Lessons in Orthopaedic Leadership: An AOA Podcast
Lessons in Orthopaedic Leadership: An AOA Podcast
Future of Orthopaedic Surgery: A Look Into Tomorrow's Sports Medicine with Rick W. Wright, MD, FAOA
Dr. Rick Wright explores the future of orthopaedic sports medicine, focusing on promising developments in cartilage replacement, meniscus substitution, ACL repair, and innovative rotator cuff treatments. His expert insights reveal how these advancements could transform patient care while addressing the economic realities of implementing cutting-edge treatments.
Welcome to the AOA Future in Orthopedic Surgery podcast series.
Speaker 2:Welcome to the AOA Future in Orthopedic Surgery podcast series. This AOA podcast series will focus on the future in orthopedic surgery and the impact on leaders in our profession. These podcasts will focus on the vast spectrum of change that will occur in the domains of culture, employment, technology, scope of practice, compensation and other areas. My name is Doug Lundy, host for this podcast series. Joining us today is Dr Rick Wright. Dr Wright is the Dan Spengler Chair in Orthopedics at Vanderbilt University.
Speaker 2:Dr Wright went to college and medical school at the University of Missouri and then he did his orthopedic surgery residency at Vanderbilt University Medical Center in Nashville, tennessee. He then went on to do his fellowship in sports medicine at the Minneapolis Sports Medicine Center. Upon completing his fellowship, he went to the Washington University School of Medicine in 1994 and eventually worked his way up to become head team physician of the St Louis Cardinals and he worked with the St Louis Rams and the St Louis Blues. He was program director while he was at Wash U, which eventually earned him the Distinguished Educator Award. He served many different committees and processes within the American Orthopedic Association and eventually became the 132nd president of the AOA. He was the 66th president of the American Board of Orthopedic Surgery, and his continued research on ACL was eventually recognized by the Academy with the 2019-2020 Kappa Delta Award.
Speaker 2:So, dr Wright, welcome to the podcast series, sir. Thank you, doug. Good to be here and, as you all probably hear, rick and I are very good friends from our time on the board together. We've known each other quite well and go back quite a ways. I can't think of anybody. I know a lot of sports medicine people but I think you and we talked about this a little bit ahead of time are the right person at this time to talk about the future in sports medicine. All right, buddy, so put on your your hat and tell us where do you think sports medicine will be 10?
Speaker 3:And, if you're so bold, 20 plus years from now well, Doug, I'll make some projections and some predictions, and I'll probably be wrong on most of them because a couple of these I would have made the same prediction 10 years ago and it still hadn't come to fruition.
Speaker 3:So I'm hoping we can accomplish some that impact a significant number of patients, large swath of the population, and may have some interest. I think we could start with cartilage, especially in the knee, although there are cartilage problems throughout the body. But I spend more time thinking about knee and shoulders so we'll stay focused there in our time together. But cartilage is at holy grail and in 1994, when I started practice, I would have said we will have a cartilage replacement in the next 10 to 20 years. And here we are, 30 years later, and we don't have. I mean, we've got some options but we don't have that perfect replacement. But I think we're starting to see there are some reasonable approaches out there. People will take small defects in the knee and do plugs from another part of the knee to transfer. I liken it to hair plug surgery where you take a plug and put it where you need it and there's been macy and a variety of things. And then there's starting to be some manufactured cartilage disc. So there's at least small to medium defects. I'm not sure that it's easy to have an off-the-shelf sitting around. And when I'm talking about small defects, I'm talking about one to 1.5 centimeter square, moderate defects, two by one, two by one and a half centimeters, where you could put something into the defect. And when you see that in a young person and it's traumatic and the rest of the knee is relatively normal, boy, that can be a real game changer. And the ability to go in, find that defect, suspect it on MRI maybe, or occasionally find it unsuspecting, somewhat unsuspecting, and be able to fix it with an off-the-shelf product. That will be when we've really kind of got this answer. Now, what we don't have and what I don't think we'll ever have, is anything that truly addresses the person that has widespread degenerative arthritis, and we can talk about that a little later if we talk about biologics. So I think that if you said, boy Rick, what would you love? I'd love to have a cost effective, off the shelf cartilage defect and, I hope, replacement cartilage, replacement product, and I hope we have something like that in another decade, a realistic, approved in this country you know there's always things floating around Europe and that sort of thing but something that you can say oh, I had X procedure, I was able to get back to my activities pretty quickly and it was very effective. We want to be able to do it arthroscopically eventually, but that's not a must. But it would be nice to be off the shelf, arthroscopic, immediate weight bearing and effective and cost effective. Along with that in that same kind of line would be.
