Good evening. Thank you for joining us tonight for the AOSSM Fellows webinar, Orthobiologics, What You Need to Know, a Primer and Research Update, with faculty Dr. Adam Anz and Dr. Jason Dragoo. Dr. Anz is an orthopedic surgeon and sports medicine specialist at the Andrews Institute Orthopedics and Sports Medicine in Gulf Breeze, Florida. Dr. Dragoo is Professor and Vice Chair of Academic Affairs of the Department of Orthopedic Surgery at University of Colorado, Endowed Chair of Regenerative Medicine and Director of at the UC Health Stedman Hawkins Clinic in Denver, CU Sports Medicine. We'd like to thank OSER for their support of this webinar, and we'd like to remind you that to submit a question on the GoToWebinar panel on your screen, you can click the questions drop-down arrow on the right-hand side of the panel. This slide shows where you input your question and where you can click send. And with that, I'll turn it over to Dr. Dragoo. Well, good evening, everyone. Thanks for joining Adam and I this evening. It's great to be with you guys here and to talk a little biologics. And so what we were planning on doing is just going back and forth with one another, not only asking questions, and we hope to answer any questions that you guys have as well, but to go back and forth with different presentations so you won't hear either of us talking for too long, and we'll try to hit a lot of different subjects, both in the mainstream of biologics as well as some future aspects of biologics as well. And just as we see here at the beginning, I just touched the wrong podcast there. And so I am back online now. So what we wanted to do is just start with a couple of introductory slides, because I think most of you have had a little bit of introduction to regenerative medicine, maybe by way of billboards or by things that you have read on the internet. And some of it is really earth shatteringly bad. And what's happened is that there's thousands of stem cell clinics that have been operating. And many of them, of course, are not orthopedic surgeons. Matter of fact, many of them are not medical doctors at all. And so what they have been doing is they have been hiring nurses and practitioners that are even licensed to give injections because they themselves as naturopathic or chiropractors can't even give injections to humans. Obviously, Google is starting to step in as well and said, this is a complete mess on the internet. We've got to clean it up. And Adam and I and others really do agree. This is a big market and there's lots of good, but at the current time, it really needs to be policed. So I was working with a local news agency, and it's actually in Chicago on an undercover project. And this is to really get an understanding of what patients go through when they're seeking care with regards to regenerative medicine. So I just wanted you guys all to hear what patients hear on TV and through these little weekend seminars. We'll go in and regenerate that tissue that you're missing. So you can get new cartilage. You can get new knees. You can get new shoulders, new nerve. Describing how stem cells repaired her injured right ankle. I can jump up and down and on an x-ray, I have an ankle joint again on the right-hand side where before I didn't have one. If you have type 2 diabetes, it can degenerate your pancreas. We just had a woman who had epilepsy, and we injected the nose area with stem cells and it went directly into her knee. I'm told that there's no proof that stem cells, as you are suggesting, actually work as you describe. So you've got to consider the source. Well, there you go. Front and center. And you see not only the hype of what stem cells could unwarrantingly do, but also some of the prejudice against our own profession. So it's interesting what's out there. But we all have to be advocates for this, and we're going to share plenty of good science to show the good part of regenerative medicine, and I hope, and we hope the future of medicine. But you see, if we don't have this advocacy, what's already happening in Canada is this whole topic of cell therapy is already gone. And so it is now unlawful to use bone marrow aspirate or fat-derived therapy in Canada because now it is classified as a drug. And so we're really working hard to prevent that from happening in the United States. And I wanted to tell all of you guys is that as you go out there and to practice yourselves, and you're interested in this whole area of biologics, to consider looking at the Biologic Association. And this is an old slide because now we have many member organizations that have joined us. But really what it is, is a collection of societies where we're all advocating on good science and good advocacy for the development of biologics. And I certainly would invite you all to come to our website. It's kind of easy to remember the Biologic Association. And you really could see how this is really working to improve our best practices within the field. So as we get started here, I just wanted to talk a couple of slides that are, again, more general. And the first is referring to cellular therapy. And maybe from the beginning, Adam's going to cover the bone marrow cells and I'm going to cover the cells derived from fat. But maybe at the beginning, we could just agree upon one thing. And that stem cell therapy really does not use stem cells. And I'm going to go over that a little bit in my talk a little bit later. But the modern day referring to this with our patients as cellular therapy is certainly more appropriate. And I think as we really begin, I know most of you are just going to say, please, can you just tell us the bottom line about what we know in 2020 about what progenitor cells or these adult-like stem cells are theoretically do in our body. And so there's lots of data, some of which is good and some of which is bad. But if you look at the whole sets of data, some things really come to the top and are likely to be true. And that number one, if we give progenitor cells to humans, they are likely to relieve pain. And there's many studies and strong basic science to show that these cells produce mediators that activate the mu opioid receptors, believe it or not. And so when you look across the literature, you see pretty much one thing in common and that most of the studies really do show pain relief when they're given to patients in pain. The second thing that is pretty strong data to show is that they're strongly anti-inflammatory. They don't work necessarily as our NSAIDs do, but they work by modulating the immune response to inflammation. And so therefore our cellular response to something that is foreign is less. And so therefore there is less inflammation. But what about the last thing? What about can they really rebuild tissue? And I think both Adam and I would agree that in 2020, the answer is truly unknown. And we'll give you the data for different areas and the uses of these different cells, but probably this we would agree upon needs a little more data before we can summarize if they can really synthesize new cartilage and new nerves, as the lady said. So to start us out, we just chose the easiest topic to talk about first, and the other topics are going to be much more complex than this. And these are the whole family of birth products. And believe it or not, when we look at all of the clinics that are opening up, the thousands throughout the United States, we really see that most of them are using these category of quote cellular products. And I think there are some summary statements we can make about these birth products as we go forward from here, but probably one of the best is buyer beware. And so then let's look at some of the summarizing literature on this. This is a great paper from Richard Hawkins and John Tokish about really what is available in these cells of the amnion if you go to the delivery unit at the hospital. Right after a delivery, if you get the amnion, what's in it? And the answer is there's a ton of cells. There's a ton of cells. There's a ton of growth factors. And so this is the whole thing that started the amniotic products and the use of regenerative medicine is that we know in the human body, these cells and these growth factors do exist in these amniotic products. But the summary statement is that when you take this tissue, both the fluid as well as the sheets of amniotic membrane, and you process it and you sterilize it, the summary statement is there's essentially no cells at