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A look at innovations in sports medicine: Past, present and future
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Innovation in orthopedic surgery and sports medicine is all around us. It characterizes where we have come from and how we have progressed to where we are today. Millions of patients benefit each day from medical innovations, which are the result of multidisciplinary collaboration between physicians, scientists, engineers and the medical device industry.
Innovation is Latin for the word innovare and means, “to renew or change.” In the current health care environment, innovation is not only related to technical advances, but also has an increasing focus on developing cost-conscious treatment methods of paramount importance to physicians, patients and insurers. This can only be accomplished, however, through rigorous, high level of evidence, scientific investigation that compares new products or treatment methods to the current standards of care.
Positive innovations
If we think back 30 years ago in sports medicine, most (if not all of our procedures) were performed via open surgical techniques. Fast-forward to the present, and arthroscopic surgery is the standard of care in sports medicine, undoubtedly having revolutionized and positively impacted the way we understand our patient’s injuries, and return our patients and athletes to the playing field. A second example of innovation in sports medicine is the suture anchor, which was introduced in the 1980s, as a simple and effective way of attaching soft tissue to bone. It is now a mainstay in arthroscopic surgery and continues to evolve. Traditionally, these procedures were much more invasive with the use of bone tunnels and additional fixation and required a longer operating room time.
Use without proper evidence
Despite positive innovations such as arthroscopy and the suture anchor, there are also examples of innovative treatments, often promoted by industry with good results and minimal risks demonstrated in short-term follow-up, that ultimately proved to be less effective or associated with more adverse results than prior treatments. The arthritis drug Vioxx was one example where potential cardiovascular risks associated with the drug began to surface 1 year after its 1999 FDA approval. The drug was supported by a $200 million marketing campaign and, sadly, warnings from researchers about the potential risks of the drug were not taken seriously. Consequently, the drug remained on the U.S. market for 4 years before being removed.
Anthony M.
DiGioia III,
Editor
The use of chymopapain as an injection to cure back pain is another example. In the 1980s, chymopapain was introduced as an enzyme that could be injected directly into a herniated disc to dissolve the portion pressing on the nerve and causing pain. Community clinics that offered chymopapain injections began to open around the United States, and we remember several here in Pittsburgh that provided the treatment. After more widespread use of the technique, followed by outcome studies, most physicians found it was not more effective than other current treatment options, and, in some cases, the use of chymopapain resulted in severe complications. The risk-benefit ratio was not acceptable in comparison to other treatments. The use of chymopapain began to decrease before it was removed from the U.S. market in 2003.
Advancements
Surgeons and scientists continue to strive for advancements in clinical care. In Pittsburgh, we are one of the leading sports medicine centers in the world for knee ligament surgery. During the past 5 years, we have begun to individualize treatment strategies for patients and look at our outcomes more objectively by using sophisticated evaluation techniques. For example in ACL surgery, we use an arthroscopic ruler to measure the size of the insertion sites and intercondylar notch to determine the most appropriate procedure based on the patient’s native anatomy. In an effort to provide more objective information about returning an athlete to play, we also investigate non-invasive imaging methods to assess graft healing after surgery.
Freddie H. Fu
Quantitative MRI and optical coherence tomography are also being used to detect early cartilage damage after ACL injury and repair. We collaborate closely with Scott Tashman, PhD, at the University of Pittsburgh Biodymanics Lab, who uses highly sophisticated stereoradiography to measure in vivo kinematics down to 0.1 mm and 0.1° of accuracy. Using this technology, we can compare joint motion to a contralateral healthy control limb and detect potential differences that we are unable to assess clinically.
Biological therapy
Biological treatment strategies, including platelet-rich plasma (PRP) and stem cell injection therapies, have recently become a hot topic in orthopedics and sports medicine. In our opinion, without appropriate scientific evidence to support widespread clinical use, the mainstream media have labeled PRP as a quick fix and cure all solution to many sports related injuries.
Christopher D.
Harner
The market value for PRP is expected to increase to $126 million by 2016. Scientifically, the composition of PRP is highly variable and may produce different effects at various time points and with different types of injury. James C-H. Wang, PhD, in the MechanoBiology Lab in our department at the University of Pittsburgh has two National Institutes of Health-funded grants to investigate the basic science of PRP. These treatments need to be studied carefully before they are widely adopted, and the precise definition of treatment indications has to be defined. In fact, we have seen potential complications associated with biological injection therapies in cases that have been referred to our institution. It is crucial that members of the scientific community are aware of these potential complications, and that the appropriate steps are being taken to understand and prevent them.
Innovation is essential to the continued development of modern health care and improving the lives of our patients. Regardless, we must always be honest and critical of ourselves in terms of what we truly consider an innovation. Along these lines, Ezekiel Emanuel, MSC, MD, PHD, of the University of Pennsylvania reminds us that “…we need to stop glorifying every new technology as an innovation. ‘New’ matters only when it’s proved better than we had before.”
It is imperative that the necessary scientific investigation occurs when investigators evaluate new products, and that both positive and negative results be reported and independently verified. When possible, objective and patient-relevant outcome measurements should be used to ensure a positive impact and better value for our patients. Collaboration with industry can be positive, but steps should be taken to minimize potential conflicts of interest. The future of sports medicine is bright as we continue to move forward keeping the goal of improved patient care at the forefront of our minds.
References:
Harris NL. J Bone Joint Surg Am. 2012;doi:10.2106/JBJS.J.00984.
For more information:
Freddie H. Fu, MD, DSc(Hon), DPs(Hon), is Distinguished Service Professor, University of Pittsburgh; David Silver Professor and Chairman, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine; and Head Team Physician, University of Pittsburgh Department of Athletics. He can be reached at the Department of Orthopedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Ave., Suite 1011, Pittsburgh, PA 15213; email: ffu@upmc.edu.
Christopher D. Harner, MD, is Blue Cross of Western Pennsylvania Endowed Chair; Professor of Orthopaedic Surgery; Chief, Division on Sports Medicine; Medical Director UPMC Center for Sports Medicine; Co-director Sports Orthopaedic Research Lab; Immediate Past-President of the American Orthopaedic Society for Sports Medicine; and head team physician for the Pittsburgh Penguins Hockey Team. He can be reached at UPMC Center for Sports Medicine, 3200 South Water St., Pittsburgh, PA 15260; email: harnercd@upmc.edu.
Disclosures: DiGioia, Fu and Harner have no relevant financial disclosures.