the risk of concussions is so high.
The concern about concussions was seen as unnecessary even five years ago, and the only tools available for assessing the damage was based on symptoms; players were allowed back on the field if they were feeling well enough to play. "Up until recently, everything had been subjective," says Warren Bodine, DO, a sports medicine specialist at Cambridge Health Alliance in the Boston area. "Now, we have new technology for neurocognitive testing. We can use a computerized program to monitor the patient's neurocognitive symptoms and ensure they return to baseline before returning to play."
In addition to neurocognitive testing, team physicians administer balance and memory tests to make sure the athlete has fully recovered. Athletes who return to play too quickly are at greater risk of re-injury because concussions negatively impact balance and biomechanics, and if the player incurs a second concussion, the implications could reach far beyond that game. Some young athletes who suffer multiple concussions have trouble completing school work and that head trauma could lead to depression and symptoms of amyotrophic lateral sclerosis later in life.
Most states recently passed legislation to protect young athletes from returning to play too soon. Concussion legislation often requires athletes to obtain clearance from medical professionals before returning to play and prevents them from returning the same day as the injury. Dr. Bodine says there are several steps athletes must complete before they are considered fit for play.
"We won't let athletes return to a game situation until they have completed all of the steps, which will take at least a week and oftentimes longer," says Dr. Bodine. "While the legislation in Massachusetts has mandated concussion awareness and management among school athletics, they have no power over club sports and town sports. In these situations, we are still seeing a lot of misunderstanding about concussions. My next coordinated effort is working with some of the club sports to educate their members about concussion management and prevention."
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