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ACOFP 55th Annual Convention & Scientific Seminars

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New Physicians and Residents: Interventional Regenerative Orthopedics:

Stem Cells and PRP

Ronald Torrance, DO

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Name of CME Activity: ACOFP 55th Annual Convention and Scientific Seminars

Dates and Location of CME Activity: March 22-25, 2018 – JW Marriott

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Signature: Date:

Rona d W orrance, ,

Plea e e ail thi or to oan aco p.or or a to 952 5116 N R N N R 19, 2018

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Ronald Torrance II DO

New reGeneration Orthopedics of Florida

ACOFP March 24th 2017

▪Employed by New reGeneration Orthopedics of Florida, A Regenexx Affiliate

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▪ Discuss where orthobiologics (Stem cells, platelet rich plasma (PRP), cytokines, etc.) came from and what are the players in the landscape.

▪ Discuss the contents of PRP and Stem Cells, as well as key differences in each

▪ Discuss the distinct difference in the field of Interventional Orthopedics vs. conventional injections/orthopedics

PROLOTHERAPY – 1937

FLUOROSCOPY (live Xray) – 1990’s ULTRASOUND

GUIDANCE 2000’s

PLATELET RICH PLASMA

(autologous)STEM CELLS INJECTIONS

Related : surgery augmentation with

biologics (fundamentally a

different field)

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Bone marrow

concentrate (BMAC)

Platelet rich plasma (PRP)

Cytokine rich serums (A2M, etc.)

Fat grafts

Culture expanded

allo and auto MSCs

Stromal vascular

fraction (FDA Crack down)

Other stem/progeni

tor cells

Recombinant growth factors

Future

Orthobiologic

Injectates:

HomologousSomeone else’s cells

▪ Can cause immunological response.▪ Need anti-rejection medications

▪ Can inherit the donor’s bad cells.

▪ Embryonic Stem cells ▪ Can carry bad genes

▪ Can form tumors

AutologousPatient’s own stem cells

▪ No immunological response

▪ Can be harvested and used in the same treatment session.

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What is PRP?

First utilized in Cardiac Surgery in 1987

Introduced in a dental paper in 1998/ Horse racing 2003

Human publication in 2006 (elbow)

Media attention 2009 (Hines Ward Pittsburgh Steelers)

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▪ Derived by the isolation of Platelets from autologous blood.

▪ Blood is drawn and spun down to isolate concentrated growth factors and cytokines that have been shown to initiate and promote healing

▪ The PRP is injected into the injury site.

▪ PRP starts a cascade of biological processes

▪ Release numerous growth factors, including PDGF, TGF-β, VEGF, SDF-1α, TNF, TNFαR, IL-1 IL-1R, TIMP, PDGF, IGF, FGF-2.

▪ These growth factors have been shown to orchestrate the key biological processes of angiogenesis, inflammation resolution, cell migration, cell proliferation, matrix synthesis, and tissue regeneration.

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What is Stem Cell Therapy?

We will discuss how it is used in orthopedics and sports medicine.

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▪ We will be discussing autologous stem cell therapy.

▪ We will discuss it in the context of Orthobiologics.

▪ Two sources of Stem Cells are utilized.

▪ Bone Marrow or BMAC

▪ Adipose or AMC

▪ Concentration of Mesenchymal Stem Cells in each.

▪ Bone Marrow is about 0.005% MSC’s

▪ Adipose is about 5% MSC’s

▪ The amount of live cells are identical in the same sample of each.

▪Capable of differentiating into osteoblasts, chondrocytes and adipocytes

▪Can differentiate into bone, tendon/ligament, cartilage and muscle.

▪Can be isolated from bone marrow and adipose tissue.

▪Stabilize the environment and release other cells that are crucial in the healing process

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Done by

approximately 95% of

US Physicians

• Knee

• Shoulder

• Hip

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• Orthobiologicinjectates facilitate healing of bone, tendon, ligament, muscle, or cartilage

• Precise placement of those injectatesinto damaged structures using imaging guidance

Studies show that US guided injections are superior to

palpation guided injections

One-third of CE-guided injections were inaccurate. US-guided injections performed by a trainee rheumatologist were more accurate than the CE-

guided injections performed by more senior rheumatologists (83% versus 66%; P 0.010).

Clinical

Exam

Guided

vs.

Ultrasound

Guided

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• Utilization of guidance

ensures that the right

area is injected.

• A cadaveric

investigation suggests

that sonographic

guidance can be used

to inject the ACJ with a

high degree of

accuracy, and should

be considered superior

to palpation guidance.

Done by approximately 1% of US Physicians

• Tendons (RTC, Biceps)

• Ligaments (SGHL, IGHL, MGHL)

• Labrum• Bone (augmentation

for AVN)• Nerves

(Suprascapular n.)

Shoulder

Injections

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Done by approximately 1% of US Physicians

• Tendons of muscles (Quadriceps, Patella,etc.)

• Bone (augmentation for edema/AVN)

• Ligaments (ACL, MCL, LCL, PCL, ALL, Coronary)

• Meniscus (medial and lateral)

Knee

Injections

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Done by approximately 1% of US Physicians

• Labrum• Joint• Tendons

(Hamstring, adductor

• Ligament (ligamentum teres)

• Muscles• Bone

(augmentation for AVN)

Hip

Injections

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Done by approximately 1% of US Physicians

• Joints (Facets and SI)• Ligaments (ILL,

Interspinous, Intertransverse, Ligamentum Flavum)

• Muscles (Multifidi) • Nerve roots

(TransforminalInjection)

• Epidurals (Cervical, Lumbar, Caudal)

• Discs (intervertebral discs)

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ElbowUCL Injuries

WristCarpal Tunnel/Median Nerve Hydro-dissectionTFCC Injuries

HandTrigger finger injectionsFPL Tears

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• Ankle

ATFL Tears

Posterior TibialTendon Tears

• Foot

Plantar Fasciitis

Flexor HallicusLongus tendonitis

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• Knee

• Shoulder

• Hip

• Spine

• Ankle

• Foot

(Above): Knee Replacement

(Left): Arthroscopic Shoulder

Surgery

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▪ This is in a sense a separate field but will be discussed.

