New Translational Work on DD and Notochordal Cells
While others have done work on back pain and notochordal cells, James Iatridis, Ph.D., is pushing the basic science envelope into the translational arena. Dr. Iatridis, Professor and Director of Spine Research at the Mount Sinai School of Medicine in New York, tells OTW, “Notochordal cells, which are present in the youngest intervertebral discs, produce several factors that may be usable as an injectable therapeutic. Everyone loses these cells as they age, and it is believed that this loss contributes to degenerating discs [DD] and back pain that so many people suffer from. We have an ongoing series of studies looking at how these notochordal cells might be harnessed to help us define and derive therapeutics.”
“In our first paper, a systematic review that was just published in the Global Spine Journal, we describe several targets for therapeutic interventions and candidates that may be useful for treatments. We describe the importance of distinguishing between the structure modifiers that cause matrix breakdown and symptom modifiers that result in painful conditions. Age related changes to the spine involve matrix breakdown, but disc degeneration (DD), which causes a patient to see their doctor is because of pain…which involves neurovascular growth into intervertebral discs. Much of the existing research on DD and therapeutics address matrix breakdown by focusing on promoting matrix regrowth and repair. We think it is also important to address symptom modification—including inhibition of neurovascular ingrowth. We found that the literature suggests some candidates for this work. These include sonic hedgehog, semaphorin 3A, noggin, and other proteins that are highly abundant in notochordal cells.”
“Our next paper, which is just out in Arthritis Research and Therapy, involves a novel culture system where we can induce controlled ‘maturation’ of these notochordal cells to track their loss and to identify proteins useful for disc repair. Following that, we will determine mechanisms for loss of notochordal cells and also use an animal model to screen the efficacy of these treatments for discogenic back pain.”
PRP a “Go” for Tennis Elbow, Knee Osteoarthritis, ACL Reconstructions?
New clarity regarding platelet-rich plasma (PRP)…Wellington K. Hsu, M.D. is the Clifford C. Raisbeck Distinguished Professor of Orthopaedic Surgery and Director of Research in the Department of Orthopaedic Surgery at Northwestern University Feinberg School of Medicine in Chicago. Dr. Hsu and colleagues have just published a review article of over 60 studies in the Journal of the American Academy of Orthopaedic Surgeons examining the use of PRP in orthopedics. Dr. Hsu tells OTW, “Right now we have many opinions on whether PRP should be used for certain orthopedic applications, but this is one of the first studies to provide actual evidence-based guidelines for each of the proposed conditions. We concluded that there are three distinct diseases that could benefit from PRP based on this evidence: tennis elbow, knee OA [osteoarthritis], and ACL [anterior cruciate ligament] reconstructions. Regarding tennis elbow and ACL reconstructions, we found that the bone to tendon healing interface in this biologic environment seems to accommodate the delivery of PRP. In these areas, the PRP is confined and can be localized. As for OA of the knee, it is yet unclear why PRP works well here. There are theories about the anti-inflammatory effects from the growth factor or cell population, but we cannot say for sure.”
“To sort out when exactly PRP will quicken healing we need more level one and level two studies. We have come a long way, however, regarding evidence. As recently as 2011, orthopedic surgeons were frustrated with the fact that patients wanted PRP because some celebrity athlete had used it. The demand for PRP is only increasing, and researchers are responding by looking into evidence to support use in various applications. In the next couple of years we will hopefully see insurance companies taking another look at PRP.”
X-Games Snowboarders: Three Times More Medals Post-Surgery
Joshua Harris, M.D.is a member of the Department of Orthopaedic Surgery at Houston Methodist Orthopedics and Sports Medicine and he tells OTW: “During my sports medicine fellowship at Rush University Medical Center in Chicago my colleagues and I began evaluating the performance and return to skiing and snowboarding in elite winter athletes competing in the Winter X-games. The stresses placed on the knees in these high-level athletes make them a very unique population to study for several reasons. The confounding variables influence the rate of return and performance upon return. These variables include, but are not limited to, contracts, scholarships, endorsements, bonuses, coaches, agents, family, etc. The multifactorial decision-making process for not only the surgery but also return to sport has prompted the Rush group to focus on determining the optimal ACL program from the diagnosis to the surgical treatment to the post-operative rehabilitation with a safe and reliable return to sport.”
