July 30, 2025 • 34 mins
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.
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Speaker 1 (00:05):
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
Speaker 2 (00:21):
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
This AOA podcast series willfocus on the future in
orthopedic surgery and theimpact on leaders in our
profession.
These podcasts will focus onthe vast spectrum of change that
(00:41):
will occur in the domains ofculture, employment, technology,
scope of practice, compensationand other areas.
My name is Doug Lundy, host forthis podcast series.
Joining us today is Dr RickWright.
Dr Wright is the Dan SpenglerChair in Orthopedics at
(01:04):
Vanderbilt University.
Dr Wright went to college andmedical school at the University
of Missouri and then he did hisorthopedic surgery residency at
Vanderbilt University MedicalCenter in Nashville, tennessee.
He then went on to do hisfellowship in sports medicine at
the Minneapolis Sports MedicineCenter.
Upon completing his fellowship,he went to the Washington
(01:27):
University School of Medicine in1994 and eventually worked his
way up to become head teamphysician of the St Louis
Cardinals and he worked with theSt Louis Rams and the St Louis
Blues.
He was program director whilehe was at Wash U, which
eventually earned him theDistinguished Educator Award.
He served many differentcommittees and processes within
(01:50):
the American OrthopedicAssociation and eventually
became the 132nd president ofthe AOA.
He was the 66th president ofthe American Board of Orthopedic
Surgery, and his continuedresearch on ACL was eventually
recognized by the Academy withthe 2019-2020 Kappa Delta Award.
(02:16):
So, dr Wright, welcome to thepodcast series, sir.
Thank you, doug.
Good to be here and, as you allprobably hear, rick and I are
very good friends from our timeon the board together.
We've known each other quitewell and go back quite a ways.
I can't think of anybody.
I know a lot of sports medicinepeople but I think you and we
talked about this a little bitahead of time are the right
(02:38):
person at this time to talkabout the future in sports
medicine.
All right, buddy, so put onyour your hat and tell us where
do you think sports medicinewill be 10?
Speaker 3 (02:52):
And, if you're so bold, 20 plus years from now
well, Doug, I'll make someprojections and some predictions
, and I'll probably be wrong onmost of them because a couple of
these I would have made thesame prediction 10 years ago and
it still hadn't come tofruition.
(03:21):
So I'm hoping we can accomplishsome that impact a significant
number of patients, large swathof the population, and may have
some interest.
I think we could start withcartilage, especially in the
knee, although there arecartilage problems throughout
the body.
But I spend more time thinkingabout knee and shoulders so
(03:42):
we'll stay focused there in ourtime together.
But cartilage is at holy grailand in 1994, when I started
practice, I would have said wewill have a cartilage
replacement in the next 10 to 20years.
And here we are, 30 years later, and we don't have.
I mean, we've got some optionsbut we don't have that perfect
(04:05):
replacement.
But I think we're starting tosee there are some reasonable
approaches out there.
People will take small defectsin the knee and do plugs from
another part of the knee totransfer.
I liken it to hair plug surgerywhere you take a plug and put
it where you need it and there'sbeen macy and a variety of
(04:29):
things.
And then there's starting to besome manufactured cartilage
disc.
So there's at least small tomedium defects.
(04:54):
I'm not sure that it's easy tohave an off-the-shelf sitting
around.
And when I'm talking aboutsmall defects, I'm talking about
one to 1.5 centimeter square,moderate defects, two by one,
two by one and a halfcentimeters, where you could put
(05:14):
something into the defect.
And when you see that in ayoung person and it's traumatic
and the rest of the knee isrelatively normal, boy, that can
be a real game changer.
And the ability to go in, findthat defect, suspect it on MRI
maybe, or occasionally find itunsuspecting, somewhat
unsuspecting, and be able to fixit with an off-the-shelf
(05:36):
product.
That will be when we've reallykind of got this answer.
Now, what we don't have andwhat I don't think we'll ever
have, is anything that trulyaddresses the person that has
widespread degenerativearthritis, and we can talk about
that a little later if we talkabout biologics.
So I think that if you said,boy Rick, what would you love?
(06:00):
I'd love to have a costeffective, off the shelf
cartilage defect and, I hope,replacement cartilage,
replacement product, and I hopewe have something like that in
another decade, a realistic,approved in this country you
know there's always thingsfloating around Europe and that
sort of thing but something thatyou can say oh, I had X
(06:22):
procedure, I was able to getback to my activities pretty
quickly and it was veryeffective.
We want to be able to do itarthroscopically eventually, but
that's not a must.
But it would be nice to be offthe shelf, arthroscopic,
immediate weight bearing andeffective and cost effective.
Along with that in that samekind of line would be.
(07:09):
Along with that in that samekind of line would be a meniscus
replacement, because a fairnumber of people will have tears
of their meniscus to the pointwhere they've got a pretty good
joint but they've lost,basically their, a meniscus out,
a cadaver meniscus, but theynever really become a real
meniscus.
And so if you have a terribleACL injury in someone where they
lose their inside or outside,medial or lateral meniscus and
you think they would be bestserved by an allograft, that's
not a patient that you can sayoh and, by the way, yes, you can
go back and play football,soccer, basketball, volleyball
and expect the meniscus to holdup.
(07:31):
It will re-tear because itnever really becomes
vascularized, never reallybecomes completely a part of
them.
So a meniscus replacement thatwould be durable and allow you
to get back to normal activities.
That's a ways off too, but isout there and will be something
that I hope we can come up with.
Speaker 2 (07:52):
Are you aware of the ongoing research in these
cartilage fields that areheading toward that?
I'm sure they're under highhigh NDAs, but you know.
Speaker 3 (08:04):
Yeah.
Speaker 2 (08:05):
Stuff's being done.
Speaker 3 (08:06):
Yes, and there are some decent products that really
usually get their start inEurope and there's some
scaffolds for meniscus out there, there's some highland, there's
cartilage replacement disc andsituations that are out there
that I don't think is that faraway that we may be able to use
use on a more widespread basisso help a knuckle dragon trauma
(08:28):
guy understand here.
Speaker 2 (08:29):
So for these small and medium-sized defects, is
this almost like a, a skin graftreplacement or something like
that on there on the back thatwe open up and y'all take in and
cut it to fit and put it inthere?
Is it a toothpaste that youinject into the chondral defect
or what, what?
Where you see this?
Speaker 3 (08:47):
It's probably going to end up for most of the time.
The best would be somethingthat is solid and you trim it up
and you implant it and it'spretty readily ready to go
pretty quickly.
Speaker 2 (09:00):
Okay, and it eventually turns into highland
cartilage.
Okay, and it eventually turnsinto highland cartilage?
Speaker 3 (09:05):
Yeah, and holds up like highland cartilage.
The problem.
The problem is that you'redealing with something that is
slicker than Teflon, slickerthan ice on ice, takes millions
of cycles and doesn't break down.
Speaker 1 (09:18):
Right.
