Latest / Becker’s Healthcare Podcast / The Future of Sports Medicine and Orthopedics With Dr. Frank A. Cordasco

Transcript

The Future of Sports Medicine and Orthopedics With Dr. Frank A. Cordasco · Becker’s Healthcare Podcast

0:00
This is Carly Beam with the Becker Spine
0:02
and Orthopedics podcast, and I'm thrilled to be
0:04
joined today by doctor Frank Cordesco
0:06
with Hospital for Special Surgery out in New
0:09
York. Doctor Cordesco, thank you so much for
0:11
being here today.
0:13
It's my pleasure, Carly.
0:15
I'll I'll give you a little brief background
0:17
on my,
0:18
my history. So, again, Frank Cordasco.
0:21
I received my orthopedic surgery residency training at
0:24
Columbia Presbyterian Medical Center, New York Orthopedic Hospital,
0:29
and my shoulder and elbow surgery fellowship training
0:31
thereafter with doctor Charles Neer, also at Columbia
0:35
n NYOH.
0:36
I've spent the majority of my career in
0:38
New York City, initially, as a faculty member
0:41
at Columbia, and then I was recruited to
0:42
the hospital for special surgery by doctor Russell
0:45
Warren,
0:46
where I've been for nearly three decades now.
0:49
I'm an attending orthopedic surgeon at the Sports
0:51
Medicine Institute at HSS as well as a
0:54
senior research scientist at HSS
0:56
and a professor of orthopedic surgery at Weill
0:59
Cornell
1:00
Medicine, which is part of Cornell University.
1:03
And I've served as the thirty fifth president
1:05
of the American Shoulder and Elbow Surgeons from
1:07
2018 to 2019,
1:10
And I'm currently an ex officio member of
1:12
the ASCS executive committee
1:14
as well as the ninth chair of the
1:16
Journal of Shoulder and Elbow Surgery family of
1:18
journals.
1:20
Thank you. And doctor Cordesco,
1:22
I've started wanna start with you. What are
1:24
the top three trends that you're following in
1:27
health care today, whether it's, you know, specific
1:30
to orthopedics
1:32
or just kind of looking overall at health
1:34
care system as a whole?
1:36
Yeah. I think that's an important question, Carly,
1:38
and I think it's pretty clear to anybody
1:40
who follows health care
1:42
and innovation. It's it's really threefold. And I'll
1:45
start by just being specific to health care
1:47
overall, and then perhaps we could delve into
1:49
sports medicine and orthopedics. But, you know, first
1:52
off, AI and automation and care, I think,
1:54
has had a a huge impact already on
1:57
a number of,
1:58
facets of human endeavor,
2:00
specifically medicine.
2:02
And so AI and automation and care is
2:05
rapidly moving into diagnostics, risk prediction, clinical documentation,
2:10
and administrative workflow automation. A lot of this
2:13
has been present now for a few years.
2:15
It's certainly an evolution, and we would expect,
2:19
you know, fairly rapid
2:21
change soon, meaning in the next one, two
2:24
to five years.
2:25
It's being used to read images, flag high
2:28
risk patients, support triage,
2:30
and reduce paperwork so clinicians can spend more
2:33
time with patients.
2:34
On the virtual care and remote monitoring and
2:37
wearables, this is, again,
2:39
amazing technology.
2:41
Obviously, telemedicine
2:42
is now a mainstream access point since the
2:44
pandemic.
2:46
It's especially useful for primary care and behavioral
2:49
health, and it reduces the need for many
2:51
in person visits for these individuals.
2:55
Remote patient monitoring, consumer wearables can feed continuous
2:58
data to clinicians,
3:00
and it enables early detection of deterioration
3:03
or more proactive chronic disease management at home.
3:07
And on the health care delivery system, it's
3:09
it's really personalized and value based care is
3:12
becoming a kind of a transition. So I
3:15
think many health systems around the country,
3:18
perhaps New York as an outlier,
3:20
are shifting from fee for service toward value
3:22
based models.
3:24
Their reward outcomes,
3:26
with coordinated whole person care.
