Written by Senior Contributor, Dr. Pamela Mehta, MD
The challenges of conventional orthopedic treatments
You never know when you might need to see an orthopedic surgeon. From cradle to coffin, accidents and injuries are an inevitable part of life, which harms your joints. Even if you can avoid accidents, the wear and tear on your joints can lead to arthritis, with approximately 150,000 knee and hip replacements performed in the United States each year, expected to triple by 2040.
While young and fit people can recover from injuries with conventional treatment, we might find that our joints don’t react the same way as we age. Tissues such as cartilage, ligaments and tendons have very little ability to regenerate and heal on their own, which gets worse with age. We often resort to joint replacements and invasive procedures to repair our joints when our bodies cannot.
Traditionally, the choice is between conservative management – physical therapy, mobility aids, steroid injections and surgical procedures, including joint replacement. Conservative measures may be less effective, but invasive surgery comes with pain and medical risks. With the conventional treatment model, the question becomes: should you risk your health or your mobility?
Regenerative medicine, the solution?
Regenerative medicine is a new area of medicine in which orthopedic surgeons aim to move away from replacement and towards joint preservation. By using orthobiologics, we can provide your body with the cells, materials and stimulation it needs to heal without you ever going under the knife.
At first glance, this seems like an ideal solution to all our problems. The promise of regenerative medicine in orthopedics is a future where a joint replacement can be delayed for as long as possible, perhaps offering a solution to long transplant waiting lists for other disciplines of medicine. However, as with any new form of treatment, regenerative medicine is not without controversy. The main debate in orthobiology is whether the body of evidence currently supports the integration of regenerative medicine techniques into national guidelines and conventional treatment strategies.
Case studies and anecdotal evidence often support orthobiologics (biological substances that orthopedic surgeons can use to help the body heal) as a treatment option. However, the size and consistency of available studies remains an issue. There is ample evidence supporting regenerative medicine techniques in specific circumstances such as osteoarthritis and tendinopathy. Still, a broader evidence base will be needed before these treatments are accepted as standard practice in wider orthopedic circles.
What is Regenerative Medicine?
Nor can we expect larger studies to prove the efficacy of these therapies, with some meta-analyses showing only marginal efficacy of plasma-rich plasma and advising against its use as a conservative treatment.
The history of regenerative medicine
The idea behind regenerative medicine is not new. The earliest story detailing the regenerative ability of the body comes from Greek mythology around the god Prometheus, who was punished for stealing fire and giving it to mankind. Prometheus was chained to a rock for Zeus’ eagle to eat his liver, day after day, his liver regenerating overnight. This story leads us to believe that the ancient Greeks were aware of the ability of the liver to regrow and regenerate at this time in history. In orthopedics, the first known “regenerative” procedure occurred in 500 BC, where Roman soldiers with joint locations were treated with hot needle therapy.
Modern orthopedic therapies in regenerative medicine have developed over the past 80 years, focusing on altering the healing response in the body. In the 1940s, Magnuson described a treatment for osteoarthritis by extensive debridement of the knee. This well-established treatment was later superseded by therapies including inducing healing by irritation of the joint via injection of saline solution (prolotherapy – Hackett et al. 1956), drilling into arthritic cartilage (Pridie 1959 ) and micro-fracturing of cartilage (Steadman 1984).
More recently, regenerative medicine has focused on implanting cells to initiate healing in musculoskeletal structures, with the introduction of modern interventions such as platelet-rich plasma, mesenchymal stem cells, and injections. of biomaterials that can induce a healing response.
Regenerative medicine and orthobiology in 2022
Modern orthopedic regenerative medicine treatments are still struggling to find a place in standard practice and major healthcare organizations, due to debate over whether the evidence base currently supports its use. Therapies such as platelet-rich plasma and injections of stem cells derived from adipose cells (fat cells) often require patients to pay out of pocket because insurance companies refuse to cover these forms of treatment.
However, an increasing number of practitioners are using orthobiologics as part of their routine practice. With a growing evidence base, these practitioners have begun to treat conditions such as osteoarthritis and tendinopathy in this way, offering treatments that include the injection of:
- Platelet-rich plasma – blood plasma with a high concentration of platelets taken from the patient’s blood.
- Mesenchymal stem cells – stem cells from adipose tissue, bone marrow, and pregnancy-related sources such as the umbilical cord, amniotic fluid, and placenta.
- Biomaterials – biological substances such as autologous chondrocytes (cells taken from the patient that produce cartilage), bovine collagen, bone matrix and proteins.
These orthobiologics are generally considered conservative treatments, meaning they are used as a less invasive alternative to surgery or as an additional option when other treatments have failed.
The popularity of orthobiologics is increasing, in no small part due to media coverage of famous athletes undergoing these procedures – Tiger Woods, Steph Curry, and Raphael Nadal, to name just a few. This may have added to the controversy surrounding regenerative medicine. In these circumstances, therapies were used to treat injuries and aid post-surgical healing – an area with less research backing.