Speaker 3 (09:19):
So replacing that, you know, replacing what the
human body made, is just,fundamentally, we, fundamentally
we can't come up with somethingthat good.
It's really a challenge.
Speaker 2 (09:28):
I have a feeling you've said that phrase to
patients along the way.
I'm sure.
Yeah, that's not the first timeI've told them that yeah, but it
tells them, like, look, this isnot because I'm sure they, as
my patients, do have convenientoptions 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
(09:53):
you're talking about meniscalreplacements and you're saying
that the allografts don't quitereplace the defective amnestics
meniscus, they don't become anew meniscus.
How would a synthetic meniscusdo that?
Are you talking about likesynthetic meniscus?
They don't become a newmeniscus.
How would a synthetic meniscusdo that?
Are you talking about likesynthetic menisci or something
that somehow is biologic enoughthat, through substitution or
(10:13):
whatever, the patient will adoptit as their own?
Speaker 3 (10:16):
Yeah, realistically, a scaffold that becomes
substituted and ingrown would bethe best product.
Not easy, but that would be thebest.
I think the best product forwhat we need.
Speaker 2 (10:29):
I could see stuff like this literally turning the
entire industry on its ear andseizing massive, massive market
share overnight, but the cost ofthese things would just be
astronomic't they?
Speaker 3 (10:44):
yes, probably because the r&d is so expensive that
it's right.
You know companies need torecoup their, their r&d and and
and they're in it.
You know they they need somemargins.
So it is tough and the theother thing with meniscus
research and looking at atlosing the meniscus is that I
(11:07):
mean you're well aware of thiseven in trauma or joint
replacement or whatever you know, tons of people lose their
meniscus when they're teenagersand and they do pretty well for
30 years it takes.
So when you do a replacement orany type of intervention, it's
great if they're doing well attwo years.
But you and I know that's justreally the tip of the iceberg
(11:29):
because these are not two-yearproblems.
You got to get somebody out 10,12, 15 years to truly know that
you have changed.
Now if they immediately go onand 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 betterthan what the natural history
was going to be, it takes sometime.
(11:50):
Because the natural history forlosing your meniscus a lot of
times, a lot of people, ispretty good you know you replace
knees, where they lost ameniscus when they were 20, and
you're replacing it in theirmid-50s, which is not great.
You don't love that, but theydid 30, 35 years pretty well
without it.
Speaker 2 (12:06):
Right, right, and my mom had a open meniscectomy in
her late thirties and didn'thave her total knee till she was
over 65.
But yeah, yeah.
I can cut this part out.
While I'm stuttering, I got tofigure out where I was going.
Yeah, oh, I got it.
So I would imagine that, toyour point, these studies are
(12:30):
already going on.
People are looking at this.
This is going to be under suchtight nda rules that the people
that do know about it can't talkabout it and the rest of us
just got to suspect that it'sunder serious development and it
could start popping out soon.
But back to your point.
You can imagine the initialclinical trials.
(12:53):
It's not like they're going todo clinical trials for six
months and then the FDA willrelease it and we'll just start
using it because you have todemonstrate long-term efficacy
on this.
So this could be released andthis could be done in small FDA
approved groups while it'swaiting for approval.
So everybody kind of hearsabout it but nobody can really
use it.
Do you see that as the course,or?
Speaker 3 (13:11):
Yeah, that's one of the challenges, and getting any
of these products approved isnot easy to even begin, you know
, in human trials.
It's a challenging environment.
Speaker 2 (13:23):
Just to your point, you got to be better than the
natural disease, and in manypeople the natural disease is
not all that bad for the initialcourse.
Yeah, interesting.
All right, my friend, let'smove to those big ligaments in
the middle of the knee.
Speaker 3 (13:37):
Yeah.
So, as you mentioned, doug,I've spent a lot of time
thinking about ligament injuriesand in sports medicine we've
had some really goodmulti-center trials on primary
ACL reconstruction and revisionACL reconstruction and I think
we're pretty comfortable sayingthat we know that using your own
(14:03):
graft, your own tissue, as yourreplacement when you tear the
ACL, the ACL doesn't heal muchand we'll get to that in a
minute but it doesn't healnaturally on its own.
And so if you're going toreplace the ACL, then in active
young individuals under the ageof 20, and as far as we can tell
(14:26):
, almost always in the revisionsetting, you should use your own
tissue and that can be patellartendon, it can be hamstring
tendons and now it's becomepopular to use the quadriceps
tendon.
We don't have quite thelong-term or the size of studies
in quadriceps tendon but it'sbecome pretty popular.
Over the age of 40, the cadavergrafts are reasonable options
(14:50):
and because most people over theage of 40, their activities
have changed and they've sloweddown In the revision setting we
want to use, we have not beenable to show that the cadaver
ever works quite as well.
Part of that is because wedon't have quite as many studies
going in that area.
We may know that someday, butright now you're safest in using
your own tissue.
(15:11):
But a couple people, coupleresearchers.
Martha Murray, who's at BostonChildren's chair there, has
spent a career slowly,painstakingly, starting in
animal studies.
Benchtop studies worked on whatwould it take to repair,
(15:31):
meaning stitch together and getthe torn ACL to heal on its own.
And she's currently in avariety of trials.
And some people are out thereusing it that are not involved
with trials.
And that's the BEAR which isthe Bridge.
And that's the bear which isthe bridge enhanced ACL repair,
which is a scaffolding made outof.
I'm about to tell you somethingI'm pretty sure you won't know,
(15:54):
but it is made out of bovinecollagen and the cow collagen.
Bovine collagen is from NewZealand, because New Zealand is
a mad cow disease free continent.
So you know, you can getcompletely safe collagen in New
Zealand from bovine Y'all nameall these ligament trials after
(16:17):
the bear moon is moon, mars isACL.
Speaker 2 (16:22):
Yeah, you guys love these four letter acronyms on
these.
Speaker 3 (16:25):
Oh yeah, Yeah's part.
You got to give it arecognizable handle.
It's marketing there and thebear trial is based on new
zealand cows yeah so the thebear uses collagen scaffold
built out of collagen that theygot from new zealand cows,
because those are safe cows,safe cows, yeah, so you.
(16:46):
So you, if you're ever in NewZealand, you can eat steak
because you know you're notgoing to get.
I don't know how you get madcow disease, but you're not
going to get it in New Zealand.
But anyway so that that hasbecome a scaffolding and her
early trials are veryencouraging.
I know there's an FDA trial nowthat is a randomized trial
between patellar tendonreconstruction and bare repair
(17:08):
and that will.
Those results will start tocome out, I think, in another
year or so and we'll find out ifyou can repair it as
effectively as reconstructing itand we'll start to learn who
should get a repair and thereare some advantages if you can
have it repaired versus areconstruction.
So that's a little bit outthere in the future that I think
(17:30):
we will have some real answersto that, I know, in the next two
years.
So that will be good to getsome real scientific answers
rather than just.
You know, when you and I wereway younger they were just going
in and stitching it togetherand and obviously most of those
failed and no one reallyunderstood the acl.