Speaker 3:Along with that in that same kind of line would be a meniscus replacement, because a fair number of people will have tears of their meniscus to the point where they've got a pretty good joint but they've lost, basically their, a meniscus out, a cadaver meniscus, but they never really become a real meniscus. And so if you have a terrible ACL injury in someone where they lose their inside or outside, medial or lateral meniscus and you think they would be best served by an allograft, that's not a patient that you can say oh and, by the way, yes, you can go back and play football, soccer, basketball, volleyball and expect the meniscus to hold up. It will re-tear because it never really becomes vascularized, never really becomes completely a part of them. So a meniscus replacement that would be durable and allow you to get back to normal activities. That's a ways off too, but is out there and will be something that I hope we can come up with.
Speaker 2:Are you aware of the ongoing research in these cartilage fields that are heading toward that? I'm sure they're under high high NDAs, but you know.
Speaker 3:Yeah.
Speaker 2:Stuff's being done.
Speaker 3:Yes, and there are some decent products that really usually get their start in Europe and there's some scaffolds for meniscus out there, there's some highland, there's cartilage replacement disc and situations that are out there that I don't think is that far away that we may be able to use use on a more widespread basis so help a knuckle dragon trauma guy understand here.
Speaker 2:So for these small and medium-sized defects, is this almost like a, a skin graft replacement or something like that on there on the back that we open up and y'all take in and cut it to fit and put it in there? Is it a toothpaste that you inject into the chondral defect or what, what? Where you see this?
Speaker 3:It's probably going to end up for most of the time. The best would be something that is solid and you trim it up and you implant it and it's pretty readily ready to go pretty quickly.
Speaker 2:Okay, and it eventually turns into highland cartilage. Okay, and it eventually turns into highland cartilage?
Speaker 3:Yeah, and holds up like highland cartilage. The problem. The problem is that you're dealing with something that is slicker than Teflon, slicker than ice on ice, takes millions of cycles and doesn't break down.
Speaker 1:Right.
Speaker 3:So replacing that, you know, replacing what the human body made, is just, fundamentally, we, fundamentally we can't come up with something that good. It's really a challenge.
Speaker 2:I have a feeling you've said that phrase to patients along the way. I'm sure.
Speaker 2:Yeah, that's not the first time I've told them that yeah, but it tells them, like, look, this is not because I'm sure they, as my patients, do have convenient options on how to do things. You're like that doesn't't work. And here's the reason. That's well said. On the meniscal cartilage side, I mean, can you see, when you're talking about meniscal replacements and you're saying that the allografts don't quite replace the defective amnestics meniscus, they don't become a new meniscus. How would a synthetic meniscus do that? Are you talking about like synthetic meniscus? They don't become a new meniscus. How would a synthetic meniscus do that? Are you talking about like synthetic menisci or something that somehow is biologic enough that, through substitution or whatever, the patient will adopt it as their own?
Speaker 3:Yeah, realistically, a scaffold that becomes substituted and ingrown would be the best product. Not easy, but that would be the best. I think the best product for what we need.
Speaker 2:I could see stuff like this literally turning the entire industry on its ear and seizing massive, massive market share overnight, but the cost of these things would just be astronomic't they?
Speaker 3:yes, probably because the r&d is so expensive that it's right. You know companies need to recoup their, their r&d and and and they're in it. You know they they need some margins. So it is tough and the the other thing with meniscus research and looking at at losing the meniscus is that I mean you're well aware of this even in trauma or joint replacement or whatever you know, tons of people lose their meniscus when they're teenagers and and they do pretty well for 30 years it takes. So when you do a replacement or any type of intervention, it's great if they're doing well at two years. But you and I know that's just really the tip of the iceberg because these are not two-year problems. You got to get somebody out 10, 12, 15 years to truly know that you have changed. Now if they immediately go on and get arthritis and you know it's not working, that's fine, or you know that's pretty obvious. But to show that it was better than what the natural history was going to be, it takes some time.
