Thank you for waking up early on the Saturday to join us. This talk will be very, I think, complementary to Scott's because it will be much more technique oriented. He did a great job of covering a lot of the science behind it, so we'll try to hit the happy medium here. Also, just at the beginning, this whole Wild West part of our regenerative medicine, part of medicine here, is coming to a close, and I think that that's really because of the FDA understanding that this whole other area, this is not our practices, but the whole other area of medicine where this is circulating has been misleading our patients and misusing and misnaming these products, and so then in short summary, the FDA has removed most of the products from the market that these practices were using, and so now it's going to be very difficult for them to survive, but a positive thing overall, I think, happening with the FDA, but certainly we need our own advocacy and our own good research to push this forward for the good part of regenerative medicine. As Scott was talking about, there's been a name shift, and we no longer talk about stem cell therapy, and I guess the question is why. Why did we rename it cellular therapy? Well, here's a little bit of the true maturing stages of a stem cell, and the truth is that these stem cells, when we age, they gradually lose their ability to make any cell or any organ within our body, and so then they cross a line where they can't make everything, and those are the cells that we use clinically. Those are best termed progenitor cells because they do retain a lot of stem-like qualities. In other words, if we want to make tendon, we want to make bone, et cetera, they still retain that. They do not retain the ability to make all cells within our body, so that is the main reasoning for renaming this whole area. So then if we're going to rename it to these cellular medicine or progenitor cells, the question from the very beginning is what do these cells do? What can they do for us? And I think what you're asking from us here at the podium is what's the data, right? What's the data on this? So I just want to be clear of what we know now. Pretty strong evidence to suggest that if you look at all the trials that use cellular medicine, almost all of them produce a therapeutic effect, and this is with placebo-controlled trials as well. There's science behind that because what we know is that these cells occupy areas on the mu-opioid receptors, and so therefore it's interesting that there is an actual mechanism of pain relief with the use of these cells, and that appears to be present clinically. They're very strongly anti-inflammatory as well. This is different than the EDSET approach and the way that they are over-the-counter medicines work, but this is immunomodulatory, so it blocks the body's inflammatory response. And so this is another big mechanism that these cells use. Now I have some good data to show here today that may suggest that the bottom thing, rebuilding tissues previously was unknown. But as of 2021, we have some level one evidence to suggest that might not be true, and I'll go over that with you guys this morning. So what we're really talking about in these orthobiologics with regard to cartilage is this problem that you see up on the screen. This has been done for years and years in orthopedic practice, where we take adult chondrocytes and in some way we mix them, we give them enzymes, we chop them, we smash them, and then we put them back. And that does work to an extent, but what doesn't work is the annealing and the fixing to the bottom part of the subchondral bone and the neighboring cartilage. That's the major deficiency of using adult-like cartilage. And one of the reasons that this whole field here in cartilage therapy exists. So as of now, we have two potential cell types that we can use, the bone marrow-derived and the adipose-derived. Scott talked a lot about those, so I'll go more into just the technique part of it. And what we're doing less is the microfracture-driven types of surgery. So pretty good evidence to suggest that if you're going to use these cells derived from bone marrow, your best source of this is the iliac crest. Number one, posterior, and the second is the anterior iliac crest. And so this can be done in the clinic, which is unfamiliar with all of us, but well-tolerated, believe it or not. And if this was a heme encore, you would just say, oh, of course we do this every day, right? Pretty well-tolerated, but foreign to us in orthopedics. The key about this technique of getting bone marrow, and I saw a lot of examples of it this week, is technique. You cannot just put a jam-cheating needle in and suck it out and get 60 cc's. That will lead to a very, very small amount of cells. So this technique is ultra-important if you're going to do this. The key thing is small volumes of aspiration. In fact, the data is, if you take one cc, it's better than four. But if you take four, much better than 10 or 20, because once you get past the one to four cc's, there's almost no more cells that you're going to get from that site. So instead, this involves placing the needle through the outer cortex and the inner table region. Again, it's the local anesthetic, especially to the periosteum, obviously, if you're going to be doing this in the clinic, but amazingly well-tolerated. Then getting to a certain area in the inner table space, and then putting your syringe, and what you're going to notice is very small amounts of the bone marrow aspirate, and then we're going to switch. We're going to switch areas in the bone marrow, we're going to take a little bit more, and it's a little bit of a mission as you're going all around the bone marrow to get small aliquots, and that's the best way to maximize your cells. Pretty good data to suggest that if you want to then improve the amount of cells further, that you can use bone marrow concentration systems, which will roughly double