all that are left. And there can be some growth factors, but what we're learning in 2020 is it's all over the board. And some products actually do contain growth factors. And that's now being proven by the recent studies that are coming out, but very little evidence to suggest that the cellular products are there. And so we don't want to call the amniotic fluid and the amniotic membrane products. We don't want to call them the cellular products or cellular medicine or certainly not stem cell medicine. And that's becoming clear over time. I don't want to show the data because the data is being published now, but Brian Cole and Lisa Fortier have a new paper coming out and without giving away some data that's going to be coming out within the next month or so, I did want to say that they came to the same conclusion when they tested nine different products. And what they found is A, almost no cells are available in any of the products. And B, the amount of growth factors or the potential benefit of the biologic varies immensely from one product to the next. And I know we take great practice when we give podium presentations and even write papers that we bury the commercial side of it. We don't list product names, but with the biologic products from Amnion, you really have to know really what you're buying. And I think that's the best thing that we can tell you as of 2020. If you want to know the best evidence that is out there, this is the paper from Jack Farr, which is really the only randomized controlled trial that's out there. And as you see from the graphs, there is an effect. And this ASA is Amnion Suspension Allograft. It's a particular product. But the bottom line is they really compared it to hyaluronic acid and saline. And you can see from the bars that there is some measurable effect. It may not be a huge effect, but it's certainly an effect and a comparison to a comparator in a randomized way. And it really proves that there is some potential benefit. And we do not want to throw out this entire category of products, but we do want to give some thought before we use them and to really look at the literature and understand what product we're actually using. A couple of other overarching comments before I send it back to Adam. The first is this process of giving regenerative medicine to humans. And the question is, well, really, how do we get the most out of it? And of course, although we're learning about it, I'd like to pose this question for you guys. And that is, look at patient one and patient two, and the question would be theoretically, which candidate would be better for this cellular therapy or regenerative therapy? And there could be lots of controversy, and Adam and I might even come up with different answers to the question. It's interesting to think about, well, how did the patient one get to where he's at? And what happened with patient number two? And so from the 30,000 foot view, taking a step back with your patient, working backwards and say, what do I really need to do to get this patient better? And I would argue that in patient number one, if you gave them a cell injection, they're not going to get much better over time. And the reason, of course, is that that patient's malaligned, there's bone marrow edema. And if you gave them injection in the joint and you can see the florid synovitis, hey, that might help a little bit. But there's many issues that need to be corrected by your therapy, your surgical therapy and your approach, versus you can have a much more uniform approach with patient number two. What's patient two's problem? Oh, it's the cartilage. Okay. And then you can have a straightforward biologic effect in a higher chance of having an efficacy with it if you really have one problem. So it's more of a theoretical approach to your patient and taking a step back before you give them the therapy. And going forward from here, we really need to use our science. And that's what our today's talks are about. This isn't throwing darts at a dartboard. This isn't guessing. This is about taking new techniques, which are vested in basic science and animal trials, and then performing human trials and then translating them into human medicine. And that's probably where our future is going to be. So thank you. So I'm going to hand the mic back to Adam here as we go forward. Adam. Thanks, Jason. I'm going to share my screen now. We've been monitoring for questions. And please feel free to send us questions. And then the intent is for, as I speak, Jason to field those questions and then ask the questions and vice versa. So send in your questions as we speak. And then we'll do our best to hit upon them. Thank you to ASSM and thank you to OSER for the opportunity. And thanks for Jason for setting the stage. I'm going to use the illustration of osteoarthritis because osteoarthritis, to me, has the most evidence that we can use to make some progress in our understanding in this space. And when we think about one point that Jason was hitting upon is that in the past, we have been kind of throwing spaghetti at a wall. And it seems like when you look at some of the way that people are approaching this, they are just trying things clinically without a good evidence base for making those decisions. And when you just throw spaghetti at a wall, you don't make much progress in terms of an understanding of what's happening there. And so instead, we need to start thinking about building pyramids. And what I mean by that is if you think about how these technologies are applied, you first have to develop the principles at the benchtop and the animal level. And then with a phased clinical approach, you prove that it's safe with a small pilot study, say in 6 to 10 humans. Then you prove that hopefully it works at one center with a comparative study of some form, maybe in about 50 patients. And then you prove that it's reproducible at multi-center level. And the understanding that phased approach is important because as you look at the body of work of all these technologies, ask yourself, where are these technologies on this pathway? And that helps you understand how much game, how much potential they have, and helps you understand their body of work. So with that being said, platelet-rich plasma has a pretty strong body of work, and we're going to review it. Bone marrow aspartate is here at the level. They're at phase 2 kind of center comparative study that we'll review. The adipose products are here and here, and then what Jason was just showing, you kind of move the placenta amnion products up to here. That was a multi-center comparative study. So they're getting some game. These other two that are appearing and people are having some buzz about A2M and exosomes, they're really down here at the bottom, preclinical, benchtop, exciting studies, but nothing has translated up the pyramid at this point. So platelet-rich plasma and bone marrow aspartate are what I'm going to focus on in this talk. And then also, if we've got time, we've been studying filgerstem-mobilized cells collected with apheresis to augment cartilage repair. So I'll show you some lessons learned there. Also, we've looked at optimizing harvest of bone marrow as well as blood at the point of care, thinking about blood flow restriction therapy and mechanisms of that sort. And then also, if we've got some time, tell you about our bio-ACL project, and our intent in this space is to really pursue this with building a pyramid so that we have a body of work to prove something or to have some answers to these questions. Now regarding products for knee osteoarthritis, we're going to start with platelet-rich plasma. Before we really go into it, I want to really review one concept, and that is that we're using our immune system with these products. We're manipulating our immune system. And that immune system is your first reaction system to any sort of change. So as Jason showed those examples, if that person has an acute cartilage injury, his knee has an inflammatory response. And then your body tries to adapt or heal said injury with some sort of healing response. And then after that, it adapts to it and restores homeostasis. And so that's important. As we think about these components of our peripheral blood and our bone marrow, this is how our immune system navigates these cellular components throughout our body, many of them starting in our bone marrow and then ending up to try and have a healing response in episodes of injury. And we