3:29
So I I think that's, you know, specific
3:31
to health care overall,
3:33
using genomics, biomarkers, and individual care
3:36
plans is becoming more and more common, particularly
3:39
in areas like oncology and condition specific
3:43
pathologies and programs.
3:45
So as it relates to what I do,
3:46
I mean, my wheelhouse is,
3:48
I I practice as an orthopedic and sports
3:50
medicine surgeon.
3:52
The three big trends that I just mentioned
3:54
translate into very practical shifts
3:57
in how I diagnose,
3:59
operate upon, and follow athletes back to return
4:02
to sport at their prior level of performance.
4:04
And it's an exciting time. And, again, a
4:06
lot of this is not new. We tend
4:08
to focus on
4:10
what we've been hearing from the media and
4:12
from our financial,
4:14
colleagues, you know, over the last year to
4:16
two. But
4:17
AI and imaging, pathology,
4:19
and,
4:20
even instrumentation in the OR has been present
4:23
already in orthopedics for the last several years,
4:26
even predating COVID.
4:28
I'll start with the imaging side. You know,
4:30
AI and imaging planning and outcomes as it
4:32
relates to imaging.
4:34
AI tools are getting very good at detecting
4:37
fractures, implant loosening,
4:39
osteoarthritis
4:40
severity, and sports injuries such as ACL tears,
4:43
meniscus tears, and rotator cuff
4:45
injuries,
4:46
both with respect to radiographs as well as
4:49
m r with MRI with with very good
4:51
accuracy and some would say approaching MSK radiologists.
4:55
And as you probably know in our field,
4:58
orthopedic surgeons and sports medicine surgeons are often
5:01
reading their own films
5:04
and acting upon these patients within twenty four
5:07
hours with respect to treatment modalities, counseling them
5:10
even before we get a report from the
5:12
radiology service. And and so AI is
5:15
helping in those cases where perhaps more information
5:18
is necessary to be to be accurate and
5:21
manage the athlete effectively.
5:24
So for sports, this means faster reads on
5:26
knee and shoulder MRIs, automated measurements,
5:29
and decision support on, you know, whether we
5:31
proceed with operative or nonoperative care.
5:35
As it relates to planning and intraoperative support,
5:37
I think AI driven templating
5:40
can predict implant sizes, alignment, and patient specific
5:43
plans and is being integrated,
5:45
as I mentioned earlier, into augmented and virtual,
5:49
components within navigation robotics for joint reconstruction
5:53
and complex reconstructive work. I think,
5:56
you know, the low hanging fruit in orthopedics
5:58
has been anything that is that involves bone.
6:02
So total joint replacements,
6:04
spine surgery with pedicle screw instrumentation.
6:07
It's
6:09
a bit easier to manage those patients with,
6:12
preoperative imaging like three d CT scans where
6:15
you can then
6:16
utilize your intraoperative devices with robotics and
6:22
computer instrumentation
6:23
to really support that. I'd have to say
6:25
that my field,
6:27
sports medicine, meaning soft tissue work in terms
6:30
of ligaments and and,
6:32
tendons,
6:34
has has probably been
6:36
a little bit behind for a number of
6:38
reasons. First off, as I mentioned, bone.
6:40
But there are some exciting,
6:42
you know, interests in the future and and
6:45
facets that I think we can touch on
6:46
in a little bit.
6:48
Moving from imaging to planning and intraoperative support,
6:51
I've I've mentioned that complex work, and I
6:54
think arthroscopy and sports procedures
6:57
will,
6:58
over the short term, in the next year
7:00
to five years,
7:01
we can expect more automated recognition of anatomy
7:04
and pathology,
7:06
in arthroscopic video and the use of augmented
7:09
reality guidance over the next few years.
7:12
And then I think the predictive analysis
7:15
models with outcomes and logistics
7:18
are is another exciting aspect of this where
7:21
we can forecast,
7:23
again, on the arthroplasty
7:24
side, length of stay, complications, and readmissions.