Speaker 3:Because the natural history for losing your meniscus a lot of times, a lot of people, is pretty good you know you replace knees, where they lost a meniscus when they were 20, and you're replacing it in their mid-50s, which is not great. You don't love that, but they did 30, 35 years pretty well without it.
Speaker 2:Right, right, and my mom had a open meniscectomy in her late thirties and didn't have her total knee till she was over 65. But yeah, yeah.
Speaker 2:I can cut this part out. While I'm stuttering, I got to figure out where I was going. Yeah, oh, I got it. So I would imagine that, to your point, these studies are already going on. People are looking at this. This is going to be under such tight nda rules that the people that do know about it can't talk about it and the rest of us just got to suspect that it's under serious development and it could start popping out soon. But back to your point. You can imagine the initial clinical trials. It's not like they're going to do clinical trials for six months and then the FDA will release it and we'll just start using it because you have to demonstrate long-term efficacy on this. So this could be released and this could be done in small FDA approved groups while it's waiting for approval. So everybody kind of hears about it but nobody can really use it. Do you see that as the course, or?
Speaker 3:Yeah, that's one of the challenges, and getting any of these products approved is not easy to even begin, you know, in human trials. It's a challenging environment.
Speaker 2:Just to your point, you got to be better than the natural disease, and in many people the natural disease is not all that bad for the initial course. Yeah, interesting. All right, my friend, let's move to those big ligaments in the middle of the knee.
Speaker 3:Yeah. So, as you mentioned, doug, I've spent a lot of time thinking about ligament injuries and in sports medicine we've had some really good multi-center trials on primary ACL reconstruction and revision ACL reconstruction and I think we're pretty comfortable saying that we know that using your own graft, your own tissue, as your replacement when you tear the ACL, the ACL doesn't heal much and we'll get to that in a minute but it doesn't heal naturally on its own. And so if you're going to replace the ACL, then in active young individuals under the age of 20, and as far as we can tell, almost always in the revision setting, you should use your own tissue and that can be patellar tendon, it can be hamstring tendons and now it's become popular to use the quadriceps tendon. We don't have quite the long-term or the size of studies in quadriceps tendon but it's become pretty popular. Over the age of 40, the cadaver grafts are reasonable options and because most people over the age of 40, their activities have changed and they've slowed down In the revision setting we want to use, we have not been able to show that the cadaver ever works quite as well. Part of that is because we don't have quite as many studies going in that area. We may know that someday, but right now you're safest in using your own tissue.
Speaker 3:But a couple people, couple researchers. Martha Murray, who's at Boston Children's chair there, has spent a career slowly, painstakingly, starting in animal studies. Benchtop studies worked on what would it take to repair, meaning stitch together and get the torn ACL to heal on its own. And she's currently in a variety of trials. And some people are out there using it that are not involved with trials. And that's the BEAR which is the Bridge. And that's the bear which is the bridge enhanced ACL repair, which is a scaffolding made out of. I'm about to tell you something I'm pretty sure you won't know, but it is made out of bovine collagen and the cow collagen. Bovine collagen is from New Zealand, because New Zealand is a mad cow disease free continent.
Speaker 3:So you know, you can get completely safe collagen in New Zealand from bovine Y'all name all these ligament trials after the bear moon is moon, mars is ACL.
Speaker 2:Yeah, you guys love these four letter acronyms on these.
Speaker 3:Oh yeah, Yeah's part. You got to give it a recognizable handle. It's marketing there and the bear trial is based on new zealand cows yeah so the the bear uses collagen scaffold built out of collagen that they got from new zealand cows, because those are safe cows, safe cows, yeah, so you. So you, if you're ever in New Zealand, you can eat steak because you know you're not going to get. I don't know how you get mad cow disease, but you're not going to get it in New Zealand.