(17:51):
And then we started replacingit and the modern era of acl
reconstruction came on.
We've been very successful withthat, but not perfect,
obviously.
No, no operation has beenperfect.
So finding out who we canrepair it in will be good.
Speaker 2 (18:04):
So more to come wow.
I imagine that would eventuallygo to the posterior ligament as
well.
Speaker 3 (18:11):
Posterior cruciate yeah, but yes the the pcl a
doesn't get injured nearly ascommonly and b a lot of the the
partial tears do heal.
It acts differently than theacl and so I've taken care of
several professional athleteswith a grade two PCL that
(18:33):
actually a couple of them madeit to the hall of fame.
So it's just a differentligament and and a different
scenario so we don't have tooperate on PCLs nearly as much.
Speaker 2 (18:44):
Well, thinking like a trauma surgeon, what about
these multi-leg knees?
Anything in the future?
You think that's going to bedifferent, or any way y'all
manage those.
Speaker 3 (18:54):
Those are very challenging injuries and I think
that what we will continue torefine 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 atknowing when a repair of some of
(19:17):
those ligaments is appropriateand when it's not, because
there's been, in certaincircumstances, pretty reasonably
high failure rate for outsidelateral sided reconstructions if
if uh as done as a repair whenit's not quite appropriate.
So I think we're going to getsmarter.
I'm not sure we're ever goingto make that a predictable uh,
(19:39):
as predictable as ACLreconstruction and as successful
those are.
As you know, those are reallyjust terrible injuries,
especially in the trauma world.
The athletic ones are badenough, but in the trauma world
where literally you can haveknee dislocation with three or
four ligaments involved ispretty crazy.
We fortunately don't see that onthe athletic fields.
Speaker 2 (19:59):
very often All right, if you'll, let me take the
ligament thought and let's moveit up to tendons.
Speaker 1 (20:07):
And.
Speaker 2 (20:07):
I think probably the best one to talk about would be
cuff right Rotator cuff.
Speaker 3 (20:11):
Yes.
Speaker 2 (20:12):
Where do you see rotator cuff?
Go on in the future.
Speaker 3 (20:19):
Well, I think some of the work.
Jed Kuhn, who's one of mypartners at Vanderbilt, started
the Moon Shoulder Group.
Jed Kuhn, who's one of mypartners at Vanderbilt, started
the Moon Shoulder Group whichreally started out looking at
rotator cuff, chronic rotatorcuff tears and showed that a lot
of those where the patientdoesn't have a traumatic event,
a lot of those do really well 75, 80% never need an operation.
(20:40):
They do well withrehabilitation.
I think what we don't have.
So that's one subset ofpatients.
Then you've got the patientswith a massive rotator cuff tear
.
They're not that old, they'repretty active and repairing
those.
What we need is and we'restarting we've got some products
out there that have somepromise, but once again
(21:04):
something that can fill in thatgap, to bridge from the torn
tendon to the ball, the humerus,the humeral head, to repair it
In the setting of a youngerperson.
You know we've swung prettystrongly to doing a lot of
reverse shoulder arthroplastiesin the setting of massive or
(21:25):
chronic rotator cuff tears and,like unfortunately in
orthopedics, sometimes thependulum swings a little too far
.
We may have swung a little toofar that that operation still,
you know, no, arthroplasty is agreat operation to be done in
the truly young, unless you haveno other options.
And so finding some scaffoldingcollagen replacement tissue
(21:49):
that can bridge a massive tearthat's retracted and
reconstitute it and give youcontinuity and give you a
functional outcome and get ridof pain, that would allow us to
back off from some of thereverse arthroplasties that
we're doing.
Those products are out thereand they're starting to be
utilized, and there's been somethat have a real potential.
(22:12):
Others have not held up as well, but, once again, the human
body is pretty amazing and whenyou try and find something that
can substitute for it, yourealize just how special the
human body is, because it's hardto replace some of these
tissues we don't do very well.
Speaker 2 (22:31):
You're also CMO at Vanderbilt.
Speaker 3 (22:33):
Correct.
Speaker 2 (22:34):
You're the Senior Vice President for Clinical
Affairs.
You're the Chair of theDepartment of Orthopedics.
At some point I'm sure the MBAfolks are coming up to you
saying, dr Wright, this stuff'sridiculously expensive.
What's the value paradigm onthis, do you?
Because I can imagine any ofthese scaffolds that are going
to come out are exceptionallyexpensive, which I'm fine with,
(22:57):
other than the fact that it doessignificantly raise up the cost
of health care and already putour health care system in need
of additional crisis.
Speaker 3 (23:14):
Yes, I think we have to be smart and judicious about
when we use these products, andI think when we're doing the
routine cases, there are wayswhere, if you're thoughtful, you
can save surgeon-directed costsin the operating room and it's
not that hard and I watch, forwhatever reason.
I've always been prettycost-effective, been typically
(23:37):
the cheapest person doing aprocedure, and sometimes we grab
some bells and whistles thatdon't change outcome and we
company, we allow the companiesgo.
Oh hey, you know this, this isgreat, you need to try it.
Sometimes we use expensiveanchors and when there's really
and just as effective, cheaperalternative, and so I think what
(24:00):
we need to do is, when we needto spend the money, spend the
money, but when you don't needto spend the money, be smarter
about saving the money Very wellsaid and at the end of the day
we'll be better off and we'llhave enough money to, because
most of these cases that we'retalking about like massive
rotator cuff tear that has noother alternatives they're not
(24:22):
crazy common.
So if we have to spend a littlemore money on that to get it
right and people have qualityadjusted life years that are
really meaningful becausethey've got a better shoulder,
that's great and you and I wantto do that and we want to spend
that money.
But I think it's incumbent uponus to realize that there's X
number of healthcare dollars outthere and that on the other
(24:45):
cases we need to be smart andnot spend it if we don't need to
.
And I think that's reallypossible if people are
thoughtful.
And I see it within my owndepartment.
We've done some situationswhere we pick common procedures
in each specialty and say and Isay, see if you can.
I never ask them to sacrificesafety or quality, but I say,
(25:08):
see if you can reduce yourin-room costs by 10%.
And with a little bit ofattention they can't.
And you make it a little bit ofa contest to see how people can
reduce costs the most effectiveway.
So I think there's money outthere to be saved and that will
allow us to still spend it whenwe need to.
But I think we all have to be.
(25:29):
I think we all have a role andresponsibility in healthcare
spends of the knowledge on therea lot of times.
Speaker 2 (25:36):
Surgeons can see at the point of care the true cost
of their decisions that theymake, 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 thisbecause I like it and the
(25:57):
patient doesn't really need it,especially since they're paying
for it.
I think that could be a goodthing.
Yeah, allowing thattransparency into there.
Anything else on rotator cuff?
Speaker 3 (26:10):
No, I mean, we could talk all day, but nothing
spectacular, nothing else thatwe haven't really touched on.
Speaker 2 (26:16):
While we're in the shoulder.
