A Practical Guide for the Current Use of Biologic Therapies in Sports Medicine

Regenerative Medicine in Orthopedic Surgery: Expanding Our Toolbox

Regenerative medicine leverages the body's inherent regenerative capabilities to repair damaged tissues and address organ dysfunction. In orthopedics, this approach includes a variety of treatments collectively known as orthoregeneration, encompassing modalities such as prolotherapy, extracorporeal shockwave therapy, pulsed electromagnetic field therapy, therapeutic ultrasound, and photobiomodulation therapy, and orthobiologics like platelet-rich plasma and cell-based therapies. These minimally invasive techniques are becoming prominent due to their potential for fewer complications in orthopedic surgery. As regenerative medicine continues to advance, surgeons must stay informed about these developments. This paper highlights the current state of regenerative medicine in orthopedics and advocates for further clinical research to validate and expand these treatments to enhance patient outcomes.

Bioactive Patch for Rotator Cuff Repairing via Enhancing Tendon-to-Bone Healing: A Large Animal Study and Short-Term Outcome of a Clinical Trial

Tissue engineering has demonstrated its efficacy in promoting tissue regeneration, and extensive research has explored its application in rotator cuff (RC) tears. However, there remains a paucity of research translating from bench to clinic. A key challenge in RC repair is the healing of tendon-bone interface (TBI), for which bioactive materials suitable for interface repair are still lacking. The umbilical cord (UC), which serves as a vital repository of bioactive components in nature, is emerging as an important source of tissue engineering materials. A minimally manipulated approach is used to fabricate UC scaffolds that retain a wealth of bioactive components and cytokines. The scaffold demonstrates the ability to modulate the TBI healing microenvironment by facilitating cell proliferation, migration, suppressing inflammation, and inducing chondrogenic differentiation. This foundation sets the stage for in vivo validation and clinical translation. Following implantation of UC scaffolds in the canine model, comprehensive assessments, including MRI and histological analysis confirm their efficacy in inducing TBI reconstruction. Encouraging short-term clinical results further suggest the ability of UC scaffolds to effectively enhance RC repair. This investigation explores the mechanisms underlying the promotion of TBI repair by UC scaffolds, providing key insights for clinical application and translational research.

Comparative single-cell transcriptional and proteomic atlas of clinical-grade injectable mesenchymal source tissues

Bone marrow aspirate concentrate (BMAC) and adipose-derived stromal vascular fraction (ADSVF) are the most marketed stem cell therapies to treat a variety of conditions in the general population and elite athletes. Both tissues have been used interchangeably clinically even though their detailed composition, heterogeneity, and mechanisms of action have neither been rigorously inventoried nor compared. This lack of information has prevented investigations into ideal dosages and has facilitated anecdata and misinformation. Here, we analyzed single-cell transcriptomes, proteomes, and flow cytometry profiles from paired clinical-grade BMAC and ADSVF. This comparative transcriptional atlas challenges the prevalent notion that there is one therapeutic cell type present in both tissues. We also provide data of surface markers that may enable isolation and investigation of cell (sub)populations. Furthermore, the proteome atlas highlights intertissue and interpatient heterogeneity of injected proteins with potentially regenerative or immunomodulatory capacities. An interactive webtool is available online.

Musculoskeletal Biorepository: Establishment, Sustainment, and Tips for Success

A biorepository, also referred to as a "biobank," is a collection of biologic samples that are stored for laboratory research. With the emergence of precision medicine, the importance of leveraging individual patient biomolecular signatures to improve diagnosis, prognosis, and treatment is becoming increasingly recognized. Successful development and sustainment of a biorepository provides the potential for transformative preclinical research. Establishing a biobank requires a team approach with involvement of the institutions' research laboratory team and regulatory body. Execution of research activities requires a coordinated team approach for case identification, consent process, data and specimen collection, specimen processing, and storage and archiving. The advancing fields of precision medicine and orthobiologics provide incredible opportunities for institutions to generate novel lines of inquiry in musculoskeletal diseases through a multiomics approach (genomic, transcriptomic, proteomic, microbiomic). In addition, a biobank is an important component of post-market surveillance for the rapidly emerging field of orthobiologics.

Platelet-Rich Plasma, Bone Marrow Aspirate Concentrate, and Hyaluronic Acid Injections Outperform Corticosteroids in Pain and Function Scores at a Minimum of 6 Months as Intra-Articular Injections for Knee Osteoarthritis: A Systematic Review and Network Meta-analysis

PURPOSE

To compare the efficacy of common intra-articular injections used in the treatment of knee osteoarthritis, including corticosteroid (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and bone marrow aspirate concentrate (BMAC), with a minimum follow-up of 6-months.

METHODS

A literature search was conducted using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in August 2022 in the following databases: PubMed/MEDLINE, Scopus, Cochrane Database of Controlled Trials, and the Cochrane Database of Systematic Reviews. Level I to II randomized clinical trials with a minimum follow-up of 6 months that investigated the treatments of interest were included. Patient-reported outcome scores for pain and function at baseline and at latest follow-up were extracted, and the change in scores was converted to uniform 0 to 100 scales. Arm-based Bayesian network meta-analysis using a random-effects model was created to compare the treatment arms in pain and function.

RESULTS

Forty-eight studies comprising a total of 9,338 knees were included. The most studied intra-articular injection was HA (40.9%), followed by placebo (26.2%), PRP (21.5%), CS (8.8%), and then BMAC (2.5%). HA and PRP both led to a significant improvement in pain compared with placebo. HA, PRP, and BMAC all led to a significant improvement in function scores when compared with placebo. Surface under the cumulative ranking curves (SUCRAs) of the interventions revealed that PRP, BMAC, and HA were the treatments with the highest likelihood of improvement in both pain and function, with overall SUCRA scores of 91.54, 76.46, and 53.12, respectively. The overall SUCRA scores for CS and placebo were 15.18 and 13.70, respectively.

CONCLUSIONS

At a minimum 6-month follow-up, PRP demonstrated significantly improved pain and function for patients with knee osteoarthritis compared with placebo. Additionally, PRP exhibited the highest SUCRA values for these outcomes when compared with BMAC, HA, and CS.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I to II studies.

Treatment of Tendon Injuries in the Servicemember Population across the Spectrum of Pathology: From Exosomes to Bioinductive Scaffolds

Tendon injuries in military servicemembers are one of the most commonly treated nonbattle musculoskeletal injuries (NBMSKIs). Commonly the result of demanding physical training, repetitive loading, and frequent exposures to austere conditions, tendon injuries represent a conspicuous threat to operational readiness. Tendon healing involves a complex sequence between stages of inflammation, proliferation, and remodeling cycles, but the regenerated tissue can be biomechanically inferior to the native tendon. Chemical and mechanical signaling pathways aid tendon healing by employing growth factors, cytokines, and inflammatory responses. Exosome-based therapy, particularly using adipose-derived stem cells (ASCs), offers a prominent cell-free treatment, promoting tendon repair and altering mRNA expression. However, each of these approaches is not without limitations. Future advances in tendon tissue engineering involving magnetic stimulation and gene therapy offer non-invasive, targeted approaches for improved tissue engineering. Ongoing research aims to translate these therapies into effective clinical solutions capable of maximizing operational readiness and warfighter lethality.

Orthobiologics as an adjunct in treatment of femoroacetabular impingement syndrome: cell-based therapies facilitate improved postoperative outcomes in the setting of acetabular chondral lesions-a systematic review

PURPOSE

To evaluate studies utilizing orthobiologics in the management of femoroacetabular impingement syndrome (FAIS) to (1) assess the indications for usage, and (2) analyze patient-reported outcome measures (PROM) following treatment. It was hypothesized that orthobiologics would (1) be utilized for symptomatic FAIS in the setting of labral or chondral pathology, and (2) improve PROM at most recent follow-up.

METHODS

The Pubmed, Ovid Medline, Cochrane, and Web of Science databases were searched for clinical studies evaluating orthobiologics [hyaluronic acid (HA), platelet-rich plasma (PRP), or cell-based therapy (CBT) for treatment of FAIS. Exclusion criteria included orthobiologics used in conjunction with cartilage transfer or scaffolding procedures and a primary indication other than FAIS. Data collection included patient demographics, indications, and baseline and most recent PROM.

RESULTS

Eleven studies (one level I, four level II, four level III, and two level IV evidence) met inclusion criteria, consisting of 440 patients with mean ages ranging from 32.8 to 47 years. All 11 studies demonstrated an improvement in PROM from baseline to most-recent follow-up. Four studies administered PRP either intraoperatively or the day after surgery as an adjunct to labral repair. CBT was used intraoperatively in the setting of acetabular chondral lesions (three studies) and labral repair (one study). When comparing to a control group at most recent follow-up, three PRP cohorts demonstrated similar PROM (n.s.), while one PRP group exhibited worse visual analog pain scores (2.5 vs. 3.4, p = 0.005) and modified Harris Hip Scores (mHHS) (82.6 vs. 78.7, p = 0.049). The four CBT studies reported favorable results compared to a control group, with a significantly higher mHHS at most recent follow-up or mean improvement from baseline in Hip Outcome Score-Activities of Daily Living (p < 0.05). Three studies reported on HA, which was utilized exclusively in the nonoperative setting.

