2019-2020 NFL and NFL Physician Society Orthobiologics Consensus Statement

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.

An Update on Orthobiologics: Cautious Optimism

Orthobiologics are rapidly growing in use given their potential to augment healing for multiple musculoskeletal conditions. Orthobiologics consist of a variety of treatments including platelet-rich plasma and stem cells that provide conceptual appeal in providing local delivery of growth factors and inflammation modulation. The lack of standardization in nomenclature and applications within the literature has led to a paucity of high-quality evidence to support their frequent use. The purpose of this review was to describe the current landscape of orthobiologics and the most recent evidence regarding their use.

Introduction to Equine Biologic and Regenerative Therapies

Regenerative medicine is defined as the process of replacing or regenerating cells, tissues, or organs to restore or establish normal function. The use of regenerative medicine in equine practice to treat injured musculoskeletal tissues with limited capacity for intrinsic healing is growing. This article provides the practitioner with a brief and basic overview of the regenerative products currently used in equine practice.

The Use of Biologics in NFL Athletes: An Expert Consensus of NFL Team Physicians

Background

There is a lack of published information outlining the use of biologics in National Football League (NFL) athletes and limited data to guide biologic treatment strategies.

Purpose

To develop a consensus on the use of biologics among NFL team physicians.

Study Design

Consensus statement.

Methods

A working group of 6 experts convened a consensus process involving NFL team physicians using validated Delphi methodology. Physicians from 32 NFL teams as well as NFL London were invited to take part. This iterative process was used to define statements on the use of biologics in NFL athletes. A recent scoping review exploring biologics in professional athletes was used to inform the first of 3 rounds of surveys, with statements considered under 7 headings: biologics in general, challenges of treating NFL athletes, terminology/nomenclature, autologous blood products, cell-based therapies, guidance for NFL team physicians, and biologic research in the NFL. In addition to rating agreement, experts were encouraged to propose further items or modifications. Predefined criteria were used to refine item lists after each survey. For a consensus within the final round, defined a priori, items were included in the final information set if a minimum of 75% of respondents agreed and fewer than 10% disagreed.

Results

Physicians from 26 NFL teams and NFL London responded to the initial invitation to participate in the Delphi process; 88.9% of participating team physicians completed the round 1 survey, with response rates of 87.5% in round 2 and 95.2% in round 3. After 3 rounds, 47 statements reached a consensus. A consensus was achieved that platelet-rich plasma has a positive impact on patellar tendinopathy and on symptoms in early osteoarthritis but not for other indications. NFL team physicians agreed that while cell therapies have the potential to improve symptoms, the misrepresentation of uncharacterized preparations as "stem cells" has contributed to the widespread use of unproven therapies.

Conclusion

This study established an expert consensus on 47 statements relating to the use of biologics in NFL athletes. In addition to providing clinical guidance for the use of biologics in NFL athletes, this study identified key areas for future focus including the development of athlete education materials.

Opinion: Patient reported motivations for seeking stem cell therapy and considerations for counseling

Stem cell therapies occupy a unique place in the American public's consciousness which has led to excessive enthusiasm over their potential to cure orthopedic conditions. Much has been written about direct-to-consumer marketing of cell therapies for a myriad of medical conditions. Far less has been studied on the attitudes that drive many patients to seek stem cell and orthobiologic therapies for musculoskeletal conditions. Previously published research on patient motivations for seeking stem cell therapy to treat orthopedic maladies such as osteoarthritis and chronic tendinopathies has shown that some patients were motivated by factors not supported by current medical evidence. These differing responses strongly suggest the need for patient-centered counseling to address misinformation about stem cell therapies for musculoskeletal conditions and increase health literacy about outcomes of orthobiologics.

The Current Role of Biologics for Meniscus Injury and Treatment

PURPOSE OF REVIEW

There is little doubt that the consensus has changed to favor preservation of meniscal function where possible. Accordingly, the indications for meniscal repair strategies have been refocused on the long-term interest of knee joint health. The development and refinements in surgical technique have been complemented by biological augmentation strategies to address intrinsic challenges in healing capacity of meniscal tissue, with variable effects.

RECENT FINDINGS

A contemporary approach to meniscal healing includes adequate surgical fixation, meniscal and synovial tissue stimulation, and management of the intraarticular milieu. Overall, evidence supporting the use of autogenous or allogeneic cell sources remains limited. The use of FDA-approved medications to effect biologically favorable mechanisms during meniscal healing holds promise. Development and characterization of biologics continue to advance with translational research focused on specific growth factors, cell and tissue behaviors in meniscal healing, and joint homeostasis. Although significant strides have been made in laboratory and pre-clinical studies, translation to clinical application remains challenging. Finally, expert consensus and standardization of nomenclature related to orthobiologics for meniscal preservation will be important for the advancement of this field.