If the goal is to move away from joint replacement and surgical management of joint conditions, we aren’t there yet. Nonetheless, you can certainly expect to see the use of orthobiologics expand and advance over the coming decade.
The future of regenerative medicine
Regenerative medicine holds the promise of delaying and possibly reducing surgical intervention in patients with degenerative joint conditions and musculoskeletal injuries. In the near future, we may see orthobiologics used as a middle-ground for conditions like arthritis, sitting somewhere between conservative treatment (such as steroid injection) and surgery.
In the far future, we may even see a complete overhaul of how we replace joints – moving away from metal and ceramic joint replacements towards biological replacement and regeneration. We can also expect a move towards orthobiologic injection as a preventative measure for degenerative joint conditions.
There are a few hurdles to overcome before orthobiologics can truly take a place among conventional treatments. Some of these hurdles are political and scientific – dealing with the controversy behind stem cell research and the lack of a solid foundation of evidence. Other hurdles include difficulties in advancing currently available treatments to enhance symptom improvement, long-term efficacy, and safety. We still face difficulties in how we can store stem cells, rapidly grow cells for grafting, and prepare the musculoskeletal system for implantation and regeneration of new tissue.
What’s clear is that regenerative medicine is an exciting and promising field that may hold the key to both expanding the range of minimally-invasive treatment options available and managing or even curing conditions that our current therapies cannot.
- Singh, JA, Yu, S., Chen, L. & Cleveland, JD (2019). Total Joint Replacement Rate in the United States: Future Projections to 2020-2040 Using the National Inpatient Sample. The Journal of Rheumatology, 49(4). https://doi.org/10.3899/jrheum.170990
- Borakati, A., Mafi, R., Mafi, P. and Khan, WS (2018). A systematic review and meta-analysis of clinical trials of mesenchymal stem cell therapy for cartilage repair. Current Stem Cell Research and Therapy, 13(3), 215–225. https://doi.org/10.2174/1574888×12666170915120620
- Johal, H., Khan, M., Yung, S.-HP, Dhillon, MS, Fu, FH, Bedi, A. and Bhandari, M. (2019). Impact of the use of platelet-rich plasma on pain in orthopedic surgery: a systematic review and meta-analysis. Sports Health, 11(4), 355–366. https://doi.org/10.1177/1941738119834972
- Tang, JZ, Nie, MJ, Zhao, JZ, Zhang, GC, Zhang, Q. & Wang, B. (2020). Platelet-rich plasma versus hyaluronic acid in the treatment of knee osteoarthritis: a meta-analysis. Journal of Orthopedic Surgery and Research, 15(1). https://doi.org/10.1186/s13018-020-01919-9
- Fei, X., Lang, L., Lingjiao, H., Wei, C. and Zhou, X. (2021). Platelet-rich plasma has better medium-term clinical outcomes than traditional steroid injection for plantar fasciitis: a systematic review and meta-analysis. Orthopedics and traumatology: surgery and research, 107(6), 103007. https://doi.org/10.1016/j.otsr.2021.103007
- Miller, LE, Parrish, WR, Roides, B., & Bhattacharyya, S. (2017). Effectiveness of platelet-rich plasma injections for symptomatic tendinopathy: systematic review and meta-analysis of randomized injection-controlled trials. BMJ Open Sport & Exercise Medicine, 3(1), e000237. https://doi.org/10.1136/bmjsem-2017-000237
- Franchini, M., Cruciani, M., Mengoli, C., Marano, G., Pupella, S., Veropalumbo, E., Masiello, F., Pati, I., Vaglio, S. and Liumbruno, G. ( 2018). Effectiveness of platelet-rich plasma as a conservative treatment in orthopaedics: systematic review and meta-analysis. Blood Transfusion, 16(6), 502–515. https://doi.org/10.2450/2018.0111-18
- Vaish, A., Murrell, W. and Vaishya, R. (2020). History of regenerative medicine in the field of orthopedics. Journal of Arthroscopic Surgery and Sports Medicine, 1(1), 154–158. https://doi.org/10.25259/jassm_12_2020
- Magnuson, P. (1974). The classic: Joint debridement: surgical treatment of degenerative arthritis. Clin Orthop Relat Res, June 1974 (101), 4–12.
- George Stuart Hackett, Hemwall, Georgia and Montgomery, Georgia (1991). Ligament and tendon relaxation (skeletal disability) treated by prolotherapy (fibro-osseous proliferation). Life Basics Institute.
- Pridie, K. (1959). The invention relates to a method of resurfacing knee joints suffering from osteoarthritis. J Bone Joint Surg Br, 1959(41), 618–619.
- Steadman, JR, Briggs, KK, Rodrigo, JJ, Kocher, MS, Gill, TJ and Rodkey, WG (2003). Results of microfractures for traumatic chondral lesions of the knee: mean follow-up of 11 years. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 19(5), 477–484. https://doi.org/10.1053/jars.2003.50112
- Mao, AS, and Mooney, DJ (2015). Regenerative Medicine: Current Therapies and Future Directions. Proceedings of the