the number of cells. Okay, good data to suggest that these systems work. So let's go from the clinical side. What are we going to use bone marrow for with regards to cartilage? Very poor evidence at this time that the bone marrow aspirate concentrates does really anything to decrease the symptoms of arthritis, and even less likely to regenerate any cartilage. Poor evidence at this point, but I must say, as a profession, we still don't know what we're doing with regards to bone marrow. Here's one of our studies that shows that if you use the different bone marrow concentration machines, they make totally different recipes of cellular mixtures. And it depends what we really want to do. Do we really want, as Scott was saying, we want to increase the white blood cells and create a reaction? Do we just want the cells? Do we want more platelets? It's all over the place. So I think we need to avoid overarching conclusions, such as BMAC doesn't work for arthritis. More testing is necessary, and we certainly need to know a little bit more about what we're putting in to the patient, rather than calling it all BMAC across the board. That happened with PRP, right? And now we don't talk that way anymore, because we know that the different formulations behave differently. So if you want to know what is the best evidence that exists today, it is this from Alberto Gobbi from Italy, is the best evidence today of how to use BMAC for cartilage regeneration. Now this, he has 10-year follow-up data. Bottom line is pretty good evidence that this works, but this requires a patch or a matrix and a mini-open technique. So he just really hasn't done this from the arthroscopic technique. I'm going to show you lots of arthroscopic techniques today, but bottom line is this is best evidence for the use of BMAC, and it is for cartilage defects, not for osteoarthritis. What about adipose tissue? This is a different animal. Again, skipping a lot of the basic science part of this, but just understanding that where we're going to find these cells in fat is totally different, right? So these cells are right around the blood vessels, these perivascular cells and parasites and the associated stromal cells that are right next to them. And so then, if we're going to harvest fat, we've got to release these cells from the fat tissue. Hence, then, you can't just chop out fat and put it in the joint. It has to be processed. And so I wanted to show you a couple things really quickly. Number one, if you're going to be doing this, become familiar with abdominal liposuction techniques. It's not hard. Again, this is in the clinic, easily tolerated, but it's uncomfortable for us, right? Just because we're not used to doing this. So maybe a couple of taking some trials in the lab just to get used to this, but otherwise it's very safe. The key to this is to put in this tumescent fluid, which is the mix in the center here, and to leave it for a minimum of 20 minutes before you harvest it. Otherwise, this doesn't work, right? So that's really the big summary. Summary number two, this area below the umbilicus and above the pubis is the safe zone for the subcutaneous tissues. Be careful about the buttock area. And when we had our biologic conference at the beginning of this, we just talked about some major complications and near misses as far as death, et cetera, because of the gluteal artery that's near, of course, that area. So be very careful in that area of the body. It is unforgiving. This is a more technique approaches to using the arthroscopic technique. So this is the second way, and it's certainly a good avenue for gaining fat tissue for us in orthopedic surgery. This is a standard shaver system, synovial-based shaver system, but it's hooked up into this fat canister. So instead of going into the Neptune, so to speak, it just goes into here. You see the fat floating on the top, and then it's decanted. And so then we're going to take all the fluid out. We're going to take the red blood cells out. And then bottom line is we'll have this fat mixture. Now that's already chopped up fat, but it is not chopped up enough for us to use. So it must then undergo further processing. You will see this as this numbing experience if you look at the literature of all these anacronyms and different ways with which fat can be processed. It's an art. There's a lot of science behind this. But bottom line is that there's lines in the sand, right? And this is appropriate. You can't use enzymes, et cetera. So only a certain amount of processing is allowed, and I will show you that line here today. So one of the things that you can use is this ball bearing system that you see to the right. This has reasonable data to suggest that the cellular population that you get from this—well, let me just rephrase. It's not a cellular population. These are actually clusters of fat tissue with the cells not separated from them. But they're in small enough clusters that it becomes biologically active, and I think that's a better way to describe it. But I wanted to tell you all that if you're going to use arthroscopic harvest, do not use this ball bearing system. It does not work. And just because of the way that the fat is harvested, it does not work with this system. So that leaves you with the left side. This is syringe emulsification. This is putting the fat tissue with lure lock adapters of decreasing diameter, and it pushes the fat through there, and then that's the thing that breaks apart the fat cells and the matrix to get a more pure population. You can still also then centrifuge. That gives you even more of the things that you want, which is that 20% of the cellular content of fat that is biologically active. As Scott was saying, no good data to suggest you need pure cells, right? This does not give you pure cells. That's not allowed by the FDA, but this does give you a more condensed biologic mixture, I would just, to phrase it that way, of cells to use. We've done