CONCLUSIONS

Intraoperative PRP and CBT have been commonly reported in the setting of hip arthroscopy for labral repairs and acetabular chondral lesions, respectively. The CBT cohorts demonstrated more favorable PROM at most recent follow-up when compared to a control group, though these results should be interpreted with caution due to heterogeneity of orthobiologic preparations.

LEVEL OF EVIDENCE

IV.

Intra-articular delivery of micronized dehydrated human amnion/chorion membrane reduces degenerative changes after onset of post-traumatic osteoarthritis

Background: Micronized dehydrated human amnion/chorion membrane (mdHACM) has reduced short term post-traumatic osteoarthritis (PTOA) progression in rats when delivered 24 h after medial meniscal transection (MMT) and is being investigated for clinical use as a disease modifying therapy. Much remains to be assessed, including its potential for longer-term therapeutic benefit and treatment effects after onset of joint degeneration. Objectives: Characterize longer-term effects of acute treatment with mdHACM and determine whether treatment administered to joints with established PTOA could slow or reverse degeneration. Hypotheses: Acute treatment effects will be sustained for 6 weeks, and delivery of mdHACM after onset of joint degeneration will attenuate structural osteoarthritic changes. Methods: Rats underwent MMT or sham surgery (left leg). mdHACM was delivered intra-articularly 24 h or 3 weeks post-surgery (n = 5-7 per group). Six weeks post-surgery, animals were euthanized and left tibiae scanned using equilibrium partitioning of an ionic contrast agent microcomputed tomography (EPIC-µCT) to structurally quantify joint degeneration. Histology was performed to examine tibial plateau cartilage. Results: Quantitative 3D µCT showed that cartilage structural metrics (thickness, X-ray attenuation, surface roughness, exposed bone area) for delayed mdHACM treatment limbs were significantly improved over saline treatment and not significantly different from shams. Subchondral bone mineral density and thickness for the delayed treatment group were significantly improved over acute treated, and subchondral bone thickness was not significantly different from sham. Marginal osteophyte degenerative changes were decreased with delayed mdHACM treatment compared to saline. Acute treatment (24 h post-surgery) did not reduce longer-term joint tissue degeneration compared to saline. Histology supported µCT findings and further revealed that while delayed treatment reduced cartilage damage, chondrocytes displayed qualitatively different morphologies and density compared to sham. Conclusion: This study provides insight into effects of intra-articular delivery timing relative to PTOA progression and the duration of therapeutic benefit of mdHACM. Results suggest that mdHACM injection into already osteoarthritic joints can improve joint health, but a single, acute mdHACM injection post-injury does not prevent long term osteoarthritis associated with meniscal instability. Further work is needed to fully characterize the durability of therapeutic benefit in stable osteoarthritic joints and the effects of repeated injections.

Substantial Variability in Platelet-Rich Plasma Composition Is Based on Patient Age and Baseline Platelet Count

Purpose

To evaluate the effect of age, sex, body mass index (BMI), and baseline blood count on the final composition of platelet rich-plasma (PRP) and to evaluate the variability of PRP applied in the same patient at 2 different times.

Methods

Potential subjects treated with PRP between January 2019 and December 2021 were identified in an institutional registry. Patient demographics and baseline blood count were prospectively recorded in a consecutive series of patients treated with PRP for a musculoskeletal condition in our Institution. The influence of sex, BMI, age, and baseline blood count on final platelet concentrations in PRP was evaluated. Finally, intrapersonal variability was evaluated.

Results

A total of 403 PRP injections from 357 patients were analyzed from an institutional prospective registry of PRP between January 2019 and December 2021. A directly proportional variation in PRP platelet count of 3.8× was observed for each unit increase in baseline blood platelet count. For every decade increase, we observed an approximate decrease of 32,666 platelets. When the first dose of PRP platelet counts was compared with the second dose of PRP platelet counts between the same patients, significant differences were found. A mean of 890,018 platelets in the first PRP and a mean of 1,244,467 in the second PRP with a mean difference of 354,448 was found (P = .008). We did not find differences in the final concentration of platelets regarding sex, BMI, or PRP protocol.

Conclusions

Overall the final composition of PRP (platelet count) was significantly influenced by patient's age and baseline platelet count. In contrast, BMI, sex and the rest of the components of the baseline blood count did not have a significant influence on final PRP. Furthermore, in patients who received 2 doses of PRP, the final concentration of platelets varied significantly between the 2 preparations.

Level of Evidence

Level IV, prognostic case series.

Regenerative methods in osteoarthritis

Osteoarthritis (OA) is the most common type of arthritis that can affect all joint structures. The primary goals of osteoarthritis treatment are to alleviate pain, reduce functional limitations, and improve quality of life. Despite its high prevalence, treatment options for osteoarthritis are limited, with most therapeutic approaches focusing on symptom management. Tissue engineering and regenerative strategies based on biomaterials, cells, and other bioactive molecules have emerged as viable options for osteoarthritis cartilage repair. Platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs) are the most commonly used regenerative therapies today to protect, restore, or increase the function of damaged tissues. Despite promising results, there is conflicting evidence regarding the efficacy of regenerative therapies, and their efficacy remains unknown. The data suggest that more research and standardization are required for the use of these therapies in osteoarthritis. This article provides an overview of the application of MSCs and PRP applications.

Orthobiologics: a review

PURPOSE

The use of biologic materials in orthopaedics (orthobiologics) has gained significant attention over the past years. To enhance the body of the related literature, this review article is aimed at summarizing these novel biologic therapies in orthopaedics and at discussing their multiple clinical implementations and outcomes.

METHODS

This review of the literature presents the methods, clinical applications, impact, cost-effectiveness, and outcomes, as well as the current indications and future perspectives of orthobiologics, namely, platelet-rich plasma, mesenchymal stem cells, bone marrow aspirate concentrate, growth factors, and tissue engineering.

RESULTS

Currently available studies have used variable methods of research including biologic materials as well as patient populations and outcome measurements, therefore making comparison of studies difficult. Key features for the study and use of orthobiologics include minimal invasiveness, great healing potential, and reasonable cost as a nonoperative treatment option. Their clinical applications have been described for common orthopaedic pathologies such as osteoarthritis, articular cartilage defects, bone defects and fracture nonunions, ligament injuries, and tendinopathies.

CONCLUSIONS

Orthobiologics-based therapies have shown noticeable clinical results at the short- and mid-term. It is crucial that these therapies remain effective and stable in the long term. The optimal design for a successful scaffold remains to be further determined.

Process Optimization and Efficacy Assessment of Standardized PRP for Tendinopathies in Sports Medicine: Retrospective Study of Clinical Files and GMP Manufacturing Records in a Swiss University Hospital

Platelet-rich plasma (PRP) preparations have recently become widely available in sports medicine, facilitating their use in regenerative therapy for ligament and tendon affections. Quality-oriented regulatory constraints for PRP manufacturing and available clinical experiences have underlined the critical importance of process-based standardization, a pre-requisite for sound and homogeneous clinical efficacy evaluation. This retrospective study (2013–2020) considered the standardized GMP manufacturing and sports medicine-related clinical use of autologous PRP for tendinopathies at the Lausanne University Hospital (Lausanne, Switzerland). This study included 48 patients (18–86 years of age, with a mean age of 43.4 years, and various physical activity levels), and the related PRP manufacturing records indicated a platelet concentration factor most frequently in the range of 2.0–2.5. The clinical follow-up showed that 61% of the patients reported favorable efficacy outcomes (full return to activity, with pain disappearance) following a single ultrasound-guided autologous PRP injection, whereas 36% of the patients required two PRP injections. No significant relationship was found between platelet concentration factor values in PRP preparations and clinical efficacy endpoints of the intervention. The results were in line with published reports on tendinopathy management in sports medicine, wherein the efficacy of low-concentration orthobiologic interventions appears to be unrelated to sport activity levels or to patient age and gender. Overall, this study confirmed the effectiveness of standardized autologous PRP preparations for tendinopathies in sports medicine. The results were discussed in light of the critical importance of protocol standardization for both PRP manufacturing and clinical administration to reduce biological material variability (platelet concentrations) and to enhance the robustness of clinical interventions (comparability of efficacy/patient improvement).