all know this inflammatory response curve. And with these products, think about how am I going to try and either initiate an inflammatory healing response or how am I going to try and turn down a sustained inflammatory response. And if you think about those concepts, it will help you be more successful as you try to implement these technologies into your practice. Now in terms of osteoarthritis, Jason, you set me up perfectly because I had this example. Sometimes we have a carpentry problem that's trumping our biology. And sometimes we have a biology problem that's trumping our carpentry. So in this example, this individual is way various. The biologics not going to have any room for help with him. He needs a corrective osteotomy. Alternatively, in this patient who's 42-year-old pilot who decided he wanted to run a 90K with his wife and he's a little bit various, then he had an injury to his meniscus and it's a complex tear and it's hard to know that we can make that complex tear much better. But think about these tools in your toolbox. Think about could I unload this knee joint for a period of time as it goes through this initial inflammatory response. Could I add a healing adjunct to help him have a healing response and help him ultimately restore homeostasis of the knee joint? So understanding these concepts helps you understand that as your knee has some sort of response to change and it triggers an inflammatory response, you're really trying to restore homeostasis and through that rebalancing of that biochemical equation, helping the patient adapt to the change that they're going through in a positive way. So thinking back to platelet-rich plasma, platelet-rich plasma is a point-of-care blood product i.e. you're taking blood and at the point of care, you're making a product based upon two principles. The first is that centrifugation creates a density gradient and that based upon the molecular weight of different components of your blood, it will layer out and then with selective harvest, you can create a product. So for instance, if you take this blood sample and you want to create a leukocyte-rich, platelet-rich plasma, you could put it in a device and have a long spin on that fluid and it would layer out with the poor plasma at the top of the spin, the buffy coat in the middle, and the red blood cell stack at the bottom. And the basis for a buffy coat-based systems is that if you grab that small inner buffy coat, you can have a high platelet-concentrated, high white blood cell concentrated product typically of a low volume. Alternatively, the other base systems are typically called plasma-based systems when typically we think about leukocyte poor platelet-rich plasma involve typically a shorter spin and with that shorter spin, the top layer has a marginal increase in your platelets about 2.5 fold and then the white blood cells and red blood cells are stacked at the bottom. And if you select that top layer, then you can create a leukocyte poor PRP and those two basis are the basis for both the buffy coat-based systems and the plasma-based systems. Now at the benchtop level, there's in vitro studies to support the use of these products in the situation of osteoarthritis or cartilage injury. In terms of clinical application, you have to dichotomize them or break them apart into the buffy coat-based products and the plasma-based products. And when you look at those independently, the buffy coat-based systems have these three high level of evidence studies for review with marginal results. I make these easy by putting yellow when there was some clear benefit, green when there was clear superiority, and red when there was no difference. Alternatively, when we look at the plasma-based systems, there's now a strong body of work to support the use and then based upon placebos with these eight studies showing superiority either to a saline placebo or hyaluronic acid. When you look at these with systematic review and meta-analysis, it's clear that platelet-rich plasma has a strong body of work to support its use for osteoarthritis. And when you look at those eight studies, six of those eight were a series of three. And that suggests that a series is something to the efficacy for this treatment. Now that's one thing that when I go to counsel my patients, I do recommend a series. And at first, I felt like I didn't have a strong hook to hang my hat on for that recommendation. However, this study really helped that solidify in my mind. This was a study in a guinea pig model, osteoarthritis, published in AJSM 2019, looking at multiple injections versus a single injection. So what they did is they looked at one versus three injections at the three and six month time point, both in the synovium as well as the cartilage. And what they found was that the control group, the synovial score did not improve. But then in the one injection group, it improved at the three month time point, but that improvement was not sustained at six months, whereas the three injection series, it was sustained at the six month time point. Similarly, with the cartilage scores, there was a disease-modifying effect, but it was not in the control group, as you see here, and it was in the intervention group. But with the one injection series, that was not sustained at six months. So this really gives credence to the idea that a series of injections with platelet-rich plasma has value for osteoarthritis, and there's a strong body of work to support that. Another concept in this space is the idea of intraosseous injections, and this is one thing that sometimes I heard the older orthopedic surgeons say hot arthritis versus cold arthritis, and it took me some time to understand that concept, but Jason captured it nicely with his example. Hot arthritis is an inflamed joint. A cold arthritis is mainly bone pain, and you can tell when you examine the patients whether they've got hot arthritis or cold arthritis, and maybe to treat the whole organ entirely, we need to think about both interventions. So intraosseous injections is taking some hold. This study from 2018, a randomized control trial in 86 patients, intraosseous and interarticular injections performed superiorly to interarticular injection alone of PRP and superiorly to HA injection interarticularly as well. Here's a second study along those same lines, 2019, similar comparison, intraosseous and interarticular compared to interarticular with at 6 and 12 months, the IO group with the best improvement. So consider intraosseous and think about the bone marrow edema, and how can you help that bone marrow edema, whether it be an intraosseous injection or whether it be unloading the bone while the joint goes through in a healing response. Now switching gears, we're going to talk about bone marrow aspirate, and bone marrow is a very heterogeneous population of cells, and we know that the small percentage of those cells, probably 0.01% are the ones that traditionally we have called a multi-potent mesenchymal stem cell, and the reason likely is that these cells and the right environmental niche can self-renew, and these cells with the right signaling proteins can differentiate, but nor naturally they monitor you as an ecosystem. They become mobilized in settings of injury, and then upon activation, they release exosomes, and those exosomes are packets of information with messenger RNA as well as proteins that help your body go through a healing response. This in the background is a zebrafish wound healing, and you'll see cells squirting from inside the blood vessel, from around the blood vessel, and we think that many of those cells have stem capabilities, and so cellular therapies is the right way to think about this, and then think about these cells, and do they have stem capabilities is the way my brain has started to think, for better or worse, and bone marrow aspirate uses those same two principles, one that we can take a bone marrow aspirate, we can perform a long spin, and we can get it to layer out, and based upon how it layers out, that buffy coat is where the cells are, and one thing to consider is that the monocytes are typically at the top of that buffy coat, whereas the neutrophils are typically at the bottom of the buffy coat, and we're going to hit upon this a little bit more later on as we think about how to optimize these products. Monocytes are the cells that we're interested in. Neutrophils, typically, we are not. So thinking about bone marrow aspirate, we need to think