Anything else that you see inthe future in terms of
instability or labrum, anythinglike that?
Speaker 3 (26:24):
Yeah, I think that we're getting smarter about
patients that are at risk forredislocation, even if you
operate on them, and that we'regetting smarter and more
aggressive in taking care ofbone loss and Hill Sachs defects
and doing things so that thefirst procedure you do on the
(26:45):
patient has a really high chanceof success.
And so and there's been somework with Jed Kuhn's group on
that Lots of groups around theworld and in this country are
really showing that there's justnot a lot of bone loss off the
glenoid that doesn't increaseyour risk of recurrence, and you
(27:07):
probably need to think aboutthat most of the time in an
instability and make sure you'renot missing something there,
because when these active peoplego back to their sports or
their work and your surgeryfails, then you put them through
four to six months of recoveryand it's pretty devastating.
(27:28):
So we're getting way moreaggressive and have a much
better understanding of when weneed to add remplissage, add a
bone block, add bone substitutesto make up for bone loss, and I
think we'll get smarter andsmarter about that get smarter
(27:51):
and smarter about that.
Speaker 2 (27:52):
Now, in late October 24, this podcast series released
the interview that we did withDr Jimmy Cook at Mizzou.
Jimmy is a veterinarian who hassubstantial background in
biologics.
You spent a fair amount of timein Mizzou, but let's back into
biologics from your perspectivein terms of where sports
medicine will be in the world ofthe biologics you can, you know
(28:14):
, you see people talk aboutthings that a lot of times y'all
will just be injecting thingsand nirvana will happen in the
knee and everything will begreat.
Where do you see the, the, thedirection of biologics in the
application of sports medicinein the next 10, 20 plus years?
Speaker 3 (28:31):
I think use is going to increase.
But use is going to increasebecause we're going to figure
out when and where and how andpreparation style neutrophilic,
low white count, high whitecount or not.
Worry about the white count inyour PRP.
We will figure out better whyit works, when it works, and
(28:55):
once we have that then I thinkyou will see if we can get to
that point.
Then I think you'll seeinsurance companies be more
willing to pay for thosetreatments and we will be able
to use it on more people.
Right now it's expensivetreatments that are limited to
(29:17):
people that can, for the mostpart, limited to people that can
afford it.
So I think we'll figure outwhat arthritic knees actually
get benefit from it becausewhile it's expensive, it's
cheaper than an arthroplasty.
So you know, you and I wouldmuch rather have a prp injection
if we knew it was going to,knew when it was going to work,
(29:38):
than an arthroplasty.
So and then, and then softtissue tendinoses, that sort of
thing.
You, there's an and and youwill find people that just are
naysayers and say, oh, it's justa bunch of hocus pocus.
But if you look through theliterature you will find, you
find these pockets of where it's.
(29:58):
It's been looked at in reallyrigorous scientific ways and it
works.
What we've got to do is find andfigure out better when there's
science behind it.
Why did it work?
What was the setting, what wasthe preparation, what was the
(30:19):
self?
You know, what was the plateletcount?
There's a lot of things thatyou just can't draw off blood,
spin it down and inject it.
You know, I mean, we've gotseveral, obviously several
companies with the preparatorymaterials to for the injections,
that's that create differentproducts.
We need to figure out whichproducts work in what scenarios
and and what the indications are, and then, and then I think
(30:42):
you're going to see it even morewidely adopted.
But we're not quite there yet.
To where?
Well, maybe Jimmy, jimmy Cook'ssmart guy, he may have a better
idea than me, but I don't thinkthat the typical practicing
orthopedist still knows exactlywhen, where and how to use PRP
to be most effective.
Speaker 2 (31:01):
Yeah.
Speaker 3 (31:02):
And all the biologics , and we're going to have more
biologics coming down the pipe.
But the same questions willexist with each new iteration
where, when and why.
Speaker 2 (31:11):
That's where I was going with biologics.
So Jimmy talked specificallyabout PRP and BMAC.
Any thoughts about and there'sa lot of stuff that's out there,
but it certainly hasn't grabbedtraction with the truly
academic people that are reallytrying to find the right thing
what do you think may be elseout there that will join PRP and
BIMAC?
Speaker 3 (31:33):
You know everyone, every patient calls both of
those products stem cells.
Speaker 2 (31:36):
Oh yeah.
Speaker 3 (31:39):
Which someday we may actually have stem cells, but
you know today we were yeah,true stem cells today we don't
really so.
So that you know the, the.
You know we saw hyaluronic acidcome along.
There may be manufactured,which may fall out of the realm
of biologic, but but astreatments we may see the
(32:02):
ability and you know we may begenetic testing people to figure
out you know which of thesetreatments work for you.
I mean, the whole world of thegenome is going to change
eventually, even affectorthopedics and how we do things
.
And you know we haven't evenscratched the surface with that
(32:22):
in our field for the most part.
Speaker 2 (32:24):
Do you think the professional sports teams are
pushing these things, or is thisgoing to be mostly the weekend
warriors that are generating thepushing to these things?
Speaker 3 (32:36):
No, the professional athlete will really wants that
edge Right and so and you justhope that you know what you
always hope in dealing with theathletes is that they're getting
advice from people that arereasonable and don't lead them
astray and send them down anon-scientific, unproven rabbit
(32:57):
hole based on anecdotal stuff.
So, but they, they, I thinkthey will help keep us pushing,
pushing the boundaries on thesetreatments and coming up with
new and better.
Speaker 2 (33:09):
I bet we could do a whole recording on sports
performance in the next 10 to 20years too.
How do you think?
Speaker 3 (33:14):
No doubt.
Speaker 2 (33:15):
Yeah, there's a lot going on there too, too, what
you just said.
You know everybody's pouringmoney into it to get it there.
It's interesting.
One of my friends was abotanist.
He got his degree and master'sdegree in botany and he loved
trees, but he found out that themoney in botany was making
grass green for golf courses andit frustrated him greatly.
(33:37):
So the stuff he was interestedin there was no money going into
.
So I think it's kind of similarto our field.
Sometimes the money goes intothe things where they, the
investors, see the high return,not necessarily for the disease
processes that we want to treat.
Speaker 3 (33:52):
Green grass.
I didn't know that.
Speaker 2 (33:55):
Green grass.
Speaker 3 (33:56):
If you think about it , it makes sense.
Speaker 2 (33:58):
It really does.
This has been a veryinteresting discussion with my
friend, rick right.
Rick is the chief medicalofficer at Vanderbilt university
medical center, senior vicepresident for clinical affairs.
He is the chair of thedepartment of orthopedic surgery
and an accomplished andwell-known expert in orthopedic
sports medicine, giving us hisinsights of where sports
(34:19):
medicine will be in the future.
Dr Wright, thank you very muchfor being on the podcast series,
sir.
Speaker 3 (34:25):
I appreciate the invitation.
It's been good visiting withyou, Doug.
Speaker 1 (34:36):
Yeah, buddy and y'all stay tuned for other futures
and orthopedic surgery on thispodcast series channel.