Speaker 3:But anyway so that that has become a scaffolding and her early trials are very encouraging. I know there's an FDA trial now that is a randomized trial between patellar tendon reconstruction and bare repair and that will. Those results will start to come out, I think, in another year or so and we'll find out if you can repair it as effectively as reconstructing it and we'll start to learn who should get a repair and there are some advantages if you can have it repaired versus a reconstruction. So that's a little bit out there in the future that I think we will have some real answers to that, I know, in the next two years. So that will be good to get some real scientific answers rather than just.
Speaker 3:You know, when you and I were way younger they were just going in and stitching it together and and obviously most of those failed and no one really understood the acl. And then we started replacing it and the modern era of acl reconstruction came on. We've been very successful with that, but not perfect, obviously. No, no operation has been perfect. So finding out who we can repair it in will be good.
Speaker 2:So more to come wow. I imagine that would eventually go to the posterior ligament as well.
Speaker 3:Posterior cruciate yeah, but yes the the pcl a doesn't get injured nearly as commonly and b a lot of the the partial tears do heal. It acts differently than the acl and so I've taken care of several professional athletes with a grade two PCL that actually a couple of them made it to the hall of fame. So it's just a different ligament and and a different scenario so we don't have to operate on PCLs nearly as much.
Speaker 2:Well, thinking like a trauma surgeon, what about these multi-leg knees? Anything in the future? You think that's going to be different, or any way y'all manage those.
Speaker 3:Those are very challenging injuries and I think that what we will continue to refine is the timing, how aggressive to be early on, whether it's better to let things settle down. And I think we have some ideas. I think we will get better at knowing when a repair of some of those ligaments is appropriate and when it's not, because there's been, in certain circumstances, pretty reasonably high failure rate for outside lateral sided reconstructions if if uh as done as a repair when it's not quite appropriate. So I think we're going to get smarter. I'm not sure we're ever going to make that a predictable uh, as predictable as ACL reconstruction and as successful those are. As you know, those are really just terrible injuries, especially in the trauma world. The athletic ones are bad enough, but in the trauma world where literally you can have knee dislocation with three or four ligaments involved is pretty crazy.
Speaker 3:We fortunately don't see that on the athletic fields.
Speaker 2:very often All right, if you'll, let me take the ligament thought and let's move it up to tendons.
Speaker 1:And.
Speaker 2:I think probably the best one to talk about would be cuff right Rotator cuff.
Speaker 3:Yes.
Speaker 2:Where do you see rotator cuff? Go on in the future.
Speaker 3:Well, I think some of the work. Jed Kuhn, who's one of my partners at Vanderbilt, started the Moon Shoulder Group. Jed Kuhn, who's one of my partners at Vanderbilt, started the Moon Shoulder Group which really started out looking at rotator cuff, chronic rotator cuff tears and showed that a lot of those where the patient doesn't have a traumatic event, a lot of those do really well 75, 80% never need an operation. They do well with rehabilitation. I think what we don't have. So that's one subset of patients. Then you've got the patients with a massive rotator cuff tear. They're not that old, they're pretty active and repairing those.
Speaker 3:What we need is and we're starting we've got some products out there that have some promise, but once again something that can fill in that gap, to bridge from the torn tendon to the ball, the humerus, the humeral head, to repair it In the setting of a younger person.
Speaker 3:You know we've swung pretty strongly to doing a lot of reverse shoulder arthroplasties in the setting of massive or chronic rotator cuff tears and, like unfortunately in orthopedics, sometimes the pendulum swings a little too far. We may have swung a little too far that that operation still, you know, no, arthroplasty is a great operation to be done in the truly young, unless you have no other options. And so finding some scaffolding collagen replacement tissue that can bridge a massive tear that's retracted and reconstitute it and give you continuity and give you a functional outcome and get rid of pain, that would allow us to back off from some of the reverse arthroplasties that we're doing. Those products are out there and they're starting to be utilized, and there's been some that have a real potential. Others have not held up as well, but, once again, the human body is pretty amazing and when you try and find something that can substitute for it, you realize just how special the human body is, because it's hard to replace some of these tissues we don't do very well.
Speaker 2:You're also CMO at Vanderbilt.
Speaker 3:Correct.