about how is it performed clinically for osteoarthritis. There's these two studies for a review. This one was a comparative study from 2016, 25 patients with bilateral knee osteoarthritis. One knee got bone marrow aspirate concentrate, the other got saline, and at six months, they had similar improvements. Both groups improved, but it was similar. We performed a randomized controlled trial on our campus in 90 patients looking at this same question. One, we dichotomized these patients into leukocyte-rich, platelet-rich plasma, which was a monocyte-rich platelet-rich plasma with a large volume compared to bone marrow aspirate. Using WOMAC and IKDC, we found similar 6- and 12-month data as you see here in our graphs. We published the 12-month data in OJSM just recently, and we just completed the analysis on the 24-month data, and we saw the same response. Similar outcomes between one injection of a monocyte-rich PRP when compared to bone marrow aspirate concentrate. So perhaps we need to learn more about bone marrow aspirate concentrate, and perhaps we need to think about more optimizing harvest. That may be the key. In conclusion, I won't hit too long. I'll just pass it over to Jason, but the one key is we need to pursue this like a developmental pyramid and always don't let the tail wag the dog, because many times you'll see that industry will kind of try to guide us, but instead we need to guide industry and think more about these developmental studies. So at this point, I will hand it over to Jason, if I can figure that out. Thanks for your time. That was really great, and we have a couple of questions just as you're toggling over. One is a great question, and that is the symptomatic osteoarthritis, and you feel someone is a candidate for cellular therapy. How do you make the decision on what to give them with regards to, is it BMAC or Adipose or PRP? How do you make that decision? So it depends upon their age. If they're a young athlete and they say, hey, I want what you think is the best thing you can give me. Now, I do a 3-injection series 2 with a leukocyte-poor PRP and the third one with bone marrow aspirate concentrate. Now, if they're an older sedentary individual, I have a conversation about no superiority of bone marrow aspirate concentrate to PRP, and additionally, from my read of the literature at this point, there's no superiority of Adipose or Amnion to PRP either. And so with such a strong track record of PRP in terms of the literature, I typically recommend that because of logistically it's simpler as well as it has a stronger track record. To me, it's a lot like if I was going to bet on a football team, I'd probably bet on Alabama because they've got a strong track record of performance. I mean, I love Auburn, don't get me wrong, but at the same time, I'm going to put my money on Alabama because they have a proven track record, whereas Auburn has won a game every now and then, but they ain't got no proven track record. Yeah, and it's a great question. And I've noticed some trends in my practice as well, and that is, you alluded to it too, Adam, that there is some osteoarthritis patients that have an inflammatory component, right? They have an effusion, they have a reactive knee, and PRP has really been shown to be really strongly anti-inflammatory. So for me, I've certainly had the most effect giving PRP or this leukocyte-poor PRP into these patients that have that inflammatory component. The flip has been, I've been a little bit disappointed with PRP with regard to, as you said, this kind of cold, bone-dry osteoarthritis, and it just hasn't created as much of an effect. And again, it's anecdotal. But for me, again, just leveraging what the cellular medicine can do and adipose-derived cells and what can it do? Well, they're pretty good at decreasing pain. And it's been, for me, a much stronger intervention than a PRP and a more lasting one in those folks that just don't have that osteoarthritis. So it's an interesting thing to talk about. I know it does change our experience, our experience changes what we do, but it's interesting different perspectives, right, on how to make the choice. Another great question, and somebody was really interested in your inner osteos injections and they asked, how do you practically do that in the clinic or in the operating room? Not in the clinic. It's got to be an operating room situation. Bone pain hurts. Bones hurt when you inject them with things. That's one thing that we've learned with bone marrow aspirate. We've done it in the OR. We've done it in the clinic, and now we're back in the OR because people feel bone pressure. And so the idea that I'm going to inject a fluid into a bone in the clinic, I'm not going to do that. I'm going to put him into the surgery center. At this point, I'm taking bone marrow aspirate and mixing it with a demilitarized bone matrix, a DBM, and creating a nice viscosity that I can inject with some radio opaque so I can watch where it goes. And my main indication is AVN at the hip with FECOT grade 2. However, I've got one patient that I saw Friday and follow-up who has a complete radial tear and her medial femoral condyle was lit up. And so we repaired her radial meniscus tear, and then we did intraosseous bioplasty for that medial femoral condyle. Two years out, she's doing great, playing tennis again and married to a doctor. So I was under the gun with that one because he was watching me like a hawk. I think that you need a carrier because if you just inject a bone marrow aspirate into a bone where you've created a conduit, it's likely just going to squirt back out. Whereas if you have a conduit or some sort of scaffold like DBM, it stays. And then I do like using radio opaque to see where it's going. Yeah. And I totally agree. And we have a lot of interaction with our physical medicine and rehab colleagues. And many of them, or let's just say all of them practically, don't have the anesthesia and the surgical side of the option to do intraosseous injections. And I do want to point out to everyone that really be careful, as Adam was saying, of doing this in the clinic. And it's our second nature as more orthopedic surgeons, I think, on this call that it is very painful and it turns out to be a mess in the clinic. So I think for our scope of interactions with the patients, that is much better done, as Adam said, in the operating room. Another question, it wasn't a question, but this is really important. And that is that somebody who's requesting these paper references, and there'll be more as this webinar keeps on continuing. And because they serve as a reviewer for insurance companies and they're the ones that have to really fight the denials, and of course the proof is in the literature. And this does have a huge impact. And so what we wanted to say is that this webinar, I think, should be on the AOSSM webpage, but also on the Biologics Association webpage. And so those are, and again, I don't know about how long it's going to be on AOSSM, but I can tell you it's going to be endured on the Biologic Association page. And so then as the years go by and you want to reference these talks, they will still be there for your appraisal. And then thank you very much for your service on fighting the insurance companies. Adam, can you comment on your research to support the use, and again, I think it did this pretty well, but the support, the use of the series of PRP versus a single injection. And then, you know, I want everyone to know, Adam and I are totally aligned, I think everything in biologics. But maybe I'll try to create another opinion, right, just to kind of bounce it back and forth. So Adam, you go support, I'll go against multiple injections, PRP versus a single. Okay, as I've felt like I've grown a little bit in this space, I've realized that we're manipulating a chemical equation, a biochemical equation. So if you think back to organic chemistry, when you had the little Erlenmeyer flask or if you still have a pool or an aquarium and you're changing or checking the pH. You know when you drip in there and you see the color change but then it reverts back and then you drip again and you're really changing that chemical equation balance by adding solvent. So with many times with an inflammatory response in the knee, a volume change is part of the reason that it's working. It's the reason that with saline, saline is not just a non it's not completely placebo because you're diluting the inflammatory environment. You're