Thank you.
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
Speaker 2 (00:21):
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
This AOA podcast series willfocus on the future in
orthopedic surgery and theimpact on leaders in our
profession.
These podcasts will focus onthe vast spectrum of change that
(00:41):
will occur in the domains ofculture, employment, technology,
scope of practice, compensationand other areas.
My name is Doug Lundy, host forthis podcast series.
Joining us today is Dr RickWright.
Dr Wright is the Dan SpenglerChair in Orthopedics at
(01:04):
Vanderbilt University.
Dr Wright went to college andmedical school at the University
of Missouri and then he did hisorthopedic surgery residency at
Vanderbilt University MedicalCenter in Nashville, tennessee.
He then went on to do hisfellowship in sports medicine at
the Minneapolis Sports MedicineCenter.
Upon completing his fellowship,he went to the Washington
(01:27):
University School of Medicine in1994 and eventually worked his
way up to become head teamphysician of the St Louis
Cardinals and he worked with theSt Louis Rams and the St Louis
Blues.
He was program director whilehe was at Wash U, which
eventually earned him theDistinguished Educator Award.
He served many differentcommittees and processes within
(01:50):
the American OrthopedicAssociation and eventually
became the 132nd president ofthe AOA.
He was the 66th president ofthe American Board of Orthopedic
Surgery, and his continuedresearch on ACL was eventually
recognized by the Academy withthe 2019-2020 Kappa Delta Award.
(02:16):
So, dr Wright, welcome to thepodcast series, sir.
Thank you, doug.
Good to be here and, as you allprobably hear, rick and I are
very good friends from our timeon the board together.
We've known each other quitewell and go back quite a ways.
I can't think of anybody.
I know a lot of sports medicinepeople but I think you and we
talked about this a little bitahead of time are the right
(02:38):
person at this time to talkabout the future in sports
medicine.
All right, buddy, so put onyour your hat and tell us where
do you think sports medicinewill be 10?
Speaker 3 (02:52):
And, if you're so bold, 20 plus years from now
well, Doug, I'll make someprojections and some predictions
, and I'll probably be wrong onmost of them because a couple of
these I would have made thesame prediction 10 years ago and
it still hadn't come tofruition.
(03:21):
So I'm hoping we can accomplishsome that impact a significant
number of patients, large swathof the population, and may have
some interest.
I think we could start withcartilage, especially in the
knee, although there arecartilage problems throughout
the body.
But I spend more time thinkingabout knee and shoulders so
(03:42):
we'll stay focused there in ourtime together.
But cartilage is at holy grailand in 1994, when I started
practice, I would have said wewill have a cartilage
replacement in the next 10 to 20years.
And here we are, 30 years later, and we don't have.
I mean, we've got some optionsbut we don't have that perfect
(04:05):
replacement.
But I think we're starting tosee there are some reasonable
approaches out there.
People will take small defectsin the knee and do plugs from
another part of the knee totransfer.
I liken it to hair plug surgerywhere you take a plug and put
it where you need it and there'sbeen macy and a variety of
(04:29):
things.
And then there's starting to besome manufactured cartilage
disc.
So there's at least small tomedium defects.
(04:54):
I'm not sure that it's easy tohave an off-the-shelf sitting
around.
And when I'm talking aboutsmall defects, I'm talking about
one to 1.5 centimeter square,moderate defects, two by one,
two by one and a halfcentimeters, where you could put
(05:14):
something into the defect.
And when you see that in ayoung person and it's traumatic
and the rest of the knee isrelatively normal, boy, that can
be a real game changer.
And the ability to go in, findthat defect, suspect it on MRI
maybe, or occasionally find itunsuspecting, somewhat
unsuspecting, and be able to fixit with an off-the-shelf
(05:36):
product.
That will be when we've reallykind of got this answer.
Now, what we don't have andwhat I don't think we'll ever
have, is anything that trulyaddresses the person that has
widespread degenerativearthritis, and we can talk about
that a little later if we talkabout biologics.
So I think that if you said,boy Rick, what would you love?
(06:00):
I'd love to have a costeffective, off the shelf
cartilage defect and, I hope,replacement cartilage,
replacement product, and I hopewe have something like that in
another decade, a realistic,approved in this country you
know there's always thingsfloating around Europe and that
sort of thing but something thatyou can say oh, I had X
(06:22):
procedure, I was able to getback to my activities pretty
quickly and it was veryeffective.
We want to be able to do itarthroscopically eventually, but
that's not a must.
But it would be nice to be offthe shelf, arthroscopic,
immediate weight bearing andeffective and cost effective.
Along with that in that samekind of line would be.
(07:09):
Along with that in that samekind of line would be a meniscus
replacement, because a fairnumber of people will have tears
of their meniscus to the pointwhere they've got a pretty good
joint but they've lost,basically their, a meniscus out,
a cadaver meniscus, but theynever really become a real
meniscus.
And so if you have a terribleACL injury in someone where they
lose their inside or outside,medial or lateral meniscus and
you think they would be bestserved by an allograft, that's
not a patient that you can sayoh and, by the way, yes, you can
go back and play football,soccer, basketball, volleyball
and expect the meniscus to holdup.
(07:31):
It will re-tear because itnever really becomes
vascularized, never reallybecomes completely a part of
them.
So a meniscus replacement thatwould be durable and allow you
to get back to normal activities.
That's a ways off too, but isout there and will be something
that I hope we can come up with.
Speaker 2 (07:52):
Are you aware of the ongoing research in these
cartilage fields that areheading toward that?
I'm sure they're under highhigh NDAs, but you know.
Speaker 3 (08:04):
Yeah.
Speaker 2 (08:05):
Stuff's being done.
Speaker 3 (08:06):
Yes, and there are some decent products that really
usually get their start inEurope and there's some
scaffolds for meniscus out there, there's some highland, there's
cartilage replacement disc andsituations that are out there
that I don't think is that faraway that we may be able to use
use on a more widespread basisso help a knuckle dragon trauma
(08:28):
guy understand here.
Speaker 2 (08:29):
So for these small and medium-sized defects, is
this almost like a, a skin graftreplacement or something like
that on there on the back thatwe open up and y'all take in and
cut it to fit and put it inthere?
Is it a toothpaste that youinject into the chondral defect
or what, what?
Where you see this?
Speaker 3 (08:47):
It's probably going to end up for most of the time.
The best would be somethingthat is solid and you trim it up
and you implant it and it'spretty readily ready to go
pretty quickly.
Speaker 2 (09:00):
Okay, and it eventually turns into highland
cartilage.
Okay, and it eventually turnsinto highland cartilage?
Speaker 3 (09:05):
Yeah, and holds up like highland cartilage.
The problem.
The problem is that you'redealing with something that is
slicker than Teflon, slickerthan ice on ice, takes millions
of cycles and doesn't break down.
Speaker 1 (09:18):
Right.
Speaker 3 (09:19):
So replacing that, you know, replacing what the
human body made, is just,fundamentally, we, fundamentally
we can't come up with somethingthat good.