Speaker 2:You're the Senior Vice President for Clinical Affairs. You're the Chair of the Department of Orthopedics. At some point I'm sure the MBA folks are coming up to you saying, dr Wright, this stuff's ridiculously expensive. What's the value paradigm on this, do you? Because I can imagine any of these scaffolds that are going to come out are exceptionally expensive, which I'm fine with, other than the fact that it does significantly raise up the cost of health care and already put our health care system in need of additional crisis.
Speaker 3:Yes, I think we have to be smart and judicious about when we use these products, and I think when we're doing the routine cases, there are ways where, if you're thoughtful, you can save surgeon-directed costs in the operating room and it's not that hard and I watch, for whatever reason. I've always been pretty cost-effective, been typically the cheapest person doing a procedure, and sometimes we grab some bells and whistles that don't change outcome and we company, we allow the companies go. Oh hey, you know this, this is great, you need to try it. Sometimes we use expensive anchors and when there's really and just as effective, cheaper alternative, and so I think what we need to do is, when we need to spend the money, spend the money, but when you don't need to spend the money, be smarter about saving the money Very well said and at the end of the day we'll be better off and we'll have enough money to, because most of these cases that we're talking about like massive rotator cuff tear that has no other alternatives they're not crazy common.
Speaker 3:So if we have to spend a little more money on that to get it right and people have quality adjusted life years that are really meaningful because they've got a better shoulder, that's great and you and I want to do that and we want to spend that money. But I think it's incumbent upon us to realize that there's X number of healthcare dollars out there and that on the other cases we need to be smart and not spend it if we don't need to. And I think that's really possible if people are thoughtful. And I see it within my own department. We've done some situations where we pick common procedures in each specialty and say and I say, see if you can. I never ask them to sacrifice safety or quality, but I say, see if you can reduce your in-room costs by 10%. And with a little bit of attention they can't. And you make it a little bit of a contest to see how people can reduce costs the most effective way.
Speaker 3:So I think there's money out there to be saved and that will allow us to still spend it when we need to. But I think we all have to be. I think we all have a role and responsibility in healthcare spends of the knowledge on there a lot of times.
Speaker 2:Surgeons can see at the point of care the true cost of their decisions that they make, and then they can weigh in their mind going. I always love losing that thing, but man, it's so expensive. The only reason I'm using this because I like it and the patient doesn't really need it, especially since they're paying for it. I think that could be a good thing. Yeah, allowing that transparency into there. Anything else on rotator cuff?
Speaker 3:No, I mean, we could talk all day, but nothing spectacular, nothing else that we haven't really touched on.
Speaker 2:While we're in the shoulder. Anything else that you see in the future in terms of instability or labrum, anything like that?
Speaker 3:Yeah, I think that we're getting smarter about patients that are at risk for redislocation, even if you operate on them, and that we're getting smarter and more aggressive in taking care of bone loss and Hill Sachs defects and doing things so that the first procedure you do on the patient has a really high chance of success.
Speaker 3:And so and there's been some work with Jed Kuhn's group on that Lots of groups around the world and in this country are really showing that there's just not a lot of bone loss off the glenoid that doesn't increase your risk of recurrence, and you probably need to think about that most of the time in an instability and make sure you're not missing something there, because when these active people go back to their sports or their work and your surgery fails, then you put them through four to six months of recovery and it's pretty devastating. So we're getting way more aggressive and have a much better understanding of when we need to add remplissage, add a bone block, add bone substitutes to make up for bone loss, and I think we'll get smarter and smarter about that get smarter and smarter about that.
Speaker 2:Now, in late October 24, this podcast series released the interview that we did with Dr Jimmy Cook at Mizzou. Jimmy is a veterinarian who has substantial background in biologics. You spent a fair amount of time in Mizzou, but let's back into biologics from your perspective in terms of where sports medicine will be in the world of the biologics you can, you know, you see people talk about things that a lot of times y'all will just be injecting things and nirvana will happen in the knee and everything will be great. Where do you see the, the, the direction of biologics in the application of sports medicine in the next 10, 20 plus years?