adding solvent to the equation and so for that reason I believe that to me explains the mechanism of action because if you add solvent at three independent time points then you're diluting the inflammatory environment at three different time points and you're pushing the chemical equation to homeostasis and then your immune system is its purpose is to try and reestablish homeostasis. So it has some momentum as you get it there. That combined with the looking at those eight studies where six of those eight were a series of three. One was a series of seven which just is not practical in our world and one was one versus two. So that leaned me towards a series of three at one-week intervals even further and then the penny dropped when I saw that guinea pig model and I saw that guinea pig miles like ah well that that explains everything or that kind of gives us some more some more evidence to tell our patients because I didn't like telling my patients hey you got to come back three times you know it's just hard to have that conversation without good evidence and so now I feel like again mechanism of action thinking through it to thinking about those body of work and then three thing about that guinea pig model really pushed me to a series. Yeah and I agree and and maybe another opinion could be well we know two things number one we don't we give injection but we don't necessarily always know exactly what we're treating and and we we think it's inflammation with regards to PRP and changing that chemistry but sometimes we don't know exactly and more important we don't know if that patient's going to be a responder. So the question is well how should we really practically do this and especially considering finances and another method to do it and I often use this in clinic is to give them a single injection and say okay nothing else planned no other visits all I want you to do is I want you to call me back in the clinic when you have your symptoms return if they if they do and it's amazing the variance across the board some people after PRP injection I haven't heard them from a year and I got worried about him especially with the COVID I said hey how are you and and they said my pain just never came back one shot one and of course the variance is also there well it never helped me at all okay well we'll do two or three more or sometimes we just say you know it's not gonna work for you and therefore we have some other answers so let's go down another with another method and of course I think that's a another legitimate way to go forward with it as well how do you talk about the cost of PRP for three in section three injection series do you you talk about all at once do you bundle it together we talk about it all at once or I talk about it independently I say look the cost of one injection is $550 and then if we are bundling two knees in it's 850 and I think it's okay to share those prizes with everybody you know we've tried to keep it very affordable and and keep it practical and then a series of three translates into you know 1650 for one knee and you know I think that's a reasonable price point if you think about the effort that you're putting into to what it takes everything about the practicality of building a practice as well and then I will say that it's been simple and what I mean by that is at one time we had two spinners and three rooms and we were doing a lot and and so PRPs has some practical aspects to it that it fit the growth of a practice very well and so as we started you know sometimes people try to push that price point up to 900 and that's just too much you know I don't think that's reflective of of what it represents and at the same time it's based upon where you live in the market too and so the practicality of it ever since we've stopped changing and that was probably three four years ago that we we ended on that price point and and everybody seemed satisfied with it and and I think it's a price point that you can look people in the eye based upon the evidence and really say look you know I think it's a worthwhile investment yeah I agree wholeheartedly what about your thoughts on interosseous bioplasty so are more of a BMAC PRP sort of injection versus subchondroplasty when you're dealing with subchondral bone edema I worry about calcium phosphate resorbing and I tell you on two levels one as I watch my HTOs as I watch my opening wedge HTOs I've been using a triple cut a triple calcium triple phosphate wedge to hold it open you know to titrate my opening and then I put my plate on and it takes forever for that thing and sometimes it does not resorb and it looks crazy on MRI when you go back and look at it and so I just don't know that the biology of a subchondroplasty you're not really pushing the body to read deposit bone you're putting a bunch of crushed up coral in there and everybody's immune system is different and some people's immune system doesn't care when you insult it with other stuff and some people's immune system does not like it when you put anything else anything other in it and so with subchondroplasty I've just been a little bit hesitant with what I've seen with HTO and I've done I did subcontra con chondroplasty originally and I felt like it was a little bit more hit-or-miss you know IOB you know IOB piece it or miss to don't get me wrong but I've just feel more confident that I'm helping their biology about pushing in the right direction with IOB P yeah and and just to give you give the audience just a few more points the one is to is to make the the strong consideration that calcium phosphate injections are not created equal and it is very they were very much different in their engineering their resorption pattern their floor ability so number one be real cautious that as Adam was saying don't make the mistake that and feel that you can choose any product because that's what's at your hospital injected into the bone you can end up with problems really fast with regard to that so again know your product before you even consider it the second part for me has been the 30,000 foot view you have somebody coming in they're in Varus they have bone marrow edema and you say well okay well I want to I want to change this they're in a severe pain and so you either give them out and a loader brace or you you do an osteotomy you want to make an intervention in their bone marrow I couldn't ever think of using calcium phosphate in that scenario right you want the remodeling you don't want to limit it so you would want to use biologics to augment that sort of response because you're changing the environment what about I just make it up as 80 year old and more on stage they're doing okay and they just have a bone marrow lesion that was new they otherwise weren't in a lot of pain are you gonna make any changes are you gonna do an osteotomy could they tolerate a brace do you have that potential to change and if you don't well something structural sites such as calcium phosphate although I agree both are a little bit hit-and-miss certainly has potential and we've had lots of wins put it put put it that way and just to let you know that there's a randomized controlled trial level one trial that's a multi center that will be done by the end of this year so we'll know more about subchondroplasty and the potential patients that are likely to be benefit it versus not I think we'll try lots of questions but maybe what we'll do is we'll go on to this last part just to make sure we hit all of the different areas and then we'll go back to the questions that sound okay Adam sure okay so what about the adipose derived cells and I'm gonna get this going here on the screen and this has been quite a journey for me personally this is right when I started I was really at the resident and fellow stage when I started in biologics and this was my first experience is being a part of the original team of the adipose drive discovery or description and it was certainly a free-for-all in a lot of different ways and it kind of really pushed the agenda and push the science really quickly and so just so everyone knows my job in this whole discovery was to attempt to induce these newly described cells into cartilage and bone so that was my part and it was a lot of trial and error because being a young scientist I didn't have a lot of background in it and so we became familiar real quickly with really the bottom line of the cells that are derived from adipose tissue and one of the earliest things we