It's really a challenge.
Speaker 2 (09:28):
I have a feeling you've said that phrase to
patients along the way.
I'm sure.
Yeah, that's not the first timeI've told them that yeah, but it
tells them, like, look, this isnot because I'm sure they, as
my patients, do have convenientoptions 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
(09:53):
you're talking about meniscalreplacements and you're saying
that the allografts don't quitereplace the defective amnestics
meniscus, they don't become anew meniscus.
How would a synthetic meniscusdo that?
Are you talking about likesynthetic meniscus?
They don't become a newmeniscus.
How would a synthetic meniscusdo that?
Are you talking about likesynthetic menisci or something
that somehow is biologic enoughthat, through substitution or
(10:13):
whatever, the patient will adoptit as their own?
Speaker 3 (10:16):
Yeah, realistically, a scaffold that becomes
substituted and ingrown would bethe best product.
Not easy, but that would be thebest.
I think the best product forwhat we need.
Speaker 2 (10:29):
I could see stuff like this literally turning the
entire industry on its ear andseizing massive, massive market
share overnight, but the cost ofthese things would just be
astronomic't they?
Speaker 3 (10:44):
yes, probably because the r&d is so expensive that
it's right.
You know companies need torecoup their, their r&d and and
and they're in it.
You know they they need somemargins.
So it is tough and the theother thing with meniscus
research and looking at atlosing the meniscus is that I
(11:07):
mean you're well aware of thiseven in trauma or joint
replacement or whatever you know, tons of people lose their
meniscus when they're teenagersand and they do pretty well for
30 years it takes.
So when you do a replacement orany type of intervention, it's
great if they're doing well attwo years.
But you and I know that's justreally the tip of the iceberg
(11:29):
because these are not two-yearproblems.
You got to get somebody out 10,12, 15 years to truly know that
you have changed.
Now if they immediately go onand 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 betterthan what the natural history
was going to be, it takes sometime.
(11:50):
Because the natural history forlosing your meniscus a lot of
times, a lot of people, ispretty good you know you replace
knees, where they lost ameniscus when they were 20, and
you're replacing it in theirmid-50s, which is not great.
You don't love that, but theydid 30, 35 years pretty well
without it.
Speaker 2 (12:06):
Right, right, and my mom had a open meniscectomy in
her late thirties and didn'thave her total knee till she was
over 65.
But yeah, yeah.
I can cut this part out.
While I'm stuttering, I got tofigure out where I was going.
Yeah, oh, I got it.
So I would imagine that, toyour point, these studies are
(12:30):
already going on.
People are looking at this.
This is going to be under suchtight nda rules that the people
that do know about it can't talkabout it and the rest of us
just got to suspect that it'sunder serious development and it
could start popping out soon.
But back to your point.
You can imagine the initialclinical trials.
(12:53):
It's not like they're going todo clinical trials for six
months and then the FDA willrelease it and we'll just start
using it because you have todemonstrate long-term efficacy
on this.
So this could be released andthis could be done in small FDA
approved groups while it'swaiting for approval.
So everybody kind of hearsabout it but nobody can really
use it.
Do you see that as the course,or?
Speaker 3 (13:11):
Yeah, that's one of the challenges, and getting any
of these products approved isnot easy to even begin, you know
, in human trials.
It's a challenging environment.
Speaker 2 (13:23):
Just to your point, you got to be better than the
natural disease, and in manypeople the natural disease is
not all that bad for the initialcourse.
Yeah, interesting.
All right, my friend, let'smove to those big ligaments in
the middle of the knee.
Speaker 3 (13:37):
Yeah.
So, as you mentioned, doug,I've spent a lot of time
thinking about ligament injuriesand in sports medicine we've
had some really goodmulti-center trials on primary
ACL reconstruction and revisionACL reconstruction and I think
we're pretty comfortable sayingthat we know that using your own
(14:03):
graft, your own tissue, as yourreplacement when you tear the
ACL, the ACL doesn't heal muchand we'll get to that in a
minute but it doesn't healnaturally on its own.
And so if you're going toreplace the ACL, then in active
young individuals under the ageof 20, and as far as we can tell
(14:26):
, almost always in the revisionsetting, you should use your own
tissue and that can be patellartendon, it can be hamstring
tendons and now it's becomepopular to use the quadriceps
tendon.
We don't have quite thelong-term or the size of studies
in quadriceps tendon but it'sbecome pretty popular.
Over the age of 40, the cadavergrafts are reasonable options
(14:50):
and because most people over theage of 40, their activities
have changed and they've sloweddown In the revision setting we
want to use, we have not beenable to show that the cadaver
ever works quite as well.
Part of that is because wedon't have quite as many studies
going in that area.
We may know that someday, butright now you're safest in using
your own tissue.
(15:11):
But a couple people, coupleresearchers.
Martha Murray, who's at BostonChildren's chair there, has
spent a career slowly,painstakingly, starting in
animal studies.
Benchtop studies worked on whatwould it take to repair,
(15:31):
meaning stitch together and getthe torn ACL to heal on its own.
And she's currently in avariety of trials.
And some people are out thereusing it that are not involved
with trials.
And that's the BEAR which isthe Bridge.
And that's the bear which isthe bridge enhanced ACL repair,
which is a scaffolding made outof.
I'm about to tell you somethingI'm pretty sure you won't know,
(15:54):
but it is made out of bovinecollagen and the cow collagen.
Bovine collagen is from NewZealand, because New Zealand is
a mad cow disease free continent.
So you know, you can getcompletely safe collagen in New
Zealand from bovine Y'all nameall these ligament trials after
(16:17):
the bear moon is moon, mars isACL.
Speaker 2 (16:22):
Yeah, you guys love these four letter acronyms on
these.
Speaker 3 (16:25):
Oh yeah, Yeah's part.
You got to give it arecognizable handle.
It's marketing there and thebear trial is based on new
zealand cows yeah so the thebear uses collagen scaffold
built out of collagen that theygot from new zealand cows,
because those are safe cows,safe cows, yeah, so you.
(16:46):
So you, if you're ever in NewZealand, you can eat steak
because you know you're notgoing to get.
I don't know how you get madcow disease, but you're not
going to get it in New Zealand.
But anyway so that that hasbecome a scaffolding and her
early trials are veryencouraging.
I know there's an FDA trial nowthat is a randomized trial
between patellar tendonreconstruction and bare repair
(17:08):
and that will.
Those results will start tocome out, I think, in another
year or so and we'll find out ifyou can repair it as
effectively as reconstructing itand we'll start to learn who
should get a repair and thereare some advantages if you can
have it repaired versus areconstruction.
So that's a little bit outthere in the future that I think
(17:30):
we will have some real answersto that, I know, in the next two
years.
So that will be good to getsome real scientific answers
rather than just.
You know, when you and I wereway younger they were just going
in and stitching it togetherand and obviously most of those
failed and no one reallyunderstood the acl.