Orthobiologics: Current role in Orthopedic Surgery and Traumatology

Orthobiologics are organic and synthetic materials that help in the cure of musculo-skeletal problems and are utilized in Orthopaedic Surgery, both in and out of the surgical theater, to augment the possibilities of curing bone and soft tissue lesions. Taking into account that their effect is frequently multifactorial and, in some occasions not entirely comprehended, together with the insufficient clinical information, orthobiologics should be scrupulously assessed against other secure and clinically accepted options. The fundamental orthobiologics today ready for use in Orthopedic Surgery are the following: osseous hollow fillers, extracellular matrix (ECM) substances, platelet-rich plasma (PRP), bone morphogenetic protein-2 (BMP-2), bone marrow aspirate (BMA), bone marrow aspirate concentrate (BMAC), and mesenchymal stem cells (MSCs). It is predictable that in the time to come we will have more secure and more efficacious orthobiologics. Meanwhile, it is paramount that orthopedic surgeons have appropriate information of contemporary orthobiologics (biological adjuvants) so that they can utilize them correctly.

Patients seeking stem cell therapies-a prospective qualitative analysis from a Regenerative Medicine Consult Service

Despite patient demand for stem cell therapies (SCTs) for musculoskeletal conditions, there remains limited research on why patients seek SCTs or their sources of information. We employ three questions into a consult intake form: (1) Why are you interested in stem cell treatment for your condition? (2) How did you find out about stem cell treatment for your condition? (3) Have you contacted a stem cell clinic? Responses analyzed, using a qualitative content analysis approach to identify themes reveal many patients seek SCTs to treat pain or delay surgery which may align with some current clinical evidence while other patients express motivations as expected outcomes (e.g., SCTs are better than standard of care or can regenerate tissue) which are not supported by current medical evidence. These differences suggests that patient-centered counseling may help patients by addressing misconceptions and increasing health literacy about expected outcomes of SCTs for treating musculoskeletal conditions.

Orthobiologics and hyaluronic acid usage in the Netherlands: an electronic survey of 265 orthopaedic surgeons and sports physicians

Purpose

“Biologic therapies” in the field of orthopaedic surgery and sports medicine, so called orthobiologics, have been gaining significant interest from physicians and patients, with increasing usage over the recent years. The aim of this study is to (1) evaluate the usage of orthobiologics in the Netherlands, (2) to clarify the reasons for the use or non-use of orthobiologics, and (3) the most addressed disease for use of orthobiologics.

Methods

The authors created a 19-quenstion online survey comprised of both closed-ended and open-ended response questions in order to examine the use of and the indication for orthobiologics. The survey was sent to all the members of the Dutch Orthopaedic Association and Netherlands Association of Sports Medicine of which 15% responded.

Results

The majority of the 265 respondents (65%) did not treat patients with or refer patients for treatment with orthobiologics. The most important reasons for not using orthobiologics were the lack of scientific evidence, the lack of good experience, and the lack of insurance coverage. Of the physicians that used orthobiologics, the most used hyaluronic acid (76%) and platelet-rich plasma (27%). Orthobiologics were most used for knee osteoarthritis and medial or lateral epicondylitis.

Conclusion

Although some orthobiologic treatments might be effective and the research interest is growing, our study shows that the majority of orthopaedic and sport physician clinicians in the Netherlands still does not make use of orthobiologics as a treatment option, but almost a third of them is contemplating to start using orthobiologics.

Level of evidence

III.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-021-00380-9.

Nonoperative and Operative Soft-Tissue and Cartilage Regeneration and Orthopaedic Biologics of the Knee: An Orthoregeneration Network (ON) Foundation Review

Orthoregeneration is defined as a solution for orthopedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include: drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the knee, including symptomatic osteoarthritis and chondral injuries, as well as injuries to tendon, meniscus, and ligament, including the anterior cruciate ligament. Promising and established treatment modalities include hyaluronic acid (HA) in liquid or scaffold form; platelet-rich plasma (PRP); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs), hematopoietic stem cells, endothelial progenitor cells, and growth factors; connective tissue progenitor cells (CTPs) including adipose-derived mesenchymal stem cells (AD-MSCs) and tendon-derived stem cells (TDSCs); matrix cell-based therapy including autologous chondrocytes or allograft; vitamin D; and fibrin clot. Future investigations should standardize solution preparations, because inconsistent results reported may be due to heterogeneity of HA, PRP, BMAC, or MSC preparations and regimens, which may inhibit meaningful comparison between studies to determine the true efficacy and safety for each treatment.

Biologics in professional and Olympic sport: a scoping review

AIMS

The aim of this study was to prepare a scoping review to investigate the use of biologic therapies in the treatment of musculoskeletal injuries in professional and Olympic athletes.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews and Arksey and O'Malley frameworks were followed. A three-step search strategy identified relevant published primary and secondary studies, as well as grey literature. The identified studies were screened with criteria for inclusion comprising clinical studies evaluating the use of biologic therapies in professional and Olympic athletes, systematic reviews, consensus statements, and conference proceedings. Data were extracted using a standardized tool to form a descriptive analysis and a thematic summary.