trying to move this out of the way one of the earliest things we found is that in the adipose tissue these these cells these MSCs were located by the blood vessels and and now we know that these perivascular cells are called parasites but they they reside in this portion of fat where the blood vessels are and so then we always I think have to remember that because if we're going to use the adipose drive therapy we've got to disrupt this local vascular supply in the fat and we'll show you the techniques to do that but it's a big thing to really consider where they're located and then came the whole understanding that maybe all of these cells located in the body are all next to the blood vessels and it came and and the parasite theory was born and there's a lot of good data to support it meaning that it doesn't matter if you're in the bone marrow or if you're in fat tissue or muscle the cells are located next to the vasculature and they're all pretty much the same and they look and are called parasites but of course any scientific sort of thought wouldn't be really justified without the counterpoint right and so then there are some articles to suggest that the cells that are located in the different anatomic compartments are different and the reason that they're different is because of their transcriptome or what genes are turned on in comparison to the other cells and again being in this environment for a long time I think both arguments are actually true but if you look at adipose tissue the MSCs are clearly parasites and they're clearly located in that area next to the blood vessels but it is likely to be true in the human body and we've seen this in the fat derived cells versus the bone marrow cells that different genes are activated and really what it means is that those cells are more mobilized to contribute to the regeneration of the part of the compartment that they're in so if you have an adipose derived cell it is geared and the genes are up regulated to be able to produce more fat because that is why it is in that particular compartment doesn't mean it can't produce cartilage etc and the same may be true for the for the muscle cells geared more for muscle regeneration etc but it is true that MSCs retain those qualities of being able to really be induced into multiple different tissues and here's just some of the basic research that came out from these original adipose derived cells showing that they do have that capacity to turn into the different tissues but we quickly learned that there was a limit and this was one of the first things that we did when we were analyzing this tissue we learned that that these cells coming from fat aren't stem cells and we learned that from a very early time that they're more adult-like they're better termed progenitor cells and so are all the cells that Adam and I are talking about these MSCs can become only a few lineages and they can only help create and give messages for a few lineages but they are not they do not meet criteria for being a stem cell and hence really the revolution of really calling cellular therapy rather than stem cell therapy and that was pretty clear from the beginning besides really getting cells to behave in culture the next thing is how do they really perform in animal studies and this is one of our trials here with a control showing the regeneration of the articular surface using the adipose derived cells from that particular animal and it was really the catapult to begin the process of looking at this in in humans and you see the astrology is striking in comparison to the controls of the ability to really help regenerate and give messages to the local environment to improve the articular cartilage at least in an animal model so that brings us to the human adipose therapy and this is really blossomed over time but the summary statement is there's two main ways to harvest the tissue one is to harvest it from the abdomen with some really strict guidelines the first is all the abdominal harvest should be above the inguinal ligaments and below the umbilicus and when you get close to the umbilicus you'll notice that that a lot of connective tissue and it will really bruise on the patient to stay away from the belly button so to speak you'll see the technique is really optimized by number one putting in the anesthetic and saline and allowing that to sit before you aspirate it and the second is the blunt aspiration technique this is tumescent liposuction technique in the same way that plastic surgeons do it you can see the mix on the screen and you can refer to that at any time in the future but I do want to give one word of caution that there is three sites there are three sites to really harvest one is the lower abdomen one is the thigh and one is the knee and I'm going to show you that but one is not the buttock and although many placements will line up and say hey please take from the buttocks that's my primary target that I would like there has been gluteal artery ruptures reported and so please be very careful that that is a significant risk the next is the arthroscopic technique and here we say we describe that and I'll turn off the sound here but it really shows that you put in a standard synovial shaver and you see the fat pad here and the arthroscope is pushed against the sidewall there of the condyle so we're not shaving out the fat pad right just the posterior border of it it goes into this container that you see to the left and this is an FDA approved container so then it can be further processed and this is what adipose drive therapy is turned into in modern-day regenerative therapy so there's lots of ways to prepare fat and again you can reference this slide and what it has to do with is processing and so if you really look at this this is really fragmentation of the fat the more you fragment the fat the more that the cells fall out in the end and of course that's FDA's big flag as well how much can you really process this tissue before you really go beyond minimally minimal manipulation and you see that there's a couple of things there fragmentation into small clusters are kind of the limit of what FDA would consider minimal manipulation and below that is likely going beyond that particular step so in modern-day there's a couple ways to do this one is the ball bearing technique and this is done in many centers and again this does not separate cells right just creates fat clusters and then the other one here sorry for the sound the other one is syringe multiplication and really what this does is blast the adipocytes apart and allows the cells to drop out in the syringe and oftentimes this is really combined with centrifugation and you can see that on the bottom there that little collection of cells at the bottom is very similar to the stromal vascular cells that you get when you use enzyme emulsification or enzyme digestion so again this is these are the two most common techniques as far as the fat processing I can tell you that the homework has been done and if you use the cells from this arthroscopic technique you can enjoy 15 to 20 percent of the cells that you get out of the after processing are these MSC type cells and of course this is a versus bone marrow where it's 0.01 or 0.02 if you use the centrifuge so again a wildly different amount of cells and that's the reason that adipose drive a tissue has really been taking taking a popularity worldwide what what hasn't been really established is his efficacy in the literature so here's the best literature to date with the adipose drive cells showing compared to physical therapy that the adipose drive cells did better but of course this falls short of enough proof of going forward but I want to tell you all many of us are doing lots of randomized controlled trials now so we have four of these going many other centers these are multi-center trials so we're going to know soon about the adipose drive cells we just don't know yet I want to show you a little bit about the surgery the technique this is all arthroscopic you need a little cannula to help hold the fat pad and tissues away from your area here this is the fiber and glue that's placed at the base of the lesion and then we harvested this fat tissue from the fat pad as I showed you so I'm gonna pump that in there with a matrix here and we just form it with a little freer here and what you're going to see is that when you push this into the fiber and glue it really does provide a really nice patch and then what we're