Speaker 3:I think use is going to increase. But use is going to increase because we're going to figure out when and where and how and preparation style neutrophilic, low white count, high white count or not. Worry about the white count in your PRP. We will figure out better why it works, when it works, and once we have that then I think you will see if we can get to that point. Then I think you'll see insurance companies be more willing to pay for those treatments and we will be able to use it on more people. Right now it's expensive treatments that are limited to people that can, for the most part, limited to people that can afford it. So I think we'll figure out what arthritic knees actually get benefit from it because while it's expensive, it's cheaper than an arthroplasty. So you know, you and I would much rather have a prp injection if we knew it was going to, knew when it was going to work, than an arthroplasty. So and then, and then soft tissue tendinoses, that sort of thing. You, there's an and and you will find people that just are naysayers and say, oh, it's just a bunch of hocus pocus. But if you look through the literature you will find, you find these pockets of where it's. It's been looked at in really rigorous scientific ways and it works.
Speaker 3:What we've got to do is find and figure out better when there's science behind it. Why did it work? What was the setting, what was the preparation, what was the self? You know, what was the platelet count? There's a lot of things that you just can't draw off blood, spin it down and inject it. You know, I mean, we've got several, obviously several companies with the preparatory materials to for the injections, that's that create different products. We need to figure out which products work in what scenarios and and what the indications are, and then, and then I think you're going to see it even more widely adopted. But we're not quite there yet. To where? Well, maybe Jimmy, jimmy Cook's smart guy, he may have a better idea than me, but I don't think that the typical practicing orthopedist still knows exactly when, where and how to use PRP to be most effective.
Speaker 2:Yeah.
Speaker 3:And all the biologics, and we're going to have more biologics coming down the pipe. But the same questions will exist with each new iteration where, when and why.
Speaker 2:That's where I was going with biologics. So Jimmy talked specifically about PRP and BMAC. Any thoughts about and there's a lot of stuff that's out there, but it certainly hasn't grabbed traction with the truly academic people that are really trying to find the right thing what do you think may be else out there that will join PRP and BIMAC?
Speaker 3:You know everyone, every patient calls both of those products stem cells.
Speaker 2:Oh yeah.
Speaker 3:Which someday we may actually have stem cells, but you know today we were yeah, true stem cells today we don't really so.
Speaker 3:So that you know the, the. You know we saw hyaluronic acid come along. There may be manufactured, which may fall out of the realm of biologic, but but as treatments we may see the ability and you know we may be genetic testing people to figure out you know which of these treatments work for you. I mean, the whole world of the genome is going to change eventually, even affect orthopedics and how we do things. And you know we haven't even scratched the surface with that in our field for the most part.
Speaker 2:Do you think the professional sports teams are pushing these things, or is this going to be mostly the weekend warriors that are generating the pushing to these things?
Speaker 3:No, the professional athlete will really wants that edge Right and so and you just hope that you know what you always hope in dealing with the athletes is that they're getting advice from people that are reasonable and don't lead them astray and send them down a non-scientific, unproven rabbit hole based on anecdotal stuff. So, but they, they, I think they will help keep us pushing, pushing the boundaries on these treatments and coming up with new and better.
Speaker 2:I bet we could do a whole recording on sports performance in the next 10 to 20 years too. How do you think?
Speaker 3:No doubt.
Speaker 2:Yeah, there's a lot going on there too, too, what you just said. You know everybody's pouring money into it to get it there. It's interesting. One of my friends was a botanist. He got his degree and master's degree in botany and he loved trees, but he found out that the money in botany was making grass green for golf courses and it frustrated him greatly. So the stuff he was interested in there was no money going into. So I think it's kind of similar to our field. Sometimes the money goes into the things where they, the investors, see the high return, not necessarily for the disease processes that we want to treat.
Speaker 3:Green grass. I didn't know that.
Speaker 2:Green grass.
Speaker 3:If you think about it, it makes sense.
Speaker 2:It really does. This has been a very interesting discussion with my friend, rick right. Rick is the chief medical officer at Vanderbilt university medical center, senior vice president for clinical affairs. He is the chair of the department of orthopedic surgery and an accomplished and well-known expert in orthopedic sports medicine, giving us his insights of where sports medicine will be in the future. Dr Wright, thank you very much for being on the podcast series, sir.
Speaker 3:I appreciate the invitation. It's been good visiting with you, Doug.
Speaker 1:Yeah, buddy and y'all stay tuned for other futures and orthopedic surgery on this podcast series channel. Thank you.