▪ Using the biologics in conjunction with a surgical procedure.

▪ Can be done pre or post operatively.

▪ Can be done in conjunction with the surgical procedure.

▪ Like Orthobiologics this a new and expanding practice in which there is not a great deal of large controlled studies at this time-actually much less research than straight PRP and Stem Cell procedures.

▪ Multiple studies showing that using PRP and Stem Cells during a surgical procedure enhances healing and shortens healing times.

▪ Studies also show that using these biologics in the post-operative period is beneficial.

▪ Ersen et al showed better biomechanical properties at the tendon-bone interface in rotator cuff repair with PRP in the rat model.

▪ Other studies have showed no better integrity of the rotator cuff repair but less pain and faster recovery. Much more research is needed.

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▪ Many small studies currently going on with augmenting surgery.

▪ Using PRP and Stem Cells with RC repair.

▪ Using PRP and Stem Cells with ACL repair.

▪ Using PRP with Hip Arthroscopy for impingement and labral repair.

▪ MUCH MORE RESEARCH IS NEEDED.

1. Community

2. Sleep

3. Stress Management

4. Nutrition

5. Exercise

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• Surround yourself with a positive environment, a pro “healing” environment

• Support can be crucial when trying to get over acute or chronic pain and can be motivation to get better

• One study shows that lack of support/isolation can be as devastating to health as smoking 15 cigarettes a day

• Think about this, we spend 1/3 of our lives asleep.

• Poor sleep upregulates the stress hormone cortisol and increases fasting glucose levels

• Higher glucose levels raises global inflammation in the body, decreasing the bodies ability to heal

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• How many people here take time out of their days for stress management?• Yoga• tai chi• Meditation• behavioral therapy• Etc.

• HPA axis dysfunction can destroy the bodies innate ability to heal

• Eat enough!• >20% of caloric

deficiency can cause a stress response

• Eat more protein than carbohydrates

• Women tend to under eat protein and a supplement like Bone Broth Protein can help

• Eat Real Food!• Food that comes from

the earth or animals that walk/swim on the earth

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• Motion is Lotion!

• Weight bearing exercise is good for bones and joints

• Core muscle strength affects every part of the body

• Exercise is eustress that helps rid the body of toxins and decreases stress levels

▪ Orthobiologics provide a promising alternative to acute and chronic tendon, bone, muscle, and ligament issues.

▪ Additional studies need to be done to delineate the full benefits.

▪ Interventional Orthopedics represents a new and exciting field that bridges the gap between simple articular injections and orthopedic surgery

▪ Orthobiologic Orthopedic assisted procedures can assist in the field of orthopedics to yield better results

▪ Remember the 5 Pillars of Health for each and everyone of your patients.

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▪ http://eorthopod.com/facet-joint-injections/

▪ https://idahospineandpain.com/TESI

▪ James P. Rathmell, M.D., Charles Aprill, M.D., Nikolai Bogduk, M.D., Ph.D., D.Sc.; Cervical Transforaminal Injection of Steroids. Anesthes2004;100(6):1595-1600.

▪ http://cyclingvideosonline.com/cyclists-survival-guide-total-knee-replacement/

▪ Zhang JY, Fabricant PD, Ishmael CR, Wang JC, Petrigliano FA, Jones KJ. Utilization of Platelet-Rich Plasma for Musculoskeletal Injuries: An Analysis of Current Treatment Trends in the United States. Orthopaedic Journal of Sports Medicine. 2016;4(12):2325967116676241. doi:10.1177/2325967116676241.

▪ ARTHRITIS & RHEUMATISM Vol. 62, No. 7, July 2010, pp 1862–1869 DOI 10.1002/art.27448

▪ http://cbjsonline.com/for-education/arthroscopic-shoulder-surgery

▪ Permission from Interventional Orthopedic Foundation to use slides for lecture.

▪ Ellera Gomes JL, da Silva RC, Silla LMR, Abreu MR, Pellanda R. Conventional rotator cuff repair complemented by the aid of mononuclear autologous stem cells. Knee Surgery, Sports Traumatology, Arthroscopy. 2012;20(2):373-377. doi:10.1007/s00167-011-1607-9.

▪ Accuracy of Ultrasound-Guided Versus Palpation-Guided Acromioclavicular Joint Injections: A Cadaveric Study. Peck, Evan et al.PM&R , Volume 2 , Issue 9 , 817 - 821

▪ Anderson, G. Oscar. Loneliness Among Older Adults: A National Survey of Adults 45+. Washington, DC: AARP Research, September 2010. https://doi.org/10.26419/res.00064.001

Paul et al, 1998 Journal of Shoulder and Elbow Surgery

24 shoulders were dissected after subacromial and AC joint injections were performed with dye

Subacromial bursa – 83%

AC Joint – 66%

Mathews et al, 2005 Journal of Shoulder and Elbow Surgery

20 shoulders injected into subacromial space using palpation guidance

Fluoroscopy “confirmed” accuracy in 90% of injections

When the bursa was dissected down injections were only 60% accurate