New Physicians and Residents: Interventional Regenerative Orthopedics: Stem Cells and PRP. Ronald Torrance, DO

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1 8 ACOFP 55th Annual Convention & Scientific Seminars New Physicians and Residents: Interventional Regenerative Orthopedics: Stem Cells and PRP Ronald Torrance, DO

2 ACOFP FULL DISCLOSURE FOR CME ACTIVITIES Please check where applicable and sign below. Provide additional pages as necessary. Name of CME Activity: ACOFP 55th Annual Convention and Scientific Seminars Dates and Location of CME Activity: March 22-25, 2018 JW Marriott Name of Faculty/Moderator: DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM A. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services. B. I have, or an immediate family member has, a financial relationship or interest with a proprietary entity producing health care goods or services. Please check the relationship(s) that applies. Research Grants Stock/Bond Holdings (excluding mutual funds) Speakers Bureaus* Ownership Consultant for Fee Employment Partnership Others, please list: Please indicate the name(s) of the organization(s) with which you have a financial relationship or interest, and the specific clinical area(s) that correspond to the relationship(s). If more than four relationships, please list on separate piece of paper: Organization With Which Relationship Exists Clinical Area Involved *If you checked Speakers Bureaus in item B, please continue: Did you participate in company-provided speaker training related to your proposed Topic? Yes: No: Did you travel to participate in this training? Yes: No: Did the company provide you with slides of the presentation in which you were trained as a speaker? Yes: No: Did the company pay the travel/lodging/other expenses? Yes: No: Did you receive an honorarium or consulting fee for participating in this training? Yes: No: Have you received any other type of compensation from the company? Please specify: Yes: No: When serving as faculty for ACOFP, will you use slides provided by a proprietary entity for your presentation and/or lecture handout materials? Yes: No: Will your Topic1 involve information or data obtained from commercial speaker training? Yes: No: DISCLOSURE OF UNLABELED/INVESTIGATIONAL USES OF PRODUCTS A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of unapproved or investigational uses of products or devices. B. The content of my material(s)/presentation in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated below: I have read the ACOFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts will require the ACOFP to identify a replacement. Signature: Date: Rona d W orrance,, Plea e e ail thi or to oan aco p.or or a to N R N N R 19, 2018

3 Ronald Torrance II DO New regeneration Orthopedics of Florida ACOFP March 24 th 2017 Employed by New regeneration Orthopedics of Florida, A Regenexx Affiliate 1

Discuss where orthobiologics (Stem cells, platelet

) came from and what are the players in the landscape.

key differences in each Discuss the distinct

vs. conventional injections/orthopedics PROLOTHERAPY

GUIDANCE 2000 s PLATELET RICH PLASMA (autologous) STEM

4 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) 2

$fraction (FDA Crack down) Cytokine rich serums (A2M, etc.$ ) Fat grafts Other stem/progeni tor cells Recombinant growth factors Homologous Someone else s cells Autologous Patient s own stem cells Can

) Fat grafts Other stem/progeni tor cells Recombinant growth factors Homologous Someone else s cells Autologous Patient s own stem cells Can

5 Future Orthobiologic Injectates: Bone marrow concentrate (BMAC) Platelet rich plasma (PRP) Culture expanded allo and auto MSCs Stromal vascular fraction (FDA Crack down) Cytokine rich serums (A2M, etc.) Fat grafts Other stem/progeni tor cells Recombinant growth factors Homologous Someone else s cells Autologous Patient s own stem 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 No immunological response Can be harvested and used in the same treatment session. 3

6 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) 4

7 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. 5

8 What is Stem Cell Therapy? We will discuss how it is used in orthopedics and sports medicine. 6

9 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 7

10 Done by approximately 95% of US Physicians Knee Shoulder Hip 8

Orthobiologic injectates facilitate healing

imaging guidance Clinical Exam Guided vs.

guided injections are superior to palpation

rheumatologist were more accurate than the

11 Orthobiologic injectates facilitate healing of bone, tendon, ligament, muscle, or cartilage Precise placement of those injectates into damaged structures using imaging guidance Clinical Exam Guided vs. Ultrasound Guided Studies show that US guided injections are superior to palpation guided injections One-third of CE-guided injections were inaccurate. USguided injections performed by a trainee rheumatologist were more accurate than the CEguided injections performed by more senior rheumatologists (83% versus 66%; P 0.010). 9

degree of accuracy, and should be considered superior to palpation guidance.

12 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 Shoulder Injections Tendons (RTC, Biceps) Ligaments (SGHL, IGHL, MGHL) Labrum Bone (augmentation for AVN) Nerves (Suprascapular n.) 10

13 11

14 Done by approximately 1% of US Physicians Knee Injections Tendons of muscles (Quadriceps, Patella,etc.) Bone (augmentation for edema/avn) Ligaments (ACL, MCL, LCL, PCL, ALL, Coronary) Meniscus (medial and lateral) 12

15 13

16 Hip Injections Done by approximately 1% of US Physicians Labrum Joint Tendons (Hamstring, adductor Ligament (ligamentum teres) Muscles Bone (augmentation for AVN) 14

17 15

18 Done by approximately 1% of US Physicians Joints (Facets and SI) Ligaments (ILL, Interspinous, Intertransverse, Ligamentum Flavum) Muscles (Multifidi) Nerve roots (Transforminal Injection) Epidurals (Cervical, Lumbar, Caudal) Discs (intervertebral discs) 16

19 17

20 Elbow UCL Injuries Wrist Carpal Tunnel/Median Nerve Hydrodissection TFCC Injuries Hand Trigger finger injections FPL Tears 18

21 19

22 Ankle ATFL Tears Posterior Tibial Tendon Tears Foot Plantar Fasciitis Flexor Hallicus Longus tendonitis 20

23 (Above): Knee Replacement (Left): Arthroscopic Shoulder Surgery Knee Shoulder Hip Spine Ankle Foot 21

24 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. 22

25 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 23

Surround yourself with a positive environment, a pro healing environment Support can be

better One study shows that lack of support/isolation can be as devastating to health as

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

26 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 24

How many people here take time out of their days for stress management?

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

>20% of caloric deficiency can cause a stress response Eat more protein than

27 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 25

eustress that helps rid the body of toxins and decreases stress levels Orthobiologics provide a promising alternative

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

28 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. 26

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.

29 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): 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): doi: / ARTHRITIS & RHEUMATISM Vol. 62, No. 7, July 2010, pp DOI /art 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): doi: /s Accuracy of Ultrasound-Guided Versus Palpation-Guided Acromioclavicular Joint Injections: A Cadaveric Study. Peck, Evan et al.pm&r, Volume 2, Issue 9, Anderson, G. Oscar. Loneliness Among Older Adults: A National Survey of Adults 45+. Washington, DC: AARP Research, September 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 27

ORTHOPEDICS BONE Recalcitrant nonunions In total hip replacement total knee surgery increased callus volume

ORTHOPEDICS BONE Recalcitrant nonunions In total hip replacement total knee surgery increased callus volume ORTHOPEDICS Orthopedics has to do with a variety of tissue: bone, cartilage, tendon, ligament, muscle. In this regard orthopedic and sports medicine share the same tissue targets. Orthopedics is mostly