(17:51):
And then we started replacingit and the modern era of acl
reconstruction came on.
We've been very successful withthat, but not perfect,
obviously.
No, no operation has beenperfect.
So finding out who we canrepair it in will be good.
Speaker 2 (18:04):
So more to come wow.
I imagine that would eventuallygo to the posterior ligament as
well.
Speaker 3 (18:11):
Posterior cruciate yeah, but yes the the pcl a
doesn't get injured nearly ascommonly and b a lot of the the
partial tears do heal.
It acts differently than theacl and so I've taken care of
several professional athleteswith a grade two PCL that
(18:33):
actually a couple of them madeit to the hall of fame.
So it's just a differentligament and and a different
scenario so we don't have tooperate on PCLs nearly as much.
Speaker 2 (18:44):
Well, thinking like a trauma surgeon, what about
these multi-leg knees?
Anything in the future?
You think that's going to bedifferent, or any way y'all
manage those.
Speaker 3 (18:54):
Those are very challenging injuries and I think
that what we will continue torefine 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 atknowing when a repair of some of
(19:17):
those ligaments is appropriateand when it's not, because
there's been, in certaincircumstances, pretty reasonably
high failure rate for outsidelateral sided reconstructions if
if uh as done as a repair whenit's not quite appropriate.
So I think we're going to getsmarter.
I'm not sure we're ever goingto make that a predictable uh,
(19:39):
as predictable as ACLreconstruction and as successful
those are.
As you know, those are reallyjust terrible injuries,
especially in the trauma world.
The athletic ones are badenough, but in the trauma world
where literally you can haveknee dislocation with three or
four ligaments involved ispretty crazy.
We fortunately don't see that onthe athletic fields.
Speaker 2 (19:59):
very often All right, if you'll, let me take the
ligament thought and let's moveit up to tendons.
Speaker 1 (20:07):
And.
Speaker 2 (20:07):
I think probably the best one to talk about would be
cuff right Rotator cuff.
Speaker 3 (20:11):
Yes.
Speaker 2 (20:12):
Where do you see rotator cuff?
Go on in the future.
Speaker 3 (20:19):
Well, I think some of the work.
Jed Kuhn, who's one of mypartners at Vanderbilt, started
the Moon Shoulder Group.
Jed Kuhn, who's one of mypartners at Vanderbilt, started
the Moon Shoulder Group whichreally started out looking at
rotator cuff, chronic rotatorcuff tears and showed that a lot
of those where the patientdoesn't have a traumatic event,
a lot of those do really well 75, 80% never need an operation.
(20:40):
They do well withrehabilitation.
I think what we don't have.
So that's one subset ofpatients.
Then you've got the patientswith a massive rotator cuff tear
.
They're not that old, they'repretty active and repairing
those.
What we need is and we'restarting we've got some products
out there that have somepromise, but once again
(21:04):
something that can fill in thatgap, to bridge from the torn
tendon to the ball, the humerus,the humeral head, to repair it
In the setting of a youngerperson.
You know we've swung prettystrongly to doing a lot of
reverse shoulder arthroplastiesin the setting of massive or
(21:25):
chronic rotator cuff tears and,like unfortunately in
orthopedics, sometimes thependulum swings a little too far
.
We may have swung a little toofar that that operation still,
you know, no, arthroplasty is agreat operation to be done in
the truly young, unless you haveno other options.
And so finding some scaffoldingcollagen replacement tissue
(21:49):
that can bridge a massive tearthat's retracted and
reconstitute it and give youcontinuity and give you a
functional outcome and get ridof pain, that would allow us to
back off from some of thereverse arthroplasties that
we're doing.
Those products are out thereand they're starting to be
utilized, and there's been somethat have a real potential.
(22:12):
Others have not held up as well, but, once again, the human
body is pretty amazing and whenyou try and find something that
can substitute for it, yourealize just how special the
human body is, because it's hardto replace some of these
tissues we don't do very well.
Speaker 2 (22:31):
You're also CMO at Vanderbilt.
Speaker 3 (22:33):
Correct.
Speaker 2 (22:34):
You're the Senior Vice President for Clinical
Affairs.
You're the Chair of theDepartment of Orthopedics.
At some point I'm sure the MBAfolks are coming up to you
saying, dr Wright, this stuff'sridiculously expensive.
What's the value paradigm onthis, do you?
Because I can imagine any ofthese scaffolds that are going
to come out are exceptionallyexpensive, which I'm fine with,
(22:57):
other than the fact that it doessignificantly raise up the cost
of health care and already putour health care system in need
of additional crisis.
Speaker 3 (23:14):
Yes, I think we have to be smart and judicious about
when we use these products, andI think when we're doing the
routine cases, there are wayswhere, if you're thoughtful, you
can save surgeon-directed costsin the operating room and it's
not that hard and I watch, forwhatever reason.
I've always been prettycost-effective, been typically
(23:37):
the cheapest person doing aprocedure, and sometimes we grab
some bells and whistles thatdon't change outcome and we
company, we allow the companiesgo.
Oh hey, you know this, this isgreat, you need to try it.
Sometimes we use expensiveanchors and when there's really
and just as effective, cheaperalternative, and so I think what
(24:00):
we need to do is, when we needto spend the money, spend the
money, but when you don't needto spend the money, be smarter
about saving the money Very wellsaid and at the end of the day
we'll be better off and we'llhave enough money to, because
most of these cases that we'retalking about like massive
rotator cuff tear that has noother alternatives they're not
(24:22):
crazy common.
So if we have to spend a littlemore money on that to get it
right and people have qualityadjusted life years that are
really meaningful becausethey've got a better shoulder,
that's great and you and I wantto do that and we want to spend
that money.
But I think it's incumbent uponus to realize that there's X
number of healthcare dollars outthere and that on the other
(24:45):
cases we need to be smart andnot spend it if we don't need to
.
And I think that's reallypossible if people are
thoughtful.
And I see it within my owndepartment.
We've done some situationswhere we pick common procedures
in each specialty and say and Isay, see if you can.
I never ask them to sacrificesafety or quality, but I say,
(25:08):
see if you can reduce yourin-room costs by 10%.
And with a little bit ofattention they can't.
And you make it a little bit ofa contest to see how people can
reduce costs the most effectiveway.
So I think there's money outthere to be saved and that will
allow us to still spend it whenwe need to.
But I think we all have to be.
(25:29):
I think we all have a role andresponsibility in healthcare
spends of the knowledge on therea lot of times.
Speaker 2 (25:36):
Surgeons can see at the point of care the true cost
of their decisions that theymake, 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 thisbecause I like it and the
(25:57):
patient doesn't really need it,especially since they're paying
for it.
I think that could be a goodthing.
Yeah, allowing thattransparency into there.
Anything else on rotator cuff?
Speaker 3 (26:10):
No, I mean, we could talk all day, but nothing
spectacular, nothing else thatwe haven't really touched on.
Speaker 2 (26:16):
While we're in the shoulder.
Anything else that you see inthe future in terms of
instability or labrum, anythinglike that?
