Orthobiologics - Post Procedure Guidelines

Orthobiologics, also known as regenerative medicine, is a rapidly advancing field that offers new options to treat acute orthopedic injuries and chronic or degenerative conditions without surgery. It is one of multiple promising treatments for muscle, joint, and soft tissue injuries.  Orthobiologics are therapies developed from natural biologic substances that promote healing.  They can be categorized into “Autologous” (i.e. you yourself provide the tissue or blood) or “allograft” (donated by another individual).  For orthopedic applications in the U.S., the FDA only allows orthobiologics that are autologous. The main advantage of using autologous products over allografts is safety; these benefits include the innate decrease in immunologic side effects, tissue rejection and reduced possibility of disease transmission. 

Autologous orthobiologics include many products including platelet rich plasma (PRP), platelet lysate (PL), alpha-2 macroglobulin, interleukin-1 receptor antagonist protein (IRAP), bone marrow aspirate (BMA) and micro-fragmented adipose tissue (MFAT).  They help reduce musculoskeletal pain and promote a healing response through growth factor and cytokine (signaling molecule) activation. They essentially can help change the biologic environment within a degenerative joint or tendon to favor repair and regeneration.  They can help naturally reduce pain and inflammation without using steroids.  This is accomplished by a variety of mechanisms including immunomodulation, angiogenesis (increases blood flow locally to tissue), and cellular regeneration, differentiation and apoptosis (repairs and remodels tissue).  These products either help activate or contain progenitor cells (i.e mesenchymal “adult” stem cells) that can help accelerate tissue healing and slow the progression of degeneration.

PRP is an autologous preparation of concentrated platelets isolated from whole blood by centrifuge.  Platelets are our “First Responders” to a site of injury and once activated, help to initiate our body’s naturally own healing mechanisms.  More than 3,000 bioactive proteins are released from activated platelets when injected into damaged tissue which help to synergistically regulate multiple pathways involved in cell proliferation and repair, recruitment of progenitor cells, modulation of inflammation, stimulation of protein synthesis and angiogenesis.  PRP can be injected into multiple musculoskeletal tissues including joints, bone, tendons, ligaments and intervertebral discs.  Although deemed an experimental treatment, the medical evidence for orthopedic applications is evolving quickly and we have good research studies that support its use for conditions like tennis elbow, gluteal tendonitis, plantar fasciitis and knee arthritis.  Since there can be tremendous variation in the composition of PRP, the efficacy of PRP is highly dependent on the quality of PRP, experience of the health care provider administering it, and the  conditions you are using it for.

Micro-fragmented adipose tissue or MFAT is another orthobiologic product used for musculoskeletal conditions.  Subcutaneous adipose tissue is a common reservoir of progenitor cells, such as mesenchymal stem cells or MSC’s.  MFAT initially was used in cosmetic and reconstructive medical procedures but more recently has been used to help treat musculoskeletal injuries or degenerative conditions such as arthritis. MSC’s have vast potential in regenerative medicine due to their ability to proliferate and differentiate into multiple lineages, including adipocytes, chondrocytes, myocytes, and osteoblasts. These cells home in on sites of injury and secrete bioactive factors that are immunomodulatory and trophic, meaning that these cells make therapeutic drugs called “exosomes” that are medicinal and secreted at a site of injury. This can have a powerful paracrine effect on the surrounding tissue to help activate cellular genes to promote healing and repair. Furthermore, MSC’s are free radical scavengers that promote cell survival and help remove toxic substances which help mediate inflammatory response. Current musculoskeletal applications have included shoulder, hip and knee osteoarthritis, osteonecrosis of the femoral head, and tendon or ligament tears such as in the rotator cuff. 

MSC’s can be obtained from different sources including bone marrow, adipose tissue, synovial tissue and muscle but the most common harvesting techniques involve either aspirating bone marrow from the pelvis (called BMA) or performing a liposuction procedure to the abdomen or flank (called MFAT).  There are many FDA-compliant devices that can harvest bone marrow aspirate or from adipose tissue. The adipose derived MSC kits can create MFAT with intact stromal vascular niche and MSC’s (cells remain viable in their natural environment) that can be safely injected back into patients for orthopedic applications. This helps promote cell viability that will allow the MSC’s to act locally on the injured tissue helping to synergistically regulate multiple pathways involved in cell proliferation and repair, modulation of inflammation, stimulation of protein synthesis and angiogenesis.  As with PRP, MFAT and BMA procedures are deemed experimental but the medical evidence for orthopedic applications is evolving quickly and we are beginning to see more studies to support its use in orthopedic degenerative conditions such as osteoarthritis and tendinopathies. It is a promising therapy to help treat common degenerative orthopedic conditions in a safe and less invasive way.