Hi, I'm Melissa Cristino from Boston Children's Hospital, and I'll be discussing, is there a role for biologics in meniscus or OCD treatment? I have no financial disclosures. When we think about orthobiologics, there's a lot of different modalities that are on the spectrum. It can be very confusing to try to interpret the amount of literature that there are on all of these different things. One helpful resource is the AOS biologic dashboard, which can provide a lot of helpful information and help you get started with familiarizing yourself with some of this literature. So I'll be discussing orthobiologics in the knee, specifically with regards to meniscal injury and osteochondritis desiccans, as well as chondral lesions. So for meniscal injury, this was a study of adolescent patients treated non-operatively for isolated meniscus tears. They were treated for at least one month of conservative management, and then underwent intra-articular PRP injection. There were no side effects reported to this intervention, and you can see on the scale on the bottom right-hand side of your screen, that outcomes did improve after the injection with less pain and higher Leisholm scores. Limitations to the study, however, was that it's a fairly small sample size, as well as there is no control group. For meniscal repair, most of the studies have been done in adults with very mixed evidence. So some studies have shown that isolated meniscal repair in combination with PRP show lower rates of failure and more healing. However, there are also studies that show that PRP does not affect healing or outcomes, in particular, in this one study on discoid lateral meniscus repairs in a case control study. This was a prospective, randomized, double-blind placebo-controlled trial of 37 patients with vertical meniscus tears. They either received an intra-articular injection of PRP or saline at the time of repair, and they did find that the PRP group had a statistically significantly higher healing rate than the control group, and also demonstrated better outcome scores. That's a better design study, but all in all, I think our literature with regards to meniscal injury and repair is still somewhat mixed in terms of the efficacy of orthobiologics. Now, moving on to discussing OCD and chondral lesions, BMAC has been proposed as a possible intervention that could have some real success here. This was a systematic review of clinical and animal studies on bone marrow aspirate concentrate, and most of the studies in this review did suggest there may be some clinical benefit to this intervention with improved outcome scores and better appearance on MRI as well as histology slides. The limitations of this, however, were that these studies really lacked scientific rigor, so it is very difficult to draw meaningful conclusions from this systematic review. There has been some reported use in children using BMAC and OCD of the talus. This was a small case series published in JPO. We've seen less studies using BMAC in the knee. However, many of our colleagues throughout the country are using this with some regularity. So this is a case by some of our colleagues down in Atlanta where the bone marrow aspirate is aspirated from the hip. It's spun down into the concentrate. The OCD lesion is drilled in a retroarticular fashion and over reamed with a cannulated drill bit, and the BMAC is then inserted directly into the lesion. And these are some examples of patients that have healed with this intervention, and you can see good healing here with this technique. Now, what do we do with our unsalvageable OCD lesions? These are more common than we would like in our young patients, often with full thickness cartilage defects. And this is really where we have to start thinking about cartilage restoration procedures in terms of OCA or cartilage regenerative procedures such as ACI. These are two studies on osteochondral allograft in adolescent patients showing good graft survivorships and 90% at 10 years, as well as good to excellent functional results following surgery. Another study in adult patients looked at whether BMAC incorporated with an osteochondral allograft would improve healing, and they did not find a statistically significant effect on healing incorporating the two. When we think about autologous chondrocyte implantation, this was a systematic review of ACI outcomes in adolescent patients. It only included five studies, but each of these studies showed improvement of outcome scores over time. This was a study looking at both adolescent and young adult patients who had ACI. They found no significant differences in the rates of failure between the adolescent and young adult groups, and good to excellent functional outcomes in both age groups. So conclusions are that things like PRP and autologous blood are safe interventions, but they really have mixed results in the literature, and we haven't seen many studies in pediatrics. BMAC results are also limited and inconclusive, but there may be some potentially promising interventions here. MACI and osteochondral allograft are being utilized more in young patients, and we'll have separate talks on those. And overall, orthobiologists can potentially enhance our healing of our patients and improve their outcomes. But the most important thing is that we really do need good comparative studies in our young patients in order to say this for sure. Thanks very much, and enjoy the rest of the course.

biologics

meniscus injuries

osteochondritis dissecans

PRP injection

cartilage restoration