Current Status of PRP Manufacturing Requirements & European Regulatory Frameworks: Practical Tools for the Appropriate Implementation of PRP Therapies in Musculoskeletal Regenerative Medicine

Providing accurate and up-to-date practical tools enabling oversight of platelet-rich plasma (PRP) legislation and of the appropriate standards to be implemented for its manufacture and use in Europe is a demanding task. This is due to rapid medico-technological advancements, slowness and disparity in legislation updates and enforcement between member states, and many reported gray-zone practices, notably for autologous PRP use. The levels of risk associated with blood manipulation processes generally dictate the manufacturing requirements for PRP preparations, which have gradually shifted toward good manufacturing practices (GMP) for standardization and overall quality enhancement. This work firstly outlines Western European and Swiss legislation for PRP products/preparations, providing key simplified information and recommendations for medical doctors seeking to implement this biological-based therapy for safe use in hospital settings, clinics, or private offices. This work secondly shows the importance of PRP-based product manufacturing standardization, which subsequently enables sound clinical evaluation of therapeutic interventions. Although the applicable legal bases provide guidelines for GMP manufacturing infrastructure and basic process design, paramount importance is set on the definition of workflows, technical specifications, and key parameters for PRP preparation and delivery. Overall, the development of simple and robust technologies and processes for PRP preparation is critical for guaranteeing the high therapeutic quality of the intervention, in collaboration with qualified GMP manufacturing platforms. Importantly, this work aims to serve as a practical tool for clinicians based in Western Europe who are willing to appropriately (i.e., administratively and technically) implement autologous PRP treatments in musculoskeletal regenerative medicine workflows, to ensure they make informed and optimal regulatory or process-based decisions.

Evidence for Utilization of Injectable Biologic Augmentation in Primary Rotator Cuff Repair: A Systematic Review of Data From 2010 to 2022

Background

Biologic healing after rotator cuff repair remains a significant challenge. Injectable biologic augmentation may improve tissue quality at the suture-tendon interface.

Purpose

To investigate the effect of injectable biologic supplementation in rotator cuff repair and to assess the quality and adherence to evolving reporting standards.

Study Design

Systematic review; Level of evidence, 3.

Methods

A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were 40 studies: 29 preclinical (in vivo animal models) and 11 clinical. Each clinical study was assessed for quality, risk of bias, and adherence to relevant MIBO (Minimum Information for Studies Evaluating Biologics in Orthopaedics) guidelines. The outcomes of interest were reported load to failure, load to gap, gap size, and stiffness in the preclinical studies, and healing rate and any patient-reported outcome measures in the clinical studies.

Results

Injectables reported included growth factors (eg, transforming growth factor-beta 3, erythropoietin), bone marrow-derived mesenchymal stem cells and adipose-derived mesenchymal stem cells (ADSCs), and other agents such as platelet-rich plasma (PRP) and hyaluronic acid. The most common findings for preclinical injectables were increased load to failure (16/29 studies; 55.2%) and improved collagen histological quality (11/29 studies; 37.9%). All 11 clinical studies (10 PRP, 1 ADSC) indicated no adverse events, with similar or improved patient-reported outcomes compared with repairs in the control groups. In 1 study utilizing an innovative delivery technique, a concentrated PRP globule with fibrin matrix was shuttled over a suture to maintain concentrated PRP at the repair site and demonstrated a significant decrease in retears (P = .03) at a 31-month follow-up. A matched-cohort study investigating augmentation with ADSCs demonstrated a significantly lower retear rate in the ADSC-augmented group than the control group at a 28-month follow-up (P < .001). On average, the clinical studies adhered to 66% of relevant MIBO reporting guidelines and had a low risk of bias.

Conclusion

Approximately 83% of preclinical studies found a positive biomechanical or histological effect, with no studies showing an overall negative effect. Clinically, utilization of innovative delivery techniques may reduce the risk of arthroscopic washout of PRP and improve retear rates. ADSCs were shown to reduce retear rates at a 28-month follow-up.

Research trends of mesenchymal stem cells application in orthopedics: A bibliometric analysis of the past 2 decades

Background

Bibliometric analysis and visualization tools were used to determine the development trend of mesenchymal stem cells (MSCs) in orthopedics in the past 20 years, so as to guide researchers to explore new directions and hotspots in the field in the future.

Methods

In the Web of Science Core Collection, all articles about the application of MSCs in orthopedics from 2002 to 2021 were searched. The qualitative and quantitative analysis was performed based on Web of Science and CiteSpace software.

Results

A total of 2,207 articles were retrieved. After excluding non-article articles such as review and letter and non-English language articles, 1,489 articles were finally included. Over the past 2 decades, the number of publications on the application of MSCs in orthopedic diseases increased. Among them, the United States, China, Japan and the United Kingdom have made significant contributions in this field. The most productive institution was Shanghai Jiao Tong University. Journal of Orthopedic Research published the largest number of publications. The journal with the highest citation frequency was Experimental Hematology. The authors with the highest output and the highest citation frequency on average were Rochy S. Tuan and Scott A. Rodeo, respectively. "Mesenchymal stem cell", "in vitro" and "Differentiation" were the top three keywords that appeared. From the keyword analysis, the current research trend indicates that the primary research hotspots of MSCs in orthopedics are the source of MSCs, in vitro experiments and the differentiation of MSCs into bone and cartilage. The frontiers of this field are the combination of MSCs and platelet-rich plasma (PRP), the treatment of knee diseases such as osteoarthritis, osteogenic differentiation, and the application of biological scaffolds combined with MSCs.

Conclusion

Over the past 2 decades, the application of MSCs in orthopedic diseases has received increasing attention. Our bibliometric analysis results provide valuable information and research trends for researchers in the field to understand the basic knowledge of the field, identify current research hotspots, potential collaborators, and future research frontiers.

Study protocol for double-blind, randomised placebo-controlled trial evaluating semitendinosus function and morbidity following tendon harvesting for anterior cruciate ligament reconstruction augmented by platelet-rich plasma

INTRODUCTION

Anterior cruciate ligament (ACL) rupture is debilitating, often requiring surgical reconstruction. An ACL reconstruction (ACLR) using a tendon autograft harvested from the semitendinosus results in substantial injury to the donor muscle. Following ACLR, patients rarely return to their preinjury level of physical activity, are at elevated risk of secondary lower limb injuries and early onset knee osteoarthritis. To date, no randomised controlled trial has evaluated the efficacy of platelet-rich plasma (PRP) in aiding knee function and semitendinosus morphology of following ALCR.

METHODS AND ANALYSIS

This is a multicentre double-blind randomised placebo-controlled trial. Fifty-four ACLR patients aged 18-50 years will be randomised to receive either a single application of PRP (ACLR+) or placebo saline (ACLR) into the semitendinosus harvest zone at the time of surgery. All patients will undergo normal postoperative rehabilitation recommended by the attending orthopaedic surgeon or physiotherapist. The primary outcome measure is between-limb difference (ACLR compared with intact contralateral) in isometric knee flexor strength at 60o knee flexion, collected 10-12 months postsurgery. This primary outcome measure will be statistically compared between groups (ACLR+ and standard ACLR). Secondary outcome measures include bilateral assessments of hamstring muscle morphology via MRI, biomechanical and electromyographic parameters during an anticipated 45° running side-step cut and multidirectional hopping task and patient-reported outcomes questionaries. Additionally, patient-reported outcomes questionaries will be collected before (baseline) as well as immediately after surgery, and at 2-6 weeks, 3-4 months, 10-12 months and 22-24 months postsurgery 10-12 months following surgery.

ETHICS AND DISSEMINATION

Ethics approval has been granted by Griffith University Human Research Ethics Committee, Greenslopes Research and Ethics Committee, and Royal Brisbane & Women's Hospital Human Research Ethics Committee. Results will be submitted for publication in a peer-reviewed medical journal.

TRIAL REGISTRATION NUMBER

ACTRN12618000762257p.

Platelet-Rich Plasma Is Not Associated With Improved Outcomes Following Hip Femoroacetabular Impingement Surgery: Very Low-Quality Evidence Suggests Hyaluronic Acid and Cell-Based Therapies May Be Beneficial—A Systematic Review of Biological Treatments

Purpose

To examine the efficacy of biologic agents in the treatment of cartilage defects associated with femoroacetabular impingement (FAI).

Methods

PubMed, Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were reviewed by 2 independent reviewers for eligible studies. We included randomized and nonrandomized control trials as well as uncontrolled case series and retrospective studies. Studies were excluded if they included injections of corticosteroids, papers that described technique only, review papers, and those not in the English language. Demographics, treatment type, outcome of treatment, and complications were extracted, whereas risk of bias and study quality were assessed independently using the risk of bias tool (ROB2) and effective public health practice project tool. A narrative synthesis was performed, and standardized mean differences were reported. Certainty of evidence was assessed using the GRADE approach.

Results

Eighteen studies consisting of 1,024 patients met the inclusion criteria. Three studies involved the use of platelet-rich plasma (PRP) as an adjuvant to surgery and were included in the meta-analysis. Three studies administered hyaluronic acid (HA) as a primary treatment. Twelve involved various cell-based methods of chondrocyte stimulation for cartilage defects associated with FAI, but heterogeneity did not allow for pooling. Low-quality evidence indicates PRP is not associated with improved outcomes following surgery (mean difference –1.42, 95% confidence interval –3.95 to 1.11, P = .27). Very-low-quality evidence suggests HA (standardized mean difference 1.15, 95% confidence interval 0.64-1.66, P < .001, Z = 4.39) and cell-based therapies may improve function and pain in patients with FAI.

