Dr. Emel quoted in two articles published in Becker's Orthopedic, Spine & Pain Management Review

Dr. Emel was recently quoted in two articles published in Becker's Orthopedic, Spine & Pain Management Review.

Please see the full text of each article below, including links to the original postings on www.beckersorthopedicandspine.com

Is PRP a Passing Trend or the Future of Sports Medicine?: 4 Physician Responses

Written by Laura Miller  July 06, 2011

Four orthopedic sports medicine physicians discuss current use of platelet-rich plasma injections for athletes and whether they think the treatment will stand up to evidence-based research.

T. Jeffrey Emel, MD, Eastern Oklahoma Orthopedic Center, Tulsa: For a traumatic patient who is young with normal anatomy, something like PRP to heal the tendon makes a lot of sense. I've been really impressed with how it works on chronic tendon problems and it seems an effective treatment that could sometimes negate the need for a surgical procedure. Of course, I don't have strong studies to support that yet.

Companies will have to help pay for the studies — which is the problem in orthopedic and sports medicine research to begin with. If you feel like what you are doing is the right thing and there's enough science behind it in a non-academic setting, we want to be able to do the right thing for our patient. But now everything has to be evidence-based, proven through studies. This is contrary to everything having to be evidence-based which is the trend in medical reimbursement.

Tom Hackett, MD, The Steadman Clinic in Vail, Colo.: We're researching PRP right now to determine the best concentration, preparation and timing of the injections at our clinic in Vail. We've done thousands of these cases that we are tracking in our database. Right now, the data is still in the gathering stage and we are evaluating the data as it comes in. Currently, we are seeing more promise in soft tissue than joint applications.

We also use biologic augmentation, a combination of PRP and a bone growth stimulator, in fractures that won't heal. We've also seen success in using patches with growth factors for Achilles tendon repair and rotator cuff repairs. One of the problems with using PRP injections is that insurance doesn't cover it most of the time so patients have to pay out of their own pocket. In terms of broader application, if patients have to pay for it there isn't as much willingness.

Bert Mandelbaum, MD, DHL (hon). at Saint John's Health Center in Santa Monica, Calif.: There are several studies out there looking at the efficacy of PRP with contradictory results. I think in the appropriate situation, PRP might be of some use surgically in enhancing the repair and regeneration, especially in an athlete. Do we need biologics to make a tendon heal? No — but might we need them to help the athletes compete at a high level? Yes, we do. As a sports medicine physician, we are always trying to get the best outcome and performance from our interventions. For example, there are studies that show using PRP during ACL repair decreases healing time in the tunnels and potentially enhances the graft strength.

I think PRP has been a major step and now people are looking at bone marrow aspirates and stem cells. There's a lot of research out there in animal and human models using stem cells for cartilage, ligament, tendon and muscle healing, but at this point none of the studies are definitive in showing efficacy in the long term yet.

Eric Millstein, MD, DISC Sports and Spine Center in Marina del Rey, Calif.: In my practice, I find PRP most helpful in chronic tendinopathies, such as tennis elbow and patellar tendonitis, as well as some revision surgeries. The idea behind PRP is that you have growth factors that help tears heal. I don't have enough confidence that it helps with every surgery I do, but I have found it helps in a compromised healing environment such as revision surgery.

The enthusiasm for PRP is high among surgeons, but it may be even more so among patients. It's one of those technologies that seems easy to apply with the anticipation that it would help patients heal more quickly than it would otherwise. I have many patients who hear about it by reading a news story or following a professional athlete. Like other sport medicine applications, randomized, controlled studies are needed.

There is a big perception out there that PRP does more than it actually does. Patients with arthritis think PRP will help cure them, but there isn't any evidence supporting this application.

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What Role Does Biologics Play in Sports Medicine?: 4 Physician Responses

Written by Laura Miller  June 28, 2011

Four leading orthopedic sports medicine physicians discuss how biologics are being used in sports medicine and what impact they will have on sports medicine in the future.

T. Jeffrey Emel, MD, at Eastern Oklahoma Orthopedic Center, Tulsa. At our practice, we have the Magellan system for PRP injections and we've seen good outcomes for several applications. I've treated some partial rotator cuff tears, knee conditions and chronic hamstring tears, and I've had good results with those procedures. We've also tried it with people who have early osteoarthritis and seen some improvement, but I don't know whether it's placebo or not.

The problem with biologics is that there aren't any good double-blind scientific papers written on it. There are some papers saying biologics on rotator cuffs might not work, but the methodology isn't consistent with what we use. The systems are pretty expensive and insurance often doesn't cover it. We'll do it on a cash basis until they improve reimbursement. Philosophically, it makes sense to put the material where the problem is and allow the tendon to heal. I think it will be the way of the future if we can get it approved by the insurance companies.

Tom Hackett, MD, at The Steadman Clinic in Vail, Colo. There's not a lot of data out yet about whether biologics helps athletes drastically or not. It appears as though its use might be beneficial in some surgeries and mesenchymal stem cell use for cartilage restoration to promote tendon healing is on the horizon. There have been some athletes recently, such as Yankees pitcher Bartolo Colon, who received stem cell treatments in conjunction with elbow repair. In sports medicine, there are more people experimenting with stem cells and it's being used in clinical trials.

It's very common among professional athletes because they want to try everything they can to get a little bit better a little bit faster. Orthopedics has come a long way in terms of the mechanical aspects of healing. I think we've been able to optimize the screws, sutures and fixation devices in our surgical procedures and we are embarking on the next frontier in terms of maximizing the biologic environment. Stem cells are definitely the future and they will probably end up being delivered with mechanical devices, such as suture anchors or patches, directly with the implants.

Bert Mandelbaum, MD, DHL (hon) at Saint John's Health Center in Santa Monica, Calif. We've been using biologics in athletes for a long time and receiving favorable results for articular cartilage early degeneration. We still don't have the ideal technologies yet, but we are at a level in our progression where we are getting better. We've developed a few techniques and we have good scaffolds for some biological interventions, but we're not able to effectively disease modify and prevent osteoarthritis in the long run.

At our practice, [we] are part of a collaboration that will show how different factors can impact cartilage in different ways. One of the big things we are focusing on is utilizing multiple therapies concurrently. That's the orthobiologic paradigm that research needs to achieve. In the future, everything is going to be based on evidence-based medicine and it's critical that we prove the interventions in steps, making sure one step follows the next.

I look forward to a paradigm where we think of sports medicine and biologics much the same way we look at sports medicine: from a holistic approach. We want to look at how we will be able to return athletes to their previous performance level. It can't just be repairing the ligament; we need enhanced healing and create restorative technologies as well.

Eric Millstein, MD, at DISC Sports and Spine Center in Marina del Rey, Calif. One of the most important questions in biologics right now is whether platelet-rich plasma is effective or not. Some of us are using it broadly while others are using it cautiously and some don't use it at all. I am one of those who is using it cautiously. There are some indications where this procedure is effective in treating pain and allowing athletes to return to play, but unfortunately this is one of those technologies where the research is lagging behind application. There are several different factors related to the formulation of PRP that need to be standardized, including concentration of platelets and use of activators, for example.

Insurance companies have not yet approved this as a covered expense, therefore one possible barrier to its use is the cost. One factor that patients weigh in their decision making process would be the cost. From the patient's perspective, it's easy, quick, done in the office and holds very little risk. I haven't had anyone too disappointed if it didn't work because I talk with them about it first.

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