the homework. So the homework is that this is, again, the cells that we want in approximately 20% of the native cells, so pretty good. That's much different than the 0.01 from bone marrow aspirate, right? So a richer source of cells. We're doing lots of randomized trials, and that's what we have to do, right, to get to the next level. I wanted to show you a little bit of the technique that's involved with this. The key to this is that if you look, there's two suction ports that are required. So for the need to be drained arthroscopically and to look like this, it will require suction from your cannula, your scope cannula, and then suction from the port with which you're working. And that's just the dynamics of the fluid. So that's the only way really to drain the fluid out. All of these techniques, and you'll just see this in a slightly different way here a little bit later on, all these techniques require removal of the calcified cartilage layer. That's also the first step in micro-drilling and microfracture, so always required. Fiber and glue here for this. This is our mixture of decellularized matrix as well as the fat-derived cells. You see how we could then patch this into chondral defects. And then what we'll do is another layer of fiber and glue to create a cocoon. This is the technique that the clinical trials that we're using for this. So almost embarrassingly, I owe you guys some data because this trial has been going on for a while and this is a COVID issue because all of these MRIs are immediately piped over to Europe and that has created some issues over the past year. So we have some data that's gonna be coming back really soon to report on this. But I think, remember that first slide where we were worried about the annealing or the healing of this tissue to the surrounding cartilage and bone. This is much better, right? It's what we wanted from it. So we'll get further evidence coming forward here over these next couple of months using this technique. But I wanted to share these level one evidence now, right? There wasn't really any good evidence to suggest that these adipose-derived cells worked in osteoarthritis. And now we have three randomized controlled trials all from East. Here is a Chinese trial and I know that the MRIs are small, but in a way, this is their best picture so we have to take their word on this, but this is a regulated trial. Shows two things. Now, number one, clinical improvement, that's what we talked about in slide number one, increasing function and decreasing pain. But they did have, with MRI analysis, a significant cartilage improvement as far as the thickness in osteoarthritis patients. So, okay, well that's one trial. Here's trial number two. This is another trial. This is not from China, but nearby showing the same thing. Decreased pain, increased function, and thickening of the cartilage with MRI analysis following up. So again, some reasonable evidence at the highest medical level. Okay, another regulated trial. But then finally, there's one other one and this is a Korean trial. And with this, improvement in pain consistent across the board, improvement in function consistent across the board. Here, they did not show evidence of having cartilage regeneration in osteoarthritis. So here's where we stand. We stand with the adipose-derived cells, improvement in pain across the board, function across the board, and some increasing evidence. I don't think we're there yet to make any sort of claims or any sort of true understanding that this truly does add to thickening of the cartilage, but this data is emerging. Our trial is the largest chondral defect trial, so we don't have that back yet. So the use of that technique that I showed you is not ready for prime time yet, but there is some evidence in osteoarthritis patients. The flip is true for BMAC. No good evidence to suggest that we should be injecting that for osteoarthritis patients, but some very reasonable evidence that if you wanted to use this in chondral defect trials, that that is where the best evidence lies. What about this science? This science of chondrocytes, as we were talking about this age-old problem, and actually not using the cells, but using one step up, which is immature chondrocytes. Pretty reasonable data to suggest that the whole physiology of the cartilage cell and the genetic makeup of it changes around the age of 13, and that's why many of us see our clinical patients that are young as, oh my gosh, this healed, when in an adult, the chances of that are very low. So there's something different about the juvenile chondrocytes, and now there's a lot of basic science data that explains the reasoning why. So then, if we have this opportunity to use it clinically, maybe this would be different story than the adult type of cells. So this can be used now in the arthroscopic technique, and that's the reason that I'm showing you the techniques, because once you learn this for one sort of application, such as maybe now these juvenile chondrocytes, you can use that for any of the biologic approaches. This is a CO2 gun, as we were testing this, that didn't help at all, so you don't need that. But what you do need is this flexible cannula, right? That was also the same as the, using the adipose-derived technique. What you do need is removal of the calcified cartilage layer, here, again, using fiber and glue, here, again, using a different type of technology, right, of the juvenile chondrocytes. You see that they, at the beginning, float in the fiber and glue, and then, so it looks like this is never going to work, right, but just know that they float. So then you have to use your freer or similar instrument to push these down, and you can see, when you work with them, they become at the level of the cartilage. And so then you can use the second layer of fiber and glue to seal them in, so it does take a little finessing of this. You can't just pipe them in and walk away. But you see that