7:28
But similar tools are emerging now in my
7:30
areas of ACL, meniscus, and shoulder surgeries on
7:34
the soft tissue side.
7:35
And, obviously, on the practical side for clinics,
7:38
clinic notes, etcetera,
7:40
AI has already,
7:42
used, for example, at my hospital at HSS
7:45
and starting to auto draft clinic notes, op
7:47
notes, and pre op plans,
7:49
which can cut documentation
7:51
time and help with burnout,
7:52
for for many physicians and physicians,
7:56
physician extenders.
7:59
So if we move from there to remote
8:01
monitoring, apps, and data rich rehab, again, this
8:04
is
8:05
really, exciting, and it has already been implemented
8:08
and executed in the last several years, but
8:11
there's more to more to follow.
8:13
So virtual follow-up now is a a stable
8:16
part of my post op care,
8:18
particularly as a,
8:20
a sports surgeon who sees
8:22
athletes from all over the country and in
8:24
some cases all over the world. So,
8:26
historically, prior to the pandemic, it would be
8:29
difficult to
8:30
have those patients
8:32
return to New York and to my office
8:34
to to seek consultation.
8:36
And, typically,
8:38
with an ACL
8:39
reconstruction, for example, we would see patients at
8:41
ten days for wound check,
8:43
one month, two months, three months, four and
8:46
a half months, six months, nine months, and
8:48
twelve months post op, and then a two
8:49
year follow-up.
8:51
And when you're dealing with patients who are
8:53
both domestic and international
8:55
distances from New York,
8:58
this has just been a a game changer
9:00
for us. So now myself,
9:02
my own athletic trainer, and my PA can
9:05
meet in a room, so to speak,
9:07
virtually with an athlete in Seattle or Los
9:09
Angeles
9:11
and their entire
9:12
group of local,
9:13
physical therapists, trainers, and even the team physicians
9:17
in their own training facility. And that's that
9:19
has been a game changer for younger
9:21
mobile patients and long distance athletes.
9:24
Yeah. Yeah. Like, imagine it's especially helpful even,
9:26
like, this week when we are
9:28
recording in January, in the middle of one
9:31
of the biggest, cold front storms in The
9:33
US.
9:35
Absolutely. Without question.
9:37
And it also enables you to to see
9:39
patients
9:40
seven days a week. You know, if if
9:42
they're if you're away at a conference,
9:44
during the middle of the week, you can
9:46
then extend hours for these types of post
9:49
op visits
9:50
into the weekends. Not that, you know, we
9:52
can get into,
9:53
you know, work life and and
9:56
healthy
9:57
wellness aspects in a later on in the
9:59
discussion if you'd like, but I think this
10:02
provides the surgeon and the patient with a
10:04
lot of flexibility in terms of when to
10:06
meet. And, again, these are most helpful, I
10:09
think, postoperatively
10:10
and during the rehabilitation and return to sport
10:13
phases
10:14
where it's so intensive in sports. You know,
10:16
my arthroplasty colleagues,
10:19
don't often require the need to see patients
10:22
as frequently was as we do in soft
10:25
tissue surgery for the obvious reasons.
10:28
So I I think it's been a, as
10:29
I said initially, a game changer.
10:32
As it relates to wearables and sensors, this
10:34
is an exciting area,
10:36
in health care
10:38
overall, as I mentioned earlier. So whether you're
10:40
managing
10:41
a cardiac patient postoperatively
10:44
or more specifically in my field,
10:47
athletes.
10:48
We're now using
10:49
and, again, these we're just touching on this
10:52
at this point from a practicality standpoint, but
10:54
I think the future is going to be
10:56
very exciting as as it relates to the
10:58
so called IMU based systems. These
11:01
are inertial measurement units, which include accelerometers,
11:04
gyroscopes, and often magnetometers.
11:08
To create these systems, they can track range
11:10
of motion, step counts, limb loading, return to
11:12
play metrics
11:14
after the types of surgeries I've discussed. So
11:16
ACL reconstructions, meniscus surgeries,
11:19
shoulder procedures, etcetera.