going to do when it's equal to the articular surfaces work we're going to put another layer of fiber and glue so that's the technique it does involve a little bit of practice and this would be certain something certainly you guys could do during this year in the laboratory is get used to these arthroscopic regenerative techniques because they do again require little practice in the lab and what we saw so far is great integration of this of these cartilage transplant over a two-year period of time I think the biggest change is number one the health of the subchondral bone and we just talked about that importance about how we don't want to cause edema or that's really been the downfall of micro fracture and the good annealing to the surrounding cartilage so again stay tuned for the results but some really good interim results the other thing Adam talked about is the offloader bracing and we did do a trial now I have to admit this trial is with micro fracture but we really showed is the ability that to use offloader brace compared to not using a brace after walking after the eight weeks of micro fracture really showed increased volume and thickness and compared to not using the brace so again it's just something to think about in the armamentarium that if you're doing regenerative therapy how can I optimize this obviously doing an osteotomy at the same time would have the same or even a greater effect here's the holy grail this is the proof of concept you'll notice that with the amniotic cells and with the bone marrow cells there is no proof of concept of really regrowing some component of the articular surface this is Korea this is one study so certainly not enough burden of proof that we could do this routinely but at least it's the proof of concept that we need to go forward with continuing this line of research and clinical trials and you can even see this I know it's small on the screen but at the six months you can actually see the changes in the articular cartilage thickness of these MRIs so in summary when we use the cells we probably can talk to the patients about the potential of pain relief and its anti-inflammatory effect but I think we do have to shop stop short of really saying that we could rebuild the articular surface and we should probably never forget optimizing our local environment and treating the entire patient's joint rather than just an articular cartilage lesion so thank you very much and what I'm going to do is send it back here to Adam if we can pull this off and then we will continue to answer your questions here's the sharing all right we've got a couple questions one is from oh here we go all right so we've got a couple questions we're right at 7 p.m. so we want to be cognizant at everybody's time I think we could take a couple questions the first is from Chris Daugherty he said Jason thank you for the concept of using a 90-degree stopcot he saw it from you at OTHI he said thanks what are your thoughts about micro drilling versus micro fracture versus abrasion for your graph technique or is that overkill yeah for the graph technique with regards to the adipose derived cells and many of the regenerative techniques I would say personally at least what we're trying is to stop short of the micro drilling and certainly stopping short of the micro fracture and let me explain why you know when you're building a house and we always like using both Adam and I are using these analogies but when you're building a house you need the strong structural support of a foundation and that foundation for articular cartilage is it's is the bone and so if you have that in your patient you have pristine bone I think from the regenerative perspective we need to be really careful at traversing that because we do know that there's potential consequences when we do that and that includes with the micro drilling and especially with a micro fracture but one of the things we learned scientifically from the animal trials is that whenever you're doing a technique that involves regeneration of their ticklish surface a requirement just like it is a micro fractures to remove the calcified cartilage layer so that might be what you're alluding to is really doing a little bit of a abrasion arthroplasty or taking your curette and removing that calcified cartilage layer first and that's what you saw that kind of peach colored bone and then applying your technique and for us we are trying to regenerate the articular cartilage without traversing the subchondral bone and using the cells within the bone marrow but we still had to do as you said a bit of a micro abrasion of that to remove cartilage or the adipose derived cells etc tends not to work because you don't have that annealing of those cells and the structure to the subchondral bone a second question from iota guns what do you mix the cells with to create the paste an a cellular cartilage matrix so many companies really have a putty that is an allograft that is prepared by taking the mineral any well there's not really mineral and in cartilage but taking out all the cellularity and just creating an extracellular matrix with it and so this is an a cell a cellular cartilage matrix again available but as Adam was saying what we have learned from the basic science studies is that we need to create a three-dimensional structure we need to give it support that isn't a comparison to layering cells at the base of a lesion they just have much more difficulty growing and gaining structure and so the creation of a some sort of scaffold and and for me and it'd be interesting to get your comments Adam for me a non-structural scaffold has been the best especially for large lesions that's because of what we know with certain things such as bio uni and astrochondro allografts that if you have something structural you can have a toggling effect and we've had some issues with biology when you have a big more rigid matrix and so I've been more worried about some of the corals and the other things of really getting consistent results and so that's why we use more of that a cellular matrix so that's the end of the questions Jason we've got right at 7 p.m. I've got kind of one more talk that kind of expands some thoughts about maximizing our point of cares which I think would be fun and I'd love to get your feedback on we doesn't look like we've had people drop off what do you think about seven more minutes of letting me share something then you give me some feedback on it and if people drop off they drop off love it and you guys feel free we understand you guys are real busy so we understand you know if times up but we'll just carry it on for another 10 minutes max if that's okay with everyone go for it all right so optimizing point-of-care harvest I shared with you that study where we were just not completely impressed with bone marrow outperforming PRP and that's really led us to the conclusion that perhaps we need to optimize our cell harvest and perhaps when we think about these products we're not getting them exactly where we want want them so we went and looked at the literature in terms of what can guide us on this subject and I'm going to just minimize this for just a second to get rid of this sidebar and then go back to that so we looked at the literature and in terms of what's out there there is excitement about being able to get these cells from the proximal humerus and the distal femur in terms of bone marrow aspirate but we know that the Iliac crest has outperformed the peripheral locations and we know that the crest is not only outperformed these peripheral locations but posterior crest has outperformed anterior crest and so we took that into our clinical practice but we also took some of the same principles that Hernegos taught us about having a strong sufficient local force having divergent harvest and then drawing just several small portions with either a parallel insertion path or a divergent insertion and as we went through our experience with it we started with posterior crest and then with moving into our OR we wanted to move to anterior crest because we thought it would be quicker and we looked at distal femur and proximal tibia and we ultimately landed back on posterior crest and one of the reasons was is that with posterior crest harvest you get a downhill flow and so bone marrow itself is a pretty viscous fluid and if you try and move it up a column of air through a small lumens syringe you don't don't really get a lot of success but if instead