the field could be maintained and workable. So, again, there's a lot of the technique involved, a bottom line, a doable thing. And as far as our results of that, that's also pending, but should be back soon, as far as the arthroscopic technique. Here's some, basically, level four studies showing open technique. So not enough data to suggest that this is better than adult chondrocytes, but basic science data suggests that it is likely to be the case. But again, stand by for additional evidence. Here's what I was talking about with regards to allografts. There's a lot of good in allograft medicine, because we use it all the time, right, for ACLs and other parts of our procedures. But with regards to amniotic fluid and amniotic tissue, most of those products are gone from the market. There's many reasons why. FDA has its reasons of homology, et cetera. I think our reason from the basic science side is we just don't understand biology enough from the allografts. So here's the good and the bad. The good is that if you go to the delivery room and you take amniotic fluid and amniotic tissue, it is a very rich source of cells, as it should be. As Scott talked about, if you then process this, you sterilize it, it becomes something very different. And that's the dichotomy of this. No one's saying that the amniotic fluid is not good. It's just when you process it, how good is it? And that is the big disparity between the products that are on the shelf and the delivery room. But I think this goes beyond this. So here's allogenic umbilical cord trials. I think these are from Korea. And it's striking to read them, right? This is in our literature. And it's striking because of the safety trials. And you look, and these are a safety trial of seven. And look at the total complications, six. Oh, wow, that's heavy. And then their conclusion is this is a safe product because the complications weren't that bad. Ah, I don't know, that's not jiving. So please, I'll just say we need to use caution of using our allogenic sort of tissue. That same sort of complications are out there in the literature for the patches, right, of rotator cuff, et cetera. If you look, they're there. So again, just use caution with the xenografts and some of the allograft types of treatments. Finally, subchondral bone. New understanding of cartilage generation of two things. Number one, evidence to suggest that this bone is also this culprit in pain generation. And we're looking for new ways here to identify the pain-generating portion of osteoarthritis or of the chondral defects. But pretty clear evidence mostly from the rheumatologic literature that the bone marrow lesions are pain-generating lesions. And so the question is what do we wanna do about that from orthopedics and especially consideration that the subchondral bone is the foundation to our house. So are we going to build cartilage above bone that's disordered and maybe not a good structural or biologic approach? There's two main ways with which we can alter the subchondral bone. I'm not gonna talk about the calcium phosphate. That's not really biologic. But from the biologic technique, we can use techniques then to remodel the bone. So to kind of drive this home, here's a patellofemoral case. And you can see not only is there a cartilage defect, but there's cysts below the bone, right? And so then the question is how can we change that besides just transplanting cartilage over the top? So here is the technique of identifying the area of the cystic formation, the abnormal bone using fluoroscopy. Then you can use that same guide wire and ream over it. The typical minimum is around a four millimeter reamer that can go directly over your K wire. This of course does two things. Number one, stimulates the local bone and gets rid of the cyst structure. But if you use this technique, you're going from normal bone to the abnormal bone. So you're dragging in all of the good physiologic bone with regards to biologics right along the way. So that's the whole point of this. It's not to take the shortest trip to your abnormal bone. It's to go through normal bone to get to the abnormal bone. Then when you have that there, then you can take out your K wire and you can use whatever you want. You can use nothing. You can use bone marrow concentrate, which are probably natural, right? From a bone derived cells to help regenerate bone and remodel your bone. But then you can then inject this right through your drill bit, right? Which is at the spot with which you want it. Again, if you're using this, you typically use thrombin because it becomes gel-like. So therefore it doesn't shoot out of the drill bit, right? You can just keep it in there, slowly withdraw the drill bit and then you can have a guided injection in this area because all of these techniques are percutaneous. Just want to show you, these studies are ongoing, but you could just see, this is just a case study, but you can just see the potential power of this. This is only three months, right? And you see how the underlying bone is remodeled in comparison to pre-treatment. So at a very short time point, we can really have these sort of interventions to remodel the bone below. So in summary, we can't forget about the bone because that may be one of the necessary factors for us to have a healthy cartilage layer on top. Lots of emerging techniques and every year, there's just more and more understanding about the data behind it, but we're certainly in the early stages. Obviously, if you have abnormal bone, you always have the osteochondral oligarth, which is another topic. But otherwise, that's the quick look at our current data as far as cartilage regeneration. Any questions? I just have to run to another meeting. Any questions about any of these techniques or anything? Thank you guys very much. Have a great day.

regenerative medicine

cartilage regeneration

cellular therapy

bone marrow

adipose-derived cells

subchondral bone remodeling