Conclusions

Low-quality evidence indicates PRP is not associated with improved outcomes following hip FAI surgery, and very-low-quality evidence suggests HA and cell-based therapies may improve outcomes.

Level of Evidence

systematic review of Level I-V studies.

Improved Outcomes with Arthroscopic Bone Marrow Aspirate Concentrate and Cartilage-Derived Matrix Implantation versus Chondroplasty for the Treatment of Focal Chondral Defects of the Knee Joint: A Retrospective Case Series

Purpose

To compare the outcomes of patients undergoing treatment of focal chondral defects (FCDs) of the knee joint with chondroplasty versus bone marrow aspirate concentrate (BMAC) and cartilage-derived matrix (CDM) implantation.

Methods

A retrospective chart review was performed for patients diagnosed with Outerbridge grade 3-4 FCDs. Patients were included if they were treated arthroscopically with BMAC/CDM implantation or chondroplasty alone between March 2016 and May 2019 and had more than 1-year follow-up. Postoperative outcomes included the visual analog scale (VAS) for pain; University of California, Los Angeles (UCLA) activity scores; Knee Outcome Survey (KOS) Activities of Daily Living (ADL) and Sports subscores; postoperative corticosteroid or hyaluronic acid injections; subsequent surgeries; and conversion to total knee arthroplasty.

Results

A total of 98 patients were identified with a mean follow-up in BMAC/CDM of 24 months (range 13-41 months) and in chondroplasty of 44 months (range 34-55 months). A subanalysis was performed to control for significant differences in age, which yielded 39 patients, ages 40-60 years. Within the subanalysis group, mean VAS scores were significantly lower in the BMAC/CDM group (1.7 vs 4.4; P = .005) and mean UCLA scores were significantly greater (7.1 vs 5.0; P = .002). Mean improvement in VAS and UCLA scores were similar between the BMAC/CDM and chondroplasty groups (–3.7 vs –1.3; P = .71, 1.9 vs 0.1; P = .14, respectively). Mean KOS ADL and Sports subscores were significantly greater among patients in the BMAC/CDM group (87% vs 55%; P = .001, 71% vs 41%; P = .002, respectively). There were no differences in postoperative injections, subsequent surgeries, or conversion to total knee arthroplasty between the BMAC/CDM and chondroplasty groups.

Conclusions

Patients with grade 3-4 FCDs of the knee had improved postoperative outcomes when treated with BMAC/CDM implantation versus chondroplasty alone, as evidenced by a significant improvement in VAS and UCLA scores and significantly greater postoperative KOS ADL, and KOS Sport subscores.

Level of Evidence

IV, therapeutic case series.

How do I: Evaluate the safety and legitimacy of unproven cellular therapies?

BACKGROUND

Unproven cellular therapies are being offered to patients for a variety of conditions and diseases for which other treatments have failed. The use of untested cellular therapies is a worldwide problem. Practitioners (e.g., physicians, scientists, QA/QI facility managers, and policy advocates) are perhaps unaware of the risks involved with such therapies. Therefore, a critical need exists to bring attention to the potential limitations and adverse effects of these therapies to inform and limit misinformation.

STUDY DESIGN AND METHODS

We describe the extent of the unproven cellular therapy problem through a search of scientific literature and social media coverage. We also describe the regulatory framework that can be used by the practitioner to review and evaluate both proven and unproven cellular therapies.

RESULTS

We report on the current state of unproven cellular therapies across the globe. A workflow to facilitate an understanding of the regulatory processes involved in the approval of cellular therapies is provided as well as a list of warnings required by regulatory agencies on various products. It is hoped that this article will serve as a tool kit to educate the practitioner on navigating the field of unproven cellular therapy products.

DISCUSSION

Increasing awareness of the issues associated with unproven therapies through education is important to help in reducing misinformation and risks to patients.

Extremity War Injury Symposium XV: Sports and Readiness Symposium Summary

Despite the recent decrease in high tempo combat operations, threats to the medical readiness of Service Members remain a persistent issue. In fact, recent research efforts have demonstrated that musculoskeletal disease nonbattle injury represents perhaps the most immediate threat to the medical readiness of Service Members over the past several years. Innovations in a number of therapeutic options, particularly orthobiologics, have shown substantial promise in accelerating recovery and returning tactical athletes to full, unrestricted duties. Posttraumatic osteoarthritis remains a vexing topic but at the same time an intersectional opportunity for a multidisciplinary approach to better understand its pathogenesis, limit its prevalence, and mitigate the functional consequences of its sequalae. The expansion of a clinical infrastructure capable of the prospective collection of Service Members' functional outcomes across military treatment facilities promises to sharpen clinicians' understanding of both the impact of novel treatments for common injuries and the success of efforts to prevent recurrence (Military Orthopaedics Tracking Injury Network, Bethesda, MD). However, policy makers and stakeholders will increasingly find themselves in an environment of increasingly limited resources, which will necessitate creative strategies to maintain the lethality of a fit, fighting force.

The Direct to Consumer Stem Cell Market and the Role of Primary Care Providers in Correcting Misinformation

INTRODUCTION

Direct to consumer stem cell and regenerative interventions (SCRIs) for various medical conditions have increased in popularity due to unmet medical needs and the promise of SCRIs to meet those needs. These interventions may have varying levels of safety and efficacy data and many lack sufficient scientific data to be marketed. The direct to consumer SCRI industry has received significant attention due to potential physical, economic, and emotional harms to patients. Patients may seek the counsel of their primary care providers when considering stem cell therapy for their condition.

METHODS

Here we describe strategies primary care providers can utilize when counseling patients.

RESULTS

Although we recommend constructing these discussions around individual patients' needs, one can utilize a general approach consisting of 4 parts. First, providers should recognize what information the patient is seeking and what is their understanding of stem cell and regenerative medicine. Next, providers should convey evidence-based information at the level of patients understanding so that they are aware of the risks, benefits, and descriptions of possible procedures. Throughout the conversations, attempts should be made to guide patients to a trusted resource that can provide additional information. Finally, providers should make an effort to address misinformation in a way that is nonjudgmental and patient-centered to make the patient feel safe and comfortable.

CONCLUSION

Effectively communicating risk information by primary care providers to patients is important given the harms reported from direct-to-consumer SCRIs. Correcting misinformation remains a priority when discussing SCRI's. Providers should strive to offer patients with additional resources such as the opportunity for consultation with a specialist or a consultation service dedicated to informing patients about regenerative medicine.

Editorial Commentary: Cell-Based Therapies for Articular Cartilage Repair Require Precise Progenitor Cell Characterization and Determination of Mechanism of Action

Biologics and cell-based therapies, in particular, have come to the forefront of orthopaedic sports medicine as agents with therapeutic and regenerative potential. Autologous chondrocyte implantation has been used successfully for many years, but a recent focus on autologous progenitor cells derived from bone marrow aspirate, adipose tissue, and/or synovium has garnered significant interest. Mobilized peripheral blood mononuclear cells [PBMCs or connective tissue progenitors (CTPs)] represent a promising cell population for potential use in articular cartilage repair. The term "stem cell" has become widely popularized, but more specific language identifying the cell type by donor type, tissue of origin, cell surface marker profile, culture conditions, and other cell behavior/characteristics should be used. In 2019, Murray et al. proposed a five-item "DOSES" tool in an effort to encourage standardized reporting for cell-based therapies emphasizing donor, origin of tissue, separation from other cell types/preparation method, exhibited cell characteristics associated with behavior, and site of delivery. The advantages of the DOSES tool include both simplicity and ability to be applied to cell types not yet discovered. However, a universally accepted list of criteria for biologics does not yet exist. Additional research is necessary to better elucidate the precise mechanisms by which cell therapies have a clinical effect and define whether the therapies for the treatment of cartilage pathology merely help alleviate symptoms or actually provide structural improvements. There are few data to suggest exogenous cell therapies directly engraft, so identifying the paracrine mediators produced by these cells would be an area of further interest.

American Medical Society for Sports Medicine Position Statement: Principles for the Responsible Use of Regenerative Medicine in Sports Medicine

ABSTRACT

Many sports medicine physicians are currently considering introducing regenerative medicine into their practice. Regenerative medicine and the subclassification of orthobiologics are a complicated topic and have produced widely varying opinions. Although there is concern by government regulators, clinicians, scientists, patient advocacy organizations, and the media regarding the use of regenerative medicine products, there is also excitement about the potential benefits with growing evidence that certain regenerative medicine products are safe and potentially efficacious in treating musculoskeletal conditions. Sports medicine physicians would benefit from decision-making guidance about whether to introduce orthobiologics into their practice and how to do it responsibly. The purpose of this position statement is to provide sports medicine physicians with information regarding regenerative medicine terminology, a brief review of basic science and clinical studies within the subclassification of orthobiologics, regulatory considerations, and best practices for introducing regenerative medicine into clinical practice. This information will help sports medicine physicians make informed and responsible decisions about the role of regenerative medicine and orthobiologics in their practice.