“We hypothesized that there would be at least 80% of skiers and snowboarders would be able to successfully return to the X-games. This hypothesis was confirmed—87% of skiers and 70% of snowboarders were able to return to sport. However, what was surprising was that snowboarders actually competed for an additional 7.3 years following surgery (versus skiers who competed for 2.6 years after surgery). Following surgery, skiers earned a similar number of medals (24) compared to pre-injury (22). However, snowboarders earned nearly three times the number of medals (7 versus 19). The difference in length of competition in the X-games (i.e., years of play) is likely the reason to account for why snowboarders earned more medals (1.9 medals per snowboarder) than skiers (1.6 medals per skier) following surgery.”
“Although there is no one specific ‘return to sport’ test that permits safe return to play without any risk, our group at Rush has also developed and implemented a functional sports assessment that tests and optimizes any potential deficiencies in the entire core and lower extremity muscle kinetic chain. The test identifies any ‘weak spots’ that can be improved prior to return to sport to help potentially reduce the risk of repeat knee injury. Future work at both Rush and at Houston Methodist is focused on identifying the optimal patient-, knee-, surgical technique-, and rehabilitation-specific characteristics to safely permit return to sport at the highest performance level possible in all types of athletes. In addition, ACL prevention programs are being integrated into athletes’ workout routines to help reduce the risk of ACL tear.”
Kerlan-Jobe, Santa Monica Group Team Up With Cedars Sinai
The Institute for Sports Sciences (ISS), recently established by the Kerlan-Jobe Orthopaedic Clinic and the Santa Monica Orthopaedic and Sports Medicine Group (SMOG), will be partnering with Cedars-Sinai Medical Center to jointly pursue strategies for leadership in orthopedics and sports medicine regionally, nationally and internationally.
Each of the three entities will continue to see patients in their current locations under each of their respective brands. And while ISS will serve as a management company and play the lead role in managing the clinics, surgery centers and imaging centers associated with the Kerlan-Jobe and SMOG groups, plans for ISS also include coordination of research and clinical trials with Cedars-Sinai, including the advanced use of orthobiologics, and activities related to development of new approaches to orthopedic treatments that minimize surgery whenever possible.
The Institute for Sports Sciences was formed by the two groups and Sovereign Healthcare, a private healthcare management company based in Southern California. Sovereign will remain a management partner with the Institute for Sports Sciences and work closely with the physician leadership and the team from Cedars-Sinai.
Jeremy Hogue, CEO of Sovereign Healthcare and on behalf of the Institute for Sports Sciences, told OTW, “ISS has been in the planning phases for a few years and the hours spent by the physician leadership of both groups have been immense. We’ve evaluated a lot of different opportunities and structures for how we could collaborate. All of us involved see the opportunity to enhance the strengths of the two groups and Cedars-Sinai as well as collaborate on more clinical and research efforts together. There is tremendous synergy, where adding the pieces together makes the whole significantly stronger for all involved.”
“We are optimistic that within one year we will begin seeing some tangible results of putting this vision into action. First and foremost, our goal is to improve patient care by offering more coordinated care across the full spectrum of orthopedic subspecialties so that we can deliver the most advanced and clinically proven treatments to every patient who walks through our doors. These two groups already do this extremely well, but we will always strive to be better. Beyond that, the two groups and Cedars will be working as true partners on everything from research and education efforts, best practices at the clinics and surgery centers to how we approach payers, employers and other third parties where we can offer a lot of value as providers. And last, I would definitely say that we expect significant physician growth in the two groups as well as potentially a third or fourth group that align with the ISS mission. The announcement we made this week is only the beginning.”
