ORTHOBIOLOGIC TREATMENTS IN BASEBALL. Casey G. Batten MD PBATS - January 19th, 2018

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1 ORTHOBIOLOGIC TREATMENTS IN BASEBALL Casey G. Batten MD PBATS - January 19th, 2018

2 The Problem Musculoskeletal injuries are common in sport Pressure to minimize down time, swift return Many injuries involve tendons & ligaments Resistant or poor/slow response (PT, NSAID, CSI) Do not heal as normal tissue

3 Phases of Healing INFLAMMATORY PHASE (1 day 3 days) Angiogenesis Inflammatory Cells PDGF, TGF-beta REPARATIVE (PROLIFERATIVE) PHASE (3 days 6 weeks) Production of collagen and ECM Recruitment of fibroblasts Type III collagen synthesis REMODELING PHASE (6 weeks 1 year) Type III collagen Type I collagen Reorganization of fibrous tissue

4 Types of Orthobiologics Bone grafts Autologous blood Autologous conditioned serum Platelet rich plasma (PRP) Growth Factors Stem cells ( BMAC / Amnion Derived Biologics)

5 PRP DEFINITION=Plasma product containing a platelet concentration greater than whole blood How do you make it?

6 Why Platelets? >30 bioactive proteins PDGF VEGF TGF

7 Platelet Concentrate Types Autologous conditioned plasma Platelet Rich Plasma Platelet Poor Plasma Leukocyte Rich PRP Activated PRP, Non-Activated PRP

8 Platelet Concentrate Types *Platelet concentration *Presence or absence of WBCs *Activation status

9 Does PRP Work?

10 In Vitro *Examined 3 different PRP preparations and the ability to stimulate cell proliferation of human bone, muscle, and tendon cells in culture compared to controls (FBS and native blood) PRP LOW PLATELET (PRP LP) PRP HIGH PLATELET (PRP HP) PRP HIGH PLATELET AND LEUKOCYTES (PRP DS) -PRP LP Significantly increased proliferation of osteoblasts, myocytes, and tenocytes -PRP HP Significantly increased tenocytes only (over controls) -PRP DS Significantly increased osteoblasts and tenocytes only

11 In Vivo METHOD: 53 patients with single row RTC repair +/- PRP RESULTS *Re-tear rates 53% w/ PRP / 40% in control *Pain and 1 and 3 month improved w/ PRP *Pain and 2 years no difference

12 In Vivo METHOD: 88 patients with RTC repair +/- platelet-rich fibrin matrix RESULTS *Constant months no difference *MRI months no difference

13 In Vivo METHOD: Case Series, partial UCL tear, failed 2 months non-op RESULTS 88% Returned to previous level of play

14 In Vivo Platelet-Rich Plasma Can Be Used to Successfully Treat Elbow Ulnar Collateral Ligament Insufficiency in High-Level Throwers Am J Orthop July;45(5): Author(s): Dines JS Williams PN Elattrache N Joshua S. Dines, MD, Phillip N. Williams, MD, Neal ElAttrache, MD, Stan Conte, ATC, Todd Tomczyk, ATC, Daryl C. Osbahr, MD, David M. Dines, MD, James Bradley, MD, and Christopher S. Ahmad, MD METHOD: 44 baseball players, PRP for partial-thickness UCL tear RESULTS *15 Excellent, 17 good, 2 fair, 10 poor *4/6 Professionals returned to play *Mean time for throwing 5 wks, 12 wks for competition *Distal partial tears all had poor outcomes

15 2018 Update Systematic review of PRP looking at level 1 data, ligament and tendon 37 studies - 38% both RTC / LE Low powered studies, 18 different preparations Dependence on subjective pain scales

16 2017 Update Evidence that PRP is associated with less pain in RTC injuries and lateral epicondylitis Insufficient evidence for all other injuries NO ADVERSE REACTIONS

17 PRP Review Lack of classification leading to mixed results Lack of standardization of procedure +/- local, peppering, # of injections, rehab Are more platelets better? Leukocytes?? Ability to tailor use of PRP Timing Mixed evidence for efficacy

18 Stem Cells Proliferate and Differentiate

19 Stem Cells

20 Bone Marrow Aspiration Concentration (BMAC)

21 The Placenta

22 Do Stem Cells Work?

23 Animal Models Stem Cells in RTC Repair

24 In Vivo METHOD: 14 complete rotator cuff repairs with injection of BM stem cells into the tendon borders. MRI acquired before and after surgery. RESULTS -Minimum 1yr f/u: *UCLA score *MRI evidence of tendon integrity 14/14 *1 patient at 2 years required repeat surgery

25 Placental Derived Biologics 29 Animal Models 14 Tendon injuries 13 Osteoarthritis / Articular Cartilage 3 Ligament injuries 1 Synovitis 6 Human Models 5 Foot and ankle 1 Knee osteoarthritis

26 Stem Cell Review Theoretical ability to normalize healing Lack of standardization of procedure Mixed evidence, need more work, but promising

27 PRP Pros: Cheap, minimally invasive Cons: Perhaps pro-inflammatory, not best for in season (tendon/lig), delayed response, no anesthetic BMAC Pros: High concentration MSC, PRP Cons: Expensive, moderately invasive Amnion Pros: May have viable stem cells, high concentration GF s not sequestered, ECM, ok anesthetic Cons: Expensive, lack of data

28 Safety of Orthobiologics PRP and BMAC is autologous Amniotic derivatives MSCs have restricted self-renewal and lineage differentiation potential and hence have fewer safety concerns

29 Thank You