Speaker 3 (26:24):
Yeah, I think that we're getting smarter about
patients that are at risk forredislocation, even if you
operate on them, and that we'regetting smarter and more
aggressive in taking care ofbone loss and Hill Sachs defects
and doing things so that thefirst procedure you do on the
(26:45):
patient has a really high chanceof success.
And so and there's been somework with Jed Kuhn's group on
that Lots of groups around theworld and in this country are
really showing that there's justnot a lot of bone loss off the
glenoid that doesn't increaseyour risk of recurrence, and you
(27:07):
probably need to think aboutthat most of the time in an
instability and make sure you'renot missing something there,
because when these active peoplego back to their sports or
their work and your surgeryfails, then you put them through
four to six months of recoveryand it's pretty devastating.
(27:28):
So we're getting way moreaggressive and have a much
better understanding of when weneed to add remplissage, add a
bone block, add bone substitutesto make up for bone loss, and I
think we'll get smarter andsmarter about that get smarter
(27:51):
and smarter about that.
Speaker 2 (27:52):
Now, in late October 24, this podcast series released
the interview that we did withDr Jimmy Cook at Mizzou.
Jimmy is a veterinarian who hassubstantial background in
biologics.
You spent a fair amount of timein Mizzou, but let's back into
biologics from your perspectivein terms of where sports
medicine will be in the world ofthe biologics you can, you know
(28:14):
, you see people talk aboutthings that a lot of times y'all
will just be injecting thingsand nirvana will happen in the
knee and everything will begreat.
Where do you see the, the, thedirection of biologics in the
application of sports medicinein the next 10, 20 plus years?
Speaker 3 (28:31):
I think use is going to increase.
But use is going to increasebecause we're going to figure
out when and where and how andpreparation style neutrophilic,
low white count, high whitecount or not.
Worry about the white count inyour PRP.
We will figure out better whyit works, when it works, and
(28:55):
once we have that then I thinkyou will see if we can get to
that point.
Then I think you'll seeinsurance companies be more
willing to pay for thosetreatments and we will be able
to use it on more people.
Right now it's expensivetreatments that are limited to
(29:17):
people that can, for the mostpart, limited to people that can
afford it.
So I think we'll figure outwhat arthritic knees actually
get benefit from it becausewhile it's expensive, it's
cheaper than an arthroplasty.
So you know, you and I wouldmuch rather have a prp injection
if we knew it was going to,knew when it was going to work,
(29:38):
than an arthroplasty.
So and then, and then softtissue tendinoses, that sort of
thing.
You, there's an and and youwill find people that just are
naysayers and say, oh, it's justa bunch of hocus pocus.
But if you look through theliterature you will find, you
find these pockets of where it's.
(29:58):
It's been looked at in reallyrigorous scientific ways and it
works.
What we've got to do is find andfigure out better when there's
science behind it.
Why did it work?
What was the setting, what wasthe preparation, what was the
(30:19):
self?
You know, what was the plateletcount?
There's a lot of things thatyou just can't draw off blood,
spin it down and inject it.
You know, I mean, we've gotseveral, obviously several
companies with the preparatorymaterials to for the injections,
that's that create differentproducts.
We need to figure out whichproducts work in what scenarios
and and what the indications are, and then, and then I think
(30:42):
you're going to see it even morewidely adopted.
But we're not quite there yet.
To where?
Well, maybe Jimmy, jimmy Cook'ssmart guy, he may have a better
idea than me, but I don't thinkthat the typical practicing
orthopedist still knows exactlywhen, where and how to use PRP
to be most effective.
Speaker 2 (31:01):
Yeah.
Speaker 3 (31:02):
And all the biologics , and we're going to have more
biologics coming down the pipe.
But the same questions willexist with each new iteration
where, when and why.
Speaker 2 (31:11):
That's where I was going with biologics.
So Jimmy talked specificallyabout PRP and BMAC.
Any thoughts about and there'sa lot of stuff that's out there,
but it certainly hasn't grabbedtraction with the truly
academic people that are reallytrying to find the right thing
what do you think may be elseout there that will join PRP and
BIMAC?
Speaker 3 (31:33):
You know everyone, every patient calls both of
those products stem cells.
Speaker 2 (31:36):
Oh yeah.
Speaker 3 (31:39):
Which someday we may actually have stem cells, but
you know today we were yeah,true stem cells today we don't
really so.
So that you know the, the.
You know we saw hyaluronic acidcome along.
There may be manufactured,which may fall out of the realm
of biologic, but but astreatments we may see the
(32:02):
ability and you know we may begenetic testing people to figure
out you know which of thesetreatments work for you.
I mean, the whole world of thegenome is going to change
eventually, even affectorthopedics and how we do things
.
And you know we haven't evenscratched the surface with that
(32:22):
in our field for the most part.
Speaker 2 (32:24):
Do you think the professional sports teams are
pushing these things, or is thisgoing to be mostly the weekend
warriors that are generating thepushing to these things?
Speaker 3 (32:36):
No, the professional athlete will really wants that
edge Right and so and you justhope that you know what you
always hope in dealing with theathletes is that they're getting
advice from people that arereasonable and don't lead them
astray and send them down anon-scientific, unproven rabbit
(32:57):
hole based on anecdotal stuff.
So, but they, they, I thinkthey will help keep us pushing,
pushing the boundaries on thesetreatments and coming up with
new and better.
Speaker 2 (33:09):
I bet we could do a whole recording on sports
performance in the next 10 to 20years too.
How do you think?
Speaker 3 (33:14):
No doubt.
Speaker 2 (33:15):
Yeah, there's a lot going on there too, too, what
you just said.
You know everybody's pouringmoney into it to get it there.
It's interesting.
One of my friends was abotanist.
He got his degree and master'sdegree in botany and he loved
trees, but he found out that themoney in botany was making
grass green for golf courses andit frustrated him greatly.
(33:37):
So the stuff he was interestedin there was no money going into
.
So I think it's kind of similarto our field.
Sometimes the money goes intothe things where they, the
investors, see the high return,not necessarily for the disease
processes that we want to treat.
Speaker 3 (33:52):
Green grass.
I didn't know that.
Speaker 2 (33:55):
Green grass.
Speaker 3 (33:56):
If you think about it , it makes sense.
Speaker 2 (33:58):
It really does.
This has been a veryinteresting discussion with my
friend, rick right.
Rick is the chief medicalofficer at Vanderbilt university
medical center, senior vicepresident for clinical affairs.
He is the chair of thedepartment of orthopedic surgery
and an accomplished andwell-known expert in orthopedic
sports medicine, giving us hisinsights of where sports
(34:19):
medicine will be in the future.
Dr Wright, thank you very muchfor being on the podcast series,
sir.
Speaker 3 (34:25):
I appreciate the invitation.
It's been good visiting withyou, Doug.
Speaker 1 (34:36):
Yeah, buddy and y'all stay tuned for other futures
and orthopedic surgery on thispodcast series channel.
Thank you.
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