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Mending Injured Athletes

A Track Record of Orthopedic Advances

Lisa Schnirring

THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 9 - SEPTEMBER 2003


Physicians have long been closely allied with competitive sports. In 157 AD, Galen served as a physician to Greek gladiators.1 Severe musculoskeletal trauma certainly shortened the careers of ancient pugilists who survived their matches. However, modern gladiators—from pick-up basketball players to football professionals—often get to "play another day" because of advances in orthopedic surgery, particularly those of the last 30 years.

Treatment Hall of Fame

It's hard to imagine orthopedic sports medicine without arthroscopy. By the late 1990s, orthopedic surgeons in the United States were performing about 700,000 knee and shoulder arthroscopies each year.2,3 Per Renström, MD, PhD, a professor in the Department of Orthopaedic Surgery at the Karolinska Institute in Stockholm, says arthroscopy tops the milestone list for many orthopedic surgeons because it offers not just a portal for diagnosis, but also provides a tool for treatment, particularly for meniscal injuries.

Early mobilization after surgery is another development that has radically changed operative management of sports medicine injuries. Physicians who served in Army rehabilitation hospitals during World War II noticed that soldiers who had walked or moved early had better outcomes. Decades later, many orthopedic surgeons who perform anterior cruciate ligament (ACL) reconstruction have their patients undergo rehabilitation exercises the same day as surgery. "Considering how we operated 25 years ago and kept people in a cast for 6 weeks, today's early mobilization is a major step forward to secure quick return to sport and to recover strength of all tissues of the body," Renström says.

Rehabilitation instead of surgery is a notable development, Renström says, particularly for injuries to the lateral ankle ligaments and the medial collateral ligament of the knee. "These ligaments were operated on 25 years ago, but today they are treated conservatively because of improved knowledge," he says.

Nicholas A. DiNubile, MD, an orthopedic surgeon in private practice in Havertown, Pennsylvania, says that the pace of change in orthopedic surgery has been quick and steady. He notes that though his orthopedic training was excellent, "None of what I do now was in my training. The field is that different," says DiNubile, who serves as orthopedic consultant to the Philadelphia 76ers basketball team and the Pennsylvania Ballet. Newer, better instruments allow for smaller incisions and quicker recoveries for patients, he says, and sports medicine has become a true science. "The fathers of sports medicine provided an anecdotal foundation that has evolved into a science, driven by outcomes and measurement," he says.

Renström adds that soft-tissue endoscopy is a new diagnostic and treatment tool that is speeding return to play for patients who have tendon injuries (eg, Achilles, peroneus longus and brevis, flexor hallucis longus).

Future Clinical Stars

Biologic treatments such as chondrocyte implantation, bone morphogenic protein (BMP), and gene therapy are the future of orthopedic surgery, noted Thomas A. Einhorn, MD, in a historical review compiled by the American Academy of Orthopaedic Surgeons.2 Einhorn is professor and chairman of the Department of Orthopaedic Surgery at Boston University School of Medicine. "The focus of the profession will shift from the development of mechanical implants to the restoration of the musculoskeletal system by regeneration," he noted. "There's nothing wrong with implants, but no matter how well made they are, they are only artificial and they will always be less than ideal."

Orthopedic surgeons have long anguished over the poor prognosis among younger patients who sustain injuries that destroy articular cartilage. Transplanting cultured hyaline cartilage to prevent arthritis once seemed like a science fiction concept, but now the treatment is becoming established in the clinical setting. According to information on the Genzyme Web site (https://www.genzymebiosurgery.com), as of March 2000 nearly 4,000 patients were on the registry as having had the company's Carticel chondrocyte implant treatment.

In 1963, Marshall R. Urist, MD, found that BMP is the key to bone growth.2 It took about 20 years for the medical community to accept the practical applications of BMP. Though not widely used in the sports setting yet, Minnesota Vikings running back Michael Bennett underwent BMP treatment in July for a Jones fracture.3

Transforming Patient Expectations?

Though orthopedic surgeons are vigorously embracing new technologies in their field, they worry that the promise of the new advances may give some patients unrealistic expectations. "This requires improved information and more personal contact with patients," says Renström. DiNubile states that "patients often see newer treatments successfully used on professional athletes, and then they expect they will return to their activities just as quickly. Expectations fuel outcomes, so up-front communication is essential if you want optimal results and happy patients."

One new trend that DiNubile notes are baby boomers who enter their older years in top physical condition. "I'm less hesitant about operating on patients who are 40 or 45 years old and have ACL tears," he says. "This surgery doesn't set people back as much; people want to stay active longer, and newer technology and improved techniques have actually changed our treatment perspective," he says.

References

  1. Medicine through time: prehistory and ancient world. Available at https://www.bbc.co.uk/education/medicine/nonint/prehist/dt/prdtbi3.shtml. Accessed August 4, 2003
  2. Twentieth century orthopaedics. AAOS Bulletin 1999;47(6):35-41
  3. Seifert K: Vikings: Bennett undergoes procedure on foot. Minneapolis Star Tribune. Available at https://www.startribune.com/stories/503/3993974.html. Accessed July 30, 2003

Lisa Schnirring is senior editor of The Physician and Sportsmedicine.


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