11:22
And some of these platforms,
11:24
combine sensor data with AI to flag patients
11:27
who, for example, may be lagging in rehab
11:30
or importantly, overloading too early,
11:33
prompting in, you know, earlier intervention from the
11:36
surgeon
11:37
and their therapists and or athletic trainer colleagues.
11:40
Yeah. And, doctor Kolesko, I wanna ask you
11:43
also just kind of touching in on
11:46
some of the some of the biggest innovations
11:48
that you think will, kind of explode in
11:51
2026,
11:52
especially as it relates to sports medicine
11:55
and, you know, these types of surgeries that
11:57
you've been, talking about.
11:59
Well, I think the wearable piece will continue
12:01
to work, you know, very effectively in the
12:04
coming in the coming twelve months.
12:06
We
12:07
you know, as I mentioned, these are available.
12:11
The the issue related to practicality
12:17
ascertained, I think, by and that's mostly
12:20
by
12:21
us.
12:22
So the surgeons have to buy into these
12:24
technologies.
12:25
And I think most of us will. The
12:27
the issue is logistically
12:29
how to implement it,
12:31
how to organize it.
12:33
We haven't really gotten into the costs associated
12:36
with monitoring this data,
12:38
and utilizing the technology. So I think as
12:41
we
12:42
as it's clear we would benefit from these
12:45
regarding the clinical need,
12:47
the the real questions remain,
12:50
again, as it relates to major health care
12:52
delivery systems as to
12:54
how we implement it, how we implement and
12:56
execute. So I think that's a big piece
12:59
over the next
13:00
twelve to twenty four months.
13:03
But technology is there.
13:05
We we didn't talk about digital rehab as
13:08
part of this, again, with respect to return
13:10
to sport.
13:12
So there are did I answer your question,
13:13
Carly? I I wanna make Yes. Yes. This
13:15
is great. Okay. As it relates to app
13:18
based protocols, you know, clearly,
13:21
if you follow any,
13:23
software apps, whether you're whether you utilize Peloton
13:26
or other,
13:28
platforms like that, it's pretty clear that we
13:31
can push exercise videos,
13:33
as well as other aspects like pain and
13:35
function scores and proms directly to dashboards
13:39
that the the athlete and their surgeon and
13:41
the team can review.
13:43
And this can support more standardized pathways for
13:47
common procedures
13:48
and also generate outcomes,
13:51
with respect to registries and our own research
13:54
and quality work. Mhmm.
13:57
Yeah. And then doctor Cortesco,
13:58
one other topic that I really wanted to,
14:01
touch base with you on is biologics
14:04
in orthopedics.
14:06
What what's your perspective on the state of
14:09
biologics in orthopedic care now, and what are
14:12
your predictions for the next two to three
14:14
years?
14:15
Well, again, this has been going on for
14:18
over two decades. If we think back to
14:20
athletes like Kobe Bryant,
14:22
traveling to Dusseldorf to obtain injection treatments, it's,
14:26
you know, this goes back a couple of
14:28
decades.
14:29
It's become much more prominent in The States,
14:33
due to regulatory reforms.
14:35
And, you know, I view biologics
14:37
in in
14:38
a couple of different ways. So as it
14:40
relates to things that we do in the
14:42
office
14:43
to either
14:44
enhance healing for patients we deem to be
14:47
nonoperative
14:48
or to
14:49
promote healing in patients who are postoperative,
14:52
I think most surgeons like myself,
14:55
utilize these on a daily basis in our
14:58
offices and sometimes in our operating rooms.
15:01
So,
15:02
you know, biologics, I think of in
15:05
three basic ways, blood borne,
15:08
bone marrow derived, and,
15:10
adipose tissue.
15:11
And so, for example, if I'm treating a
15:14
younger athlete who has early osteoarthritis
15:17
that is not a surgical problem,
15:19
I might utilize
15:21
a biologic
15:22
to enhance
15:23
pain relief and symptom relief. And I think
15:26
I'll before getting into details, I'll I'll I'll
15:29
sort of qualify this by saying, we wish
15:32
we had more data than we do.