you think about your trajectory you get a nice upward angle a vector of your needle then it seems to flow nicer and our harvest actually went quicker and so we kind of went full circle because we started with posterior crest and we ended with posterior crest and really it was gravity that was helping the harvest go quicker and turning them lateral to cubitus aided this and this is something that we proved with some data we started with distal femoral harvest as part of one study with something that was just not very impressive and then we went to anterior crest and we were getting more growth but it was variable and then as we moved to posterior crest we got more consistent harvest and that was something that we felt like we reinvented the wheel but it was something that confirmed the location is if you want to optimize a bone marrow aspirate posterior crest is the best harvest site we then started thinking about other alternatives to if we can't really manipulate the products afterwards more than minimally manipulated can we manipulate the subjects or the patients before we harvest their blood so we thought about working with this with some of our colleagues in Naples and we took 20 subjects we did 20 minutes of vigorous exercise and we compared blood and blood products with two PRP devices both a plasma based device as well as a buffy coat based both systems had higher platelet concentrations but the buffy coat based PRP at a larger volume and a higher concentration of cells that were labeled as hemipoietic by our cell counter so yes we felt like we could supercharge PRP or just change it with exercise and we started calling this exercise mobilized PRP we then started asking the question in addition to exercise could we use filger stem filger stem is a synthetic form of a natural hormone that causes your body to upregulate production in your bone marrow and the release of cells to your peripheral circulation we asked the question could we give people filger stem and then use a point-of-care device to make a cell product and we did this up at Auburn University with Mike Goodlett and colleagues we did tense we took 10 subjects on day one we did a bone marrow aspirate on day 30 we gave them four days of neupogen and then did a blood draw and processed it with a PRP or a buffy coat based device and what we found was a pretty cellular product it was a cellular product that was equivalent to bone marrow in terms of total nucleated cells it was a more the product had more hemipoietic progenitor cells as is marked by our automated hemocytometer and when we went to culture those cells we found something pretty interesting we found that as we would expect the platelet-rich plasma it really didn't grow any colonies and the colony forming units for the bone marrow started to form fibroblast colonies but the the mobilized PRP did form colonies but those colonies were interesting they were more associated with white blood cells and monocytes and so as we started looking at them with different markers we definitely saw cells that were dividing but we also saw markers that are more consistent with white blood cells and specifically monocytes and that was encouraging and exciting because along the same lines we've been looking at filger stem mobilized monocytes for some time on our campus and thinking about these cells that we can get with filger stem and apheresis this is an individual who we've given some doses of neupogen and then we've connect them to this apheresis machine and then we get a cell product that we can then use to augment some of our procedures and we're just completed a phase 2b study under an FDA IND for the indication of cartilage repair that showed some some encouraging results that we stopped the study early because there was statistical improvement and so we wanted to also ask what how much game do these cells have and so the cartilage repair study we stopped because we had a significance with with half the patients enrolled but then we also wanted to do some studies to say how much of these cells have stem capabilities so we took these cells in our lab down here we did proliferative cultures to show that we can get them to reproduce and we also looked at differentiating these cells and we can get these cells to differentiate into cartilage cells and to adipose cells and then also into bone cells and then we also looked at an endoderm assay and an ectoderm assay and so our ectoderm assay we were able to get them to differentiate into neuro cells and the endoderm assay was positive you can see that one cell kind of laying out like he's a about to start a basement membrane so we started thinking these cells may be more pluripotent than multipotent and that's kind of interesting to us and it's something that we're excited about and seeing where we go from here with it the last thing I want to just share with you is just fun blood flow restriction therapies showing up in our ATC and PT clinics it's the brainchild of this individual who thought that if he modified venous flow as he worked out he could have a positive physiologic effects on growing muscles and that's him at age 70 he's still got really good guns it's the basis for these systems that we see out here we wanted to ask ourselves does the mechanism of action of BFR also involve a systemic release of cells or a cell mobilization event so we took 10 male subjects we did a control session with no BFR an intervention session with BFR and what we saw was a spike in lactic acid which has been well documented in the literature but what we saw are we documented that people haven't really looked into is is there a cellular response and sure enough right at time point zero right when they're done they have a cellular mobilization response that's marked with this same marker that we use for hematopoietic progenitor cells so I wanted to just sort of show that because I thought it's it's interesting and and we know we need to understand these cellular mechanisms better but I also wanted to just see what you think about some of that stuff that we're doing and are we thinking the right way or thinking the wrong way Jason Jason, are you muted? Can you hear me? I still can't hear you. Can you hear me? Can y'all hear Jason? Let me unshare my screen. Oh, man. Is that better? Yes, I can hear you now. Okay, sorry. Malfunction. Hey, well, Adam, I know it's closing time here, but I do agree with you that BMAC is in its infancy. And the technical challenge is, as you noted, is how close the monocytes are in the cells of interest in comparison to the neutrophils. And our technology with our centrifuges are falling short. And so we're not creating clear preparations. And so as we get better as a whole, I think our benefit of BMAC is going to improve. Our efficiency is going to improve. That even is true for one of our studies that we just finished. And we ran the same bone marrow through three different systems and got three completely different types of preparations of bone marrow. And so, again, we have a long way to go. And I congratulate you on doing some really great research to help push the envelope on that. And everyone joining, thank you guys so much for joining us. I know we're a little late, but thank you for spending part of your Tuesday with us. And any additional questions, reach out to us by email. I'm sure we would be happy to respond and also to review this presentation, both at AOSSM site and the Biologics Association. So thank you again for your time. Thank you, Adam. Thanks, Jason. Enjoyed it. Thank you very much to Drs. Anzandregu for your preparation in presenting tonight's content. We also want to thank OSER for support of this webinar. And listed here are resources for attendees. These slides are available for download in the handout section. And we also want to remind current fellows, if you've not already applied for the AOSSM candidate membership, the application fee is free for current fellows and is covered by OSER. You may apply online at the AOSSM website. Next week's webinar will cover transition to practice as a future team physician, pearls for success and medical legal implications with Dr. Matthew Provencher and a special guest. Thank you all for joining us and have a great night.

Orthobiologics

platelet-rich plasma

bone marrow aspirate concentrate

osteoarthritis

evidence-based practice

in vitro studies

clinical applications

phased approach

intraosseous injections

inflammatory component

regenerative medicine