Umbilical Cord-Derived Wharton's Jelly for Regenerative Medicine Applications: A Systematic Review

Musculoskeletal ailments affect millions of people around the world and place a high burden on healthcare. Traditional treatment modalities are limited and do not address underlying pathologies. Mesenchymal stem cells (MSCs) have emerged as an exciting therapeutic alternative and Wharton’s jelly-derived mesenchymal stem cells (WJSCs) are some of these. This review reports the clinical and functional outcomes of the applications of WJSCs in orthopedic surgery. A systematic review was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The studies that used culture-expanded, mesenchymal stem or stromal cells, MSCs and/or connective tissues procured from Wharton’s jelly (WJ), from January 2010 to October 2021, were included. Conventional non-operative therapies and placebos were used as comparisons. Six studies that directly discussed WJSCs use in an animal model or the basic scientific testing using an injury model were identified. Five publications studied cartilage injury, three studied degenerative disc disease, one was related to osteoarthritis, and one was related to osteochondral defects. The results of these studies suggested the benefits of WJSCs in the management of these orthopedic pathologies. To adequately assess the safety and efficacy of WJSCs in orthopedic surgery, further randomized controlled clinical studies are necessary.

The use of biologics to improve patient-reported outcomes in hip preservation

Despite lack of clear understanding, the use of biologic treatment methods has increased in the United States. Therapeutic methods, including platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC) and hyaluronic acid (HA) among other biologics, are commonly associated with relief of pain in a number of different orthopedic conditions. Within the past two decades, hip preservationists have investigated the roles of these biologic treatments in both non-operative and surgical management of common hip conditions. The purpose is to review the published literature surrounding the application and efficacy of biologics, most notably PRP, BMAC and HA, in the clinical management of hip conditions. The hip conditions examined in this review include hip osteoarthritis, femoroacetabular impingement syndrome and associated labral tear pathology, avascular necrosis of the femoral head and gluteal/hamstring tendinopathy. While our review of the literature suggests that there is support for the implementation of biologics to relieve pain and improve function for hip conditions. Through further research efforts, it is important to stay updated with the clinical efficacy of biologics in hip preservation.

3D Biomimetic Scaffold for Growth Factor Controlled Delivery: An In-Vitro Study of Tenogenic Events on Wharton's Jelly Mesenchymal Stem Cells

The present work described a bio-functionalized 3D fibrous construct, as an interactive teno-inductive graft model to study tenogenic potential events of human mesenchymal stem cells collected from Wharton’s Jelly (hWJ-MSCs). The 3D-biomimetic and bioresorbable scaffold was functionalized with nanocarriers for the local controlled delivery of a teno-inductive factor, i.e., the human Growth Differentiation factor 5 (hGDF-5). Significant results in terms of gene expression were obtained. Namely, the up-regulation of Scleraxis (350-fold, p ≤ 0.05), type I Collagen (8-fold), Decorin (2.5-fold), and Tenascin-C (1.3-fold) was detected at day 14; on the other hand, when hGDF-5 was supplemented in the external medium only (in absence of nanocarriers), a limited effect on gene expression was evident. Teno-inductive environment also induced pro-inflammatory, (IL-6 (1.6-fold), TNF (45-fold, p ≤ 0.001), and IL-12A (1.4-fold)), and anti-inflammatory (IL-10 (120-fold) and TGF-β1 (1.8-fold)) cytokine expression upregulation at day 14. The presented 3D construct opens perspectives for the study of drug controlled delivery devices to promote teno-regenerative events.

Platelet-Rich Plasma: Fundamentals and Clinical Applications

Platelet-rich plasma (PRP) is perhaps the most widely studied of the biologic therapies, with an ever-growing body of evidence supporting its safety and efficacy in decreasing inflammation and pain and promoting healing in the setting of both nonoperative and operative treatments. PRP is produced by the centrifugation of whole blood, isolating its constituent parts based on their unique densities. These density gradients can be selectively harvested so as to obtain different concentrations of various blood product components, such as platelets and leukocytes. A precise and consistent method for describing the essential characteristics of different PRP formulations is critical for both practical and research purposes. The concentration of platelets, method of activation, and the total number of red blood cells (RBCs), white blood cells (WBCs), and neutrophils relative to baseline values are all of particular importance in accurately describing a PRP formulation. The biologic activity of PRP is manifold: platelet α granules promote the release of various growth factors, including vascular endothelial growth factor and tissue growth factor β, while inflammation is modulated through inhibition of the nuclear factor-κB pathway. PRP has been convincingly shown to be efficacious in the setting of patellar tendinopathies, knee osteoarthritis, and lateral epicondylitis. In fact, several recent randomized controlled trials have demonstrated the superiority of PRP over both corticosteroids and hyaluronic acid in treating knee OA-related symptoms. There is also substantial promise for the utility of PRP in treating partial hamstring tears and as an adjunct to rotator cuff (RC) repair, especially in the setting of small- to medium-sized tears, where it appears to exert substantial analgesic effects and promote enhanced rates of RC repair healing.

Tendon-Derived Progenitor Cells With Multilineage Potential Are Present Within Human Patellar Tendon

Background:

Progenitor cells serve as a promising source of regenerative potential in a variety of tissue types yet remain underutilized in tendinopathy. Tendon-derived progenitor cells (TDPCs) have previously been isolated from hamstring tendon but only as part of a concomitant medical procedure. Determining the presence of TDPCs in patellar tendon may facilitate clinical utilization of these cells because of the relative accessibility of this location for tissue harvest.

Purpose:

To characterize TDPCs in human patellar tendon samples.

Study Design:

Descriptive laboratory study.

Methods:

Human patellar tendon samples were obtained during elective knee surgery. TDPCs were isolated and seeded at an optimal low cell density and subcultured to confluence for up to 2 passages. Flow cytometry was used to analyze for the expression of CD90+, CD105+, CD44+, and CD31–, CD34–, and CD45– markers. The multilineage differentiation potential of TDPCs was tested in vitro via adipogenic, osteogenic, and chondrogenic culture with subsequent cytochemical staining for Oil Red O, Alizarin Red, and Alcian Blue, respectively. Enzyme-linked immunosorbent assay was used to quantify the amount of adiponectin, alkaline phosphatase, and SRY-box transcription factor 9 secreted into cell culture supernatant for further confirmation of lineage differentiation. Results were analyzed statistically using the 2-tailed Student t test.

Results:

TDPCs demonstrated near-uniform expression of CD90, CD105, and CD44 with minimal expression of CD34, CD31, and CD45. Adipogenic, osteogenic, and chondrogenic differentiation of TDPCs was confirmed using qualitative analysis. The expression of adiponectin, alkaline phosphatase, and SRY-box transcription factor 9 were significantly increased in differentiated cells versus undifferentiated TDPCs (P < .05).

Conclusion:

TDPCs can be successfully isolated from human patellar tendon samples, and they exhibit characteristics of multipotent progenitor cells.

Clinical Relevance:

These data demonstrate the promise of patellar tendon tissue as a source of progenitor cells for use in biologic therapies for the treatment of tendinopathy.

Treatment of Partial-Thickness Rotator Cuff Tears With a Resorbable Bioinductive Bovine Collagen Implant: 1-Year Results From a Prospective Multicenter Registry

Background:

Surgical treatment of partial-thickness rotator cuff tears remains challenging and controversial, with several traditional options including debridement with acromioplasty, transtendon or in situ repair, and take-down and repair. A resorbable bioinductive bovine collagen implant has shown promise as an alternative treatment option for partial-thickness tears.

Purpose:

Data from a registry were analyzed to further establish that the implant contributes to improved patient-reported outcome (PRO) scores across a large number of patients treated for partial-thickness rotator cuff tears.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 19 centers in the United States enrolled patients >21 years old with partial-thickness tears of the rotator cuff in a comprehensive prospective multicenter registry. PRO scores were recorded preoperatively and postoperatively at 2 and 6 weeks, 3 and 6 months, and 1 year: American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, Veterans RAND 12-Item Health Survey (physical and mental component scores), and Western Ontario Rotator Cuff scores. Revisions were reported throughout the study.

Results:

The registry included 272 patients with partial-thickness tears (49 grade 1 tears, 101 grade 2 tears, and 122 grade 3 tears), 241 who underwent isolated bioinductive repair (IBR; collagen implant placed after bursectomy without a traditional rotator cuff repair), and 31 who had take-down and repair with bioinductive augmentation. Patients experienced statistically significant and sustained improvement from baseline for all PRO scores beginning at 3 months. Among patients with grade ≥2 tears, those with take-down and repair had significantly inferior scores at 2 and 6 weeks for most PRO scores as compared with those who underwent IBR, but the difference was no longer significant at 1 year for all but the physical component score of the Veterans RAND 12-Item Health Survey. There were 11 revisions, which occurred at a mean ± SD of 188.7 ± 88.0 days after the index surgery. There were no infections.

Conclusion:

This registry analysis further establishes across a large data set that this resorbable bioinductive bovine collagen implant improves PROs in all grades of partial-thickness tears, whether used as IBR or in conjunction with take-down and repair. IBR may offer improved early clinical outcomes (≤6 weeks) and comparable outcomes at 1 year when compared with a more invasive “take-down and repair” approach.