RESULTS

A total of 202 studies were initially identified, and 35 met criteria for the scoping review; 33 (94.3%) were published within the last eight years, and 18 (51.4%) originated from the USA. Platelet rich plasma was the most studied biologic therapy, being evaluated in 33 (94.3%) studies. Ulnar collateral ligament and hamstring injuries were the conditions most studied (nine (25.7%) studies and seven (20.0%) studies, respectively). Athletes most frequently participated in baseball, soccer, and American football. Only two (5.7%) studies were level 1 evidence, with interpretation and comparison between studies limited by the variations in the injury profile, biologic preparations, and rehabilitation protocols.

CONCLUSION

There is diverse use of biologic therapies in the management of musculoskeletal injuries in professional and Olympic athletes. There is currently insufficient high-level evidence to support the widespread use of biologic therapies in athletes. Further research priorities include the development of condition/pathology-specific preparations of biologic therapies, and of outcome measures and imaging modalities sufficiently sensitive to detect differences in outcomes, should they exist. Cite this article: Bone Joint J 2021;103-B(7):1189-1196.

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.

The future of meniscus science: international expert consensus

Purpose

The purpose of this study was to evaluate the main focus areas for research and development for furthering the state of meniscus science in 2021.

Methods

An electronic survey including 10 questions was sent in a blind fashion to the faculty members of the 5^th International Conference on Meniscus Science and Surgery. These faculty served as an expert consensus on the future of research and development areas of meniscus science. Survey responses were analyzed using descriptive statistics and ranking weighted averages were calculated to score survey questions.

Results

Of the 82 faculty, 76 (93%) from 18 different countries completed the survey (84% male, 16% female). The highest ranked future research and development focus areas were meniscus repair, biologics, osteotomy procedures, addressing meniscus extrusion, and the development of new therapies for the prevention of posttraumatic osteoarthritis. Currently, the most ‘valuable’ type of biologic reported for meniscus treatment was platelet-rich plasma. The main reported global research limitation was a lack of long-term clinical outcomes data. The most promising emerging medical technologies for improving meniscus science were 3-D printing, personalized medicine, and artificial implants.

Conclusions

This survey suggests that the future of meniscus science should be focused on meniscal preservation techniques through meniscus repair, addressing meniscal extrusion, and the use of orthobiologics. The lack of long-term clinical outcomes was the main reported research limitation globally for meniscus treatment. Future product development utilizing emerging medical technologies suggest the use of 3-D printing for meniscal transplants/scaffolds, personalized treatment, and bioengineering for artificial implants.

Level of Evidence

Level V.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-021-00345-y.

Utilization of Orthobiologics by Sports Medicine Physicians: A Survey-based Study

Introduction:

Investigations are rapidly increasing into products referred to as orthobiologics and their utility in the nonsurgical and surgical treatment of diverse orthopaedic pathology.

Methods:

Members (599) of the American Orthopaedic Society for Sports Medicine were sent a survey that assessed their usage, motivation for use, and perceived efficacy of the following orthobiologics: leukocyte-rich platelet-rich plasma, leukocyte-poor platelet-rich plasma (PRP-LP), bone marrow aspirate concentrate, amniotic membrane products, adipose-derived mesenchymal stromal cells, and umbilical cord–derived cells. Application of these orthobiologics for the following pathologies was assessed: osteoarthritis, muscle injuries, tendon injuries, ligament injuries, labral injuries, and focal articular cartilage tears.

Results:

The survey was completed by 165 respondents (27.5%), of which 66.1% reported using at least one orthobiologic in their practice. Orthobiologic users reported the following: 71.6% are increasing their use, and 23.9% advertise their use. PRP-LP is the most commonly used orthobiologic for 76.1%, with 30% of PRP-LP users reporting use due to competitor utilization. The pathology most commonly treated with orthobiologics is osteoarthritis, for 71.6% of users, who primarily use PRP-LP in the knee joint. Leukocyte-rich platelet-rich plasma is the most popular orthobiologic in muscle, ligament, tendon, and labral injuries, whereas bone marrow aspirate concentrate is most popular for focal articular cartilage injuries. Primary orthobiologic-eligible groups were adults and recreational noncompetitive athletes. More than half (>50%) of orthobiologic users perceived all but umbilical cord–derived cells to be efficacious.

Conclusion:

Orthobiologics are used by a significant number of sports medicine physicians and are likely increasing in popularity. Among orthobiologics, platelet-rich plasmas are the most popular, and osteoarthritis is the pathology most likely to be treated. Orthobiologics are sometimes used for reasons other than clinical efficacy, especially competitor utilization, and physicians are disparate in their application of these products.