15:35
And I think that's going to explode with
15:37
the help of AI over the next two
15:39
years.
15:40
So historically, we believe that these products can
15:43
help, and we have
15:45
patient data that suggests that it will help,
15:47
but we don't necessarily have the numbers
15:50
for evidence based
15:52
assessment
15:54
that will that would allow health care delivery
15:57
systems
15:57
to feel comfort comfortable reimbursing for it. So
16:00
as you know now,
16:02
most of these techniques are not reimbursable upon,
16:06
rather by health care delivery systems. So the
16:08
onus is on the patient,
16:11
to
16:12
sort of establish these resource allocations, which is
16:15
hard. So as a surgeon, as a clinical
16:18
practitioner,
16:19
it's hard for me to recommend a technology
16:22
that requires the patient to expand a resource
16:25
allocation.
16:27
Having said that, there is data available for,
16:31
for example, PRP
16:33
to manage
16:34
the use of these, techniques
16:37
for early osteoarthritis.
16:39
So there are lots of systematic reviews
16:41
and meta analyses
16:43
that will allow
16:45
us to definitively say
16:47
PRP is better than, for example, viscosupplementation
16:51
for the management of early osteoarthritis.
16:54
And I think that's that's
16:56
an easy lift for most of us because
16:59
the data is there.
17:00
So I I mentioned the management of
17:03
early o a in young athletes.
17:06
There are other aspects,
17:08
and a lot of this, Carly, honestly, is
17:11
joint and disease specific. So we know, for
17:13
example, and we've published on this at HSS,
17:17
that some joints are more responsive and some
17:20
tendon groups are more responsive to the application
17:22
of PRP
17:24
short of surgery. So many of these are
17:26
nonoperative treatments.
17:28
So for example,
17:29
ECRB tendinosis,
17:31
ECRB is the extensor carpi radialis brevis. It's,
17:35
an elbow extensor tendon,
17:37
otherwise known as tennis elbow. The same can
17:40
be said of the common flexor tendon group,
17:43
so called,
17:45
golfer's elbow.
17:46
These these
17:48
treatments like platelet rich plasma have been shown
17:51
to be helpful
17:52
in Mhmm. Our own research and the research
17:54
of others.
17:55
And if you contrast that, for example, with
17:58
rotator cuff
17:59
tears or tendinosis,
18:03
the the application of PRP has probably been
18:05
less useful in that setting.
18:07
So without getting into
18:10
the weeds, so to speak, I I I
18:12
wanna make it clear
18:13
that there are differences
18:15
among
18:16
tendon groups
18:18
within
18:19
the human body,
18:21
and there are also differences in the host
18:23
response.
18:24
So what may work for me with the
18:27
same problem
18:28
that you might have may not work for
18:30
you, and and it's this is across many,
18:32
many numbers of people.
18:34
And we don't know the details of this,
18:36
and I'm certainly no ex expert in regenerative
18:38
medicine.
18:40
But it's very clear that what you bring
18:42
to the table based upon your own genetics
18:44
and your own,
18:46
composition, if you will, without once again getting
18:49
into
18:50
the nuances of what types of factors we're
18:52
talking about,
18:54
it's clear that the differences between humans have
18:57
an impact on the responses to these biologics,
19:00
which makes it that much more difficult.
19:02
So I know it's an exciting area, and
19:04
we're all interested in it.
19:06
But I I think we don't have a
19:07
lot of the data that we need to
19:10
to promote it on a regular basis.
19:12
Having said that, is it used in most
19:14
sports medicine practices around The US and around
19:17
the world?
19:18
Absolutely.
19:19
But we just don't have the data that
19:21
that a purist would would like to have
19:24
to implement this across
19:26
all patient populations.
19:29
Thank you for, breaking all that down. And
19:31
we are coming to,
19:33
about time. So doctor Cordesco, I wanna thank
19:36
you again for joining us on today's podcast.
19:39
It was great chatting, and I look forward
19:41
to connecting again in the future.
19:43
Perfect.