Cell-free stem cell-derived extract formulation for treatment of knee osteoarthritis: study protocol for a preliminary non-randomized, open-label, multi-center feasibility and safety study

Background

Musculoskeletal conditions are highly prevalent, and knee OA is most common. Current treatment modalities have limitations and either fail to solve the underlying pathophysiology or are highly invasive. To address these limitations, attention has focused on the use of biologics. The efficacy of these devices is attributed to presence of growth factors (GFs), cytokines (CKs), and extracellular vesicles (EVs). With this in mind, we formulated a novel cell-free stem cell-derived extract (CCM) from human progenitor endothelial stem cells (hPESCs). A preliminary study demonstrated the presence of essential components of regenerative medicine, namely GFs, CKs, and EVs, including exosomes, in CCM. The proposed study aims to evaluate the safety and efficacy of intraarticular injection of the novel cell-free stem cell-derived extract (CCM) for the treatment of knee OA.

Methods and analysis

This is a non-randomized, open-label, multi-center, prospective study in which the safety and efficacy of intraarticular CCM in patients suffering from grade II/III knee OA will be evaluated. Up to 20 patients with grade II/III OA who meet the inclusion and exclusion criteria will be consented and screened to recruit 12 patients to receive treatment. The study will be conducted at up to 2 sites within the USA, and the 12 participants will be followed for 24 months. The study participants will be monitored for adverse reactions and assessed using Numeric Pain Rating Scale (NPRS), Patient-Reported Outcomes Measurement Information System (PROMIS) Score, Knee Injury and Osteoarthritis Outcome Score Jr. (KOOS Jr.), 36-ietm short form survey (SF-36), Single Assessment Numeric Evaluation (SANE), physical exams, plain radiography, and magnetic resonance imaging (MRI) with Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score for improvements in pain, function, satisfaction, and cartilage regeneration.

Discussion

This prospective study will provide valuable information into the safety and efficacy of intraarticular administration of cell-free stem cell-derived extract (CCM) in patients suffering with grade II/III knee OA. The outcomes from this initial study of novel CCM will lay the foundation for a larger randomized, placebo-controlled, multi-center clinical trial of intraarticular CCM for symptomatic knee OA.

Trial registration

Registered on July 21, 2021. ClinicalTrials.gov NCT04971798

The Epidemiology, Risk Factors, and Nonsurgical Treatment of Injuries Related to Endurance Running

ABSTRACT

Running is a popular form of exercise that is easily accessible to various populations; endurance running, defined as distances beyond 5 km, continues to grow within the sport. Endurance running-related injuries are common in the lower extremities and are primarily overuse related. A multitude of risk factors for injury exist, including extrinsic factors, such as running distance and frequency, and intrinsic factors, such as biomechanics and nutrition status. Training and rehabilitation techniques vary with a general focus on strengthening and gradual increase in activity, but evidence is mixed, and it is difficult to generalize programs across different running populations. Management of specific running groups, including youth runners, is an area in which additional research is needed. New treatments, such as orthobiologics and wearable technology, have promising potential to optimize performance and recovery and minimize injury. However, they need to be further evaluated with high-quality studies.

Editorial Commentary: Risks of Biologic Therapies in Sports Medicine: Landmines on the Road to the Holy Grail

Biologic therapies hold great promise in the treatment of a variety of sports medicine conditions, including cartilage injuries, osteoarthritis, and tendon or ligament tears. Cell-based therapies currently under investigation include autologous products such as platelet-rich plasma, bone marrow aspirate concentrate, other adipose and mesenchymal stem cell products, and allogeneic products such as umbilical cord and placenta-derived products. However, their use does not come without risk, and the complications of these treatments can be underreported. Risks include infection, sterile inflammatory response, or a combination. Many times, when offering injection therapy, we consider the greatest risk a lack of efficacy. A "no harm, no foul" attitude is taken. Many of us think that the biggest risk of such injections, due to out-of-pocket expense, would be damage to someone's checkbook more than damage to their health. However, there are real medical risks to our treatments. Regulatory efforts around the use of biologics are needed to track both efficacy and side effects, as we advance this technology and expand its use in the future.

Safety and efficacy of umbilical cord-derived Wharton's jelly compared to hyaluronic acid and saline for knee osteoarthritis: study protocol for a randomized, controlled, single-blind, multi-center trial

Background

Osteoarthritis (OA) is the most common joint disorder in the United States of America (USA) with a fast-rising prevalence. Current treatment modalities are limited, and total knee replacement surgeries have shown disadvantages, especially for grade II/III OA. The interest in the use of biologics, including umbilical cord (UC)-derived Wharton’s jelly (WJ), has grown in recent years. The results from a preliminary study demonstrated the presence of essential components of regenerative medicine, namely growth factors, cytokines, hyaluronic acid (HA), and extracellular vesicles, including exosomes, in WJ. The proposed study aims to evaluate the safety and efficacy of intra-articular injection of UC-derived WJ for the treatment of knee OA symptoms.

Methods

A randomized, controlled, single-blind, multi-center, prospective study will be conducted in which the safety and efficacy of intra-articular administration of UC-derived WJ are compared to HA (control) and saline (placebo control) in patients suffering from grade II/III knee OA. A total of 168 participants with grade II or III knee OA on the KL scale will be recruited across 53 sites in the USA with 56 participants in each arm and followed for 1 year post-injection. Patient satisfaction, Numeric Pain Rating Scale, Knee Injury and Osteoarthritis Outcome Score, 36-Item Short Form Survey (SF-36), and 7-point Likert Scale will be used to assess the participants. Physical exams, X-rays, and MRI with Magnetic Resonance Observation of Cartilage Repair Tissue score will be used to assess improvement in associated anatomy.

Discussion

The study results will provide valuable information into the safety and efficacy of intra-articular administration of Wharton’s jelly for grade II/III knee osteoarthritis. The results of this study will also add to the treatment options available for grade II/III OA as well as help facilitate the development of a more focused treatment strategy for patients.

Trial registration

ClinicalTrials.gov, NCT04711304. Registered on January 15, 2021

Evaluation of immediate and short-term efficacy of DualStim therapy with and without intracavernosal umbilical cord-derived Wharton's jelly in patients with erectile dysfunction: Study protocol for a randomized controlled trial

Introduction

Erectile dysfunction (ED) affects a significant portion of the United States population and causes negative psychological burdens that affects men and their partner's quality of life and satisfaction. Extracorporeal shock therapy (ESWT) utilizing focused ESWT and radial ESWT in Low-intensity shock wave therapy has been used to treat ED with some success. Wharton's Jelly (WJ) is a biologic substance with large amounts of stem cells, growth factors, cytokines and extracellular components. The use of combined focused and radial ESWT (DualStim therapy) with injected WJ have potential uses in ED that may have advantages over current treatments.

Materials

A randomized, single-blinded, controlled clinical trial will be conducted to evaluate the efficacy and safety of DualStim therapy and intracavernosal injection of WJ in moderate to severe ED. A total of 60 patients with moderate to severe ED will be enrolled and treated with DualStim therapy with intracavernosal injection of WJ or saline for a period of 7 weeks. The International Index of Erectile Function – Erectile Function score will be used to gauge the treatment related changes in relation to the subject's baseline. The scores will be recorded at baseline and compared to follow-ups 1,3 and 6 months post-treatment. Any adverse events or severe adverse events will be recorded in the corresponding case report forms. Sexual Encounter Profile, as well as the Global Assessment Questionnaire and the Erection Hardness Score will be used to determine the sexual activity improvement from baseline leading to optimal penetration at follow-ups 1,3 and 6 months post-treatment.

Discussion

This clinical trial is one of the first studies to determine the immediate and short-term efficacy of DualStim therapy, with and without intracavernosal injection of formulated umbilical cord-derived WJ to improve and/or restore erectile function in patients with moderate to severe ED. This study will also provide insight into the safety and efficacy of WJ. We anticipate clinically significant improvement in patients suffering from moderate and severe ED treated with DualStim therapy with WJ compared to their baseline and DualStim with saline.

The 2020 NBA Orthobiologics Consensus Statement

This 2020 NBA Orthobiologics Consensus Statement provides a concise summary of available literature and practical clinical guidelines for team physicians and players. We recognize that orthobiologic injections are a generally safe treatment modality with a significant potential to reduce pain and expedite early return to play in specific musculoskeletal injuries. The use of orthobiologics in sports medicine to safely reduce time loss and reinjury is of considerable interest, especially as it relates to the potential effect on a professional athlete. While these novel substances have potential to enhance healing and regeneration of injured tissues, there is a lack of robust data to support their regular use at this time. There are no absolutes when considering the implementation of orthobiologics, and unbiased clinical judgment with an emphasis on player safety should always prevail. Current best evidence supports the following: Key Points There is support for the use of leukocyte-poor platelet-rich plasma in the treatment of knee osteoarthritis. There is support for consideration of using leukocyte-rich platelet-rich plasma for patellar tendinopathy. The efficacy of using mesenchymal stromal cell injections in the management of joint and soft tissue injuries remains unproven at this time. There are very few data to suggest that current cell therapy treatments lead to any true functional tissue regeneration. Meticulous and sterile preparation guidelines must be followed to minimize the risk for infection and adverse events if these treatments are pursued.Given the high variability in orthobiologic formulations, team physicians must stay up-to-date with the most recent peer-reviewed literature and orthobiologic preparation protocols for specific injuries.Evidence-based treatment algorithms are necessary to identify the optimal orthobiologic formulations for specific tissues and injuries in athletes.Changes in the regulatory environment and improved standardization are required given the exponential increase in utilization as novel techniques and substances are introduced into clinical practice.

Clinically Significant Outcomes Following the Treatment of Focal Cartilage Defects of the Knee With Microfracture Augmentation Using Cartilage Allograft Extracellular Matrix: A Multicenter Prospective Study

PURPOSE

To determine the short-term outcomes following microfracture augmented with cartilage allograft extracellular matrix for the treatment of symptomatic focal cartilage defects of the adult knee.

METHODS

Forty-eight patients enrolled by 8 surgeons from 8 separate institutions were included in this study. Patients underwent microfracture augmented by cartilage allograft extracellular matrix (BioCartilage; Arthrex, Naples, FL) and were followed at designated time points (3, 6, 12, and 24 months) to assess patient-reported outcomes (PROs), clinically significant outcomes (CSOs), and failure and complication rates. Magnetic resonance imaging (MRI) was offered at 2 years postoperatively regardless of symptomatology, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) 2.0 score was documented.

RESULTS

PRO compliance was 81.3% at 6 months, 72.9% at 12 months, and 47.9% at 2 years. All joint-specific and function-related PROs significantly improved compared to baseline at 3, 6, 12, 18, and 24 months of follow-up (P < .01), apart from Marx activity scale, which demonstrated a significant decline in postoperative scores at 2 years (P = .034). The percentage of patients achieving CSOs (as defined for microfracture) at 2 years was 90% for minimal clinically important difference and 85% for patient acceptable symptomatic state. Patient factors including age, sex, body mass index, symptoms duration, smoking, presence of a meniscal tear, lesion size, and location were not associated with CSO achievement at 2 years. One patient (2.1%) failed treatment 9.5 months postoperatively due to graft delamination and required a reoperation consisting of arthroscopic debridement. One complication (2.1%) consisting of complaints of clicking, grinding, and crepitus 15 months following the index procedure was reported. Two-year postoperative MRI demonstrated a mean 40.5 ± 22.9 MOCART 2.0 score.

CONCLUSIONS

In this preliminary study, we found cartilage allograft extracellular matrix to be associated with improvement in functional outcomes, high rates of CSO achievement, and low failure and complication rates at 2-year follow-up.

LEVEL OF EVIDENCE

Level III, prospective multicenter cohort study.

Strategies to Identify Mesenchymal Stromal Cells in Minimally Manipulated Human Bone Marrow Aspirate Concentrate Lack Consensus

BACKGROUND

There is a need to identify and quantify mesenchymal stromal cells (MSCs) in human bone marrow aspirate concentrate (BMAC) source tissues, but current methods to do so were established in cultured cell populations. Given that surface marker and gene expression change in cultured cells, it is doubtful that these strategies are valid to quantify MSCs in fresh BMAC.

PURPOSE

To establish the presence, quantity, and heterogeneity of BMAC-derived MSCs in minimally manipulated BMAC using currently available strategies.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Five published strategies to identify MSCs were compared for suitability and efficiency to quantify clinical-grade BMAC-MSCs and cultured MSCs at the single cell transcriptome level on BMAC samples being used clinically from 15 orthopaedic patients and on 1 cultured MSC sample. Strategies included (1) the guidelines by the International Society for Cellular Therapy (ISCT), (2) CD271 expression, (3) the Ghazanfari et al transcriptional profile, (4) the Jia et al transcriptional profile, and (5) the Silva et al transcriptional profile.

RESULTS

ISCT guidelines did not identify any MSCs in BMAC at the transcriptional level and only 1 in 9 million cells at the protein level. Of 12,850 BMAC cells, 9 expressed the CD271 gene. Only 116 of 396 Ghazanfari genes were detected in BMAC, whereas no cells expressed all of them. No cells expressed all Jia genes, but 25 cells expressed at least 13 of 22. No cells expressed all Silva genes, but 19 cells expressed at least 8 of 23. Most importantly, the liberalized strategies tended to identify different cells and most of them clustered with immune cells.

CONCLUSION

Currently available methods need to be liberalized to identify any MSCs in fresh human BMAC and lack consensus at the single cell transcriptome and protein expression levels. These different cells should be isolated and challenged to establish phenotypic differences.

CLINICAL RELEVANCE

This study demonstrated that improved strategies to quantify MSC concentrations in BMAC for clinical applications are urgently needed. Until then, injected minimally manipulated MSC doses should be reported as rough estimates or as unknown.

Umbilical cord-derived Wharton's jelly for treatment of knee osteoarthritis: study protocol for a non-randomized, open-label, multi-center trial

Background

Osteoarthritis (OA) is the most common joint disorder in the USA, and knee OA has the highest prevalence. Inflammation and decrease in vascularization are key factors in the degeneration of articular cartilage and the associated pain and decrease in function. To combat this process, the use of biologics including umbilical cord-derived Wharton’s Jelly (UC-derived WJ) has grown. UC-derived WJ contains large quantities of regenerative factors, including growth factors (GFs), cytokines (CKs), hyaluronic acid (HA), and extracellular vesicles (EVs). The proposed study evaluates the safety and efficacy of intraarticular injection of UC-derived WJ for treatment of knee OA symptoms.

Methods and analysis

This is a non-randomized, open-label, multi-center, prospective study in which the safety and efficacy of intraarticular UC-derived WJ in patients suffering from grade II/III OA will be assessed. Twelve patients with grade II/III OA who meet the inclusion and exclusion criteria will be recruited for this study which will be conducted at up to two sites within the USA. The participants will be followed for 1 s. Participants will be assessed using the Numeric Pain Rating Scale (NPRS), Knee Injury and Osteoarthritis Outcome Score (KOOS), 36-item short form survey (SF-36), Single Assessment Numeric Evaluation (SANE), physical exams, plain radiography, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score for improvements in pain, satisfaction, function, and cartilage regeneration.

Discussion

This prospective study will contribute to the limited amount of data on UC-derived WJ, particularly with regard to its safety and efficacy. The outcomes from this study will also lay the groundwork for a large placebo-controlled trial of intraarticular UC-derived WJ for symptomatic knee OA.

Trial registration

ClinicalTrials.gov NCT04719793. Registered on 22 January 2021

Academic physician specialists' views toward the unproven stem cell intervention industry: areas of common ground and divergence

BACKGROUND AND AIMS

Premature commercialization of unproven stem cell interventions (SCIs) has received significant attention within the regenerative medicine community. Patients considering SCIs may encounter misinformation and seek out guidance from their physicians who are trusted brokers of health information. However, little is known about the perspectives of academic physician specialists toward the SCI industry. The purpose of this study was to capture the attitudes of physician specialists with experience addressing patient questions about unproven SCIs.

METHODS

The authors undertook 25 semi-structured interviews with academic physicians in cardiology, ophthalmology, orthopedics, pulmonology and neurology primarily from one academic center.

RESULTS

The authors identified two major themes: concerns and mediators of appropriateness of offering SCIs as therapies to patients. Specialists were generally aware of the industry and reported scientific and commercial concerns, including the scientific uncertainty of SCIs, medical harms to patients, misleading marketing and its impact on patient informed consent and economic harms due to large out-of-pocket costs for patients. All specialists outside of orthopedics voiced that it was inappropriate to be offering SCIs to patients today. These views were informed by previously expressed concerns surrounding safety and properly informing patients, levels of evidence needed prior to offering SCIs therapeutically and desired qualifications for clinicians. Among the specialties, orthopedists reported that under certain conditions, SCIs may be appropriate for patients with limited clinical options but only when safety is adequate, expectations are managed and patients are well informed about the risks and chances of benefit. Most participants expressed a desire for phase 3 studies and Food and Drug Administration approval prior to marketing SCIs, but some also shared the challenges associated with upholding these thresholds of evidence, especially when caring for out-of-option patients.

CONCLUSIONS

The authors' results suggest that medical specialists are aware of the industry and express several concerns surrounding SCIs but differ in their views on the appropriateness and clinical evidence necessary for offering SCIs currently to patients. Additional educational tools may help physicians with patient engagement and expectation management surrounding SCIs.

Promising improvement of chronic lateral elbow tendinopathy by using adipose derived mesenchymal stromal cells: a pilot study

Purpose

Study the effect of Adipose derived stromal cells (ASCs) injection as therapeutic procedure on the common extensor tendinopathy.

Methods

Eighteen Tennis players with chronic, recalcitrant LET (who have previously been unsuccessfully treated with nonoperative treatments) underwent clinical evaluation and magnetic resonance imaging (MRI) before intervention. Stromal vascular fraction cells (SVF) were expanded by in vitro culture and ASCs were obtained and characterized by flow cytometry. ASCs were injected into the site of tendinopathy (identified by ultrasound imaging at the origin of the common extensor tendon) on a single occasion followed by physiotherapy. Players underwent serial clinical evaluations during a 12-month period and repeated MRI at 6-month post-injection.

Results

At 6-month clinical evaluation revealed significant improvements compared to baseline in mean Visual Analog Scale (VAS) scores for: (1) maximum pain score (from 6.28 ± 1.65, to 1.0 ± 0.43; p < .001); (2) Mean quick Disabilities of the Arm, Shoulder and Hand (QuickDASH-Compulsory score: 51.38 ± 12.02 to 12.33 ± 4.66; p < .001); (3) QuickDASH-Sport score: 56.94 ± 15.44 to 8.68 ± 8.86; p < .001). Validated MRI scoring system grade of tendinopathy also improved significantly: 4.22 ± 0.26 to 2.22 ± 0.10 (p < .001). At 12-month from injection, VAS maximun pain score further decreased to 0.74 ± 0.44 (p < .001) and QuickDASH-Compulsory score to 5.56 ± 3.58 (p < .001). Average time to return to play tennis was 3,31 ± 0,61 month post-intervention.

Conclusion

Tennis players with recalcitrant LET showed significant clinical improvement and structural repair at the origin of the common tendon origin after injection of autologous ASCs. Results of this study are promising and open a new biological therapeutic modality to treat LET. Even if the results of this pilot study are positive, future well-designed studies, i.e. prospective randomized trials are needed to define the role of cell therapy in treating LET.

Cell-free Stem Cell-Derived Extract Formulation for Regenerative Medicine Applications

Stem cells for regenerative medicine purposes offer therapeutic benefits, but disadvantages are still ill defined. The benefit of stem cells may be attributed to their secretion of growth factors (GFs), cytokines (CKs), and extracellular vesicles (EVs), including exosomes. We present a novel cell-free stem cell-derived extract (CCM), formulated from human progenitor endothelial stem cells (hPESCs), characterized for biologically active factors using ELISA, nanoparticle tracking analysis and single particle interferometric reflectance imaging sensing. The effect on fibroblast proliferation and ability to induce stem cell migration was analyzed using Alamar Blue proliferation and Transwell migration assays, respectively. GFs including IGFBP 1, 2, 3, and 6, insulin, growth hormone, PDGF-AA, TGF-α, TGF-β1, VEGF, and the anti-inflammatory cytokine, IL-1RA were detected. Membrane enclosed particles within exosome size range and expressing exosome tetraspanins CD81 and CD9 were identified. CCM significantly increased cell proliferation and induced stem cell migration. Analysis of CCM revealed presence of GFs, CKs, and EVs, including exosomes. The presence of multiple factors including exosomes within one formulation, the ability to promote cell proliferation and induce stem cell migration may reduce inflammation and pain, and augment tissue repair.

Umbilical cord-derived Wharton's jelly for regenerative medicine applications in orthopedic surgery: a systematic review protocol

BACKGROUND

Musculoskeletal injuries and conditions affect millions of individuals. These ailments are typically managed by immobilization, physiotherapy, or activity modification. Regenerative medicine has experienced tremendous growth in the past decades, especially in musculoskeletal medicine. Umbilical cord-derived Wharton's jelly is an exciting new option for such therapies. Wharton's jelly is a connective tissue located within the umbilical cord largely composed of mesenchymal stem cells and extracellular matrix components, including collagen, chondroitin sulfate, hyaluronic acid, and sulfated proteoglycans. Wharton's jelly is a promising and applicable biologic source for orthopedic regenerative application.

METHODS

A systematic search will be conducted in PubMed, ScienceDirect, and Google Scholar databases of English, Italian, French, Spanish, and Portuguese language articles published to date. References will be screened and assessed for eligibility by two independent reviewers as per PRISMA guidelines. Articles will be considered without exclusion to sex, activity, or age. Studies will be included if they used culture-expanded, mesenchymal stem/stromal cells of mesenchymal stem cells and/or connective tissue obtained from Wharton's jelly. Studies will be excluded if Wharton's jelly is not the sole experimental examined cell type. Placebos, conventional non-operative therapies including steroid injections, exercise, and NSAIDs will be compared. The study selection process will be performed independently by two reviewers using a reference software. Data synthesis and meta-analysis will be performed separately for clinical and pre-clinical studies.

DISCUSSION

The results will be published in relevant peer-reviewed scientific journals. Investigators will present results at national or international conferences.

TRIAL REGISTRATION

The protocol was registered on PROSPERO international prospective register of systematic reviews prior to commencement, CRD42020182487 .

A humoral solution: Autologous blood products and tissue repair

Autologous blood-derived products (ABP) are the focus of growing scientific interest and are investigated and used for multiple medical indications. ABPs hold promise thanks to their availability, ease of preparation, and low risk of adverse allogenic reaction, hypersensitivity, and contamination. Compositional analysis of ABPs reveals a diverse mixture of cellular components, cytokines and growth factors that play roles in healing processes such as tissue proliferation and angiogenesis, modulation of the local environment through chemotaxis and regulation of inflammation and the extracellular matrix, as well as several immunomodulatory actions. Thus, the administration of ABP induces supraphysiological levels of components necessary for orchestrating reparative efforts in currently difficult-to-treat medical conditions. In this article, we review the variety of autologous blood-derived products, their composition, current clinical uses, regulatory climate, and mechanisms of action.

Meniscal substitution, a developing and long-awaited demand

The menisci represent indispensable intraarticular components of a well-functioning knee joint. Sports activities, traumatic incidents, or simply degenerative conditions can cause meniscal injuries, which often require surgical intervention. Efforts in biomechanical and clinical research have led to the recommendation of a meniscus-preserving rather than a meniscus-resecting treatment approach. Nevertheless, partial or even total meniscal resection is sometimes inevitable. In such circumstances, techniques of meniscal substitution are required. Autologous, allogenic, and artificial meniscal substitutes are available which have evolved in recent years. Basic anatomical and biomechanical knowledge, clinical application, radiological and clinical outcomes as well as future perspectives of meniscal substitutes are presented in this article. A comprehensive knowledge of the different approaches to meniscal substitution is required in order to integrate these evolving techniques in daily clinical practice to prevent the devastating effects of lost meniscal tissue.

Editorial Commentary: Orthobiologics-The Evolution From Symptom to Structural Modification in the Treatment of Articular Cartilage Defects

The race is on to identify the optimal recipe for the treatment of focal cartilage defects. Although many attempts had been made, beyond the use of osteochondral allografts, the restoration of pristine hyaline cartilage still seems distant and out of reach. The fundamental assumption is that cartilage restoration constructs must provide both structural integrity and adequate biological features that provide the optimal environment for hyaline cartilage formation. Augmentation of biologic scaffolds and grafts with orthobiologic agents may attend to both needs by improving defect fill and integration to the host articular cartilage interface.

Umbilical cord-derived Wharton's jelly for regenerative medicine applications

Background

The last decade has seen an explosion in the interest in using biologics for regenerative medicine applications, including umbilical cord-derived Wharton’s Jelly. There is insufficient literature assessing the amount of growth factors, cytokines, hyaluronic acid, and extracellular vesicles including exosomes in these products. The present study reports the development of a novel Wharton’s jelly formulation and evaluates the presence of growth factors, cytokines, hyaluronic acid, and extracellular vesicles including exosomes.

Methods

Human umbilical cords were obtained from consenting caesarian section donors. The Wharton’s jelly was then isolated from the procured umbilical cord and formulated into an injectable form. Randomly selected samples from different batches were analyzed for sterility testing and to quantify the presence of growth factors, cytokines, hyaluronic acid, and extracellular vesicles.

Results

All samples passed the sterility test. Growth factors including IGFBP 1, 2, 3, 4, and 6, TGF-α, and PDGF-AA were detected. Several immunomodulatory cytokines, such as RANTES, IL-6R, and IL-16, were also detected. Pro-inflammatory cytokines MCSFR, MIP-1a; anti-inflammatory cytokines TNF-RI, TNF-RII, and IL-1RA; and homeostatic cytokines TIMP-1 and TIMP-2 were observed. Cytokines associated with wound healing, ICAM-1, G-CSF, GDF-15, and regenerative properties, GH, were also expressed. High concentrations of hyaluronic acid were observed. Particles in the extracellular vesicle size range were also detected and were enclosed by the membrane, indicative of true extracellular vesicles.

Conclusion

There are numerous growth factors, cytokines, hyaluronic acid, and extracellular vesicles present in the Wharton’s jelly formulation analyzed. The amount of these factors in Wharton’s jelly is higher compared with other biologics and may play a role in reducing inflammation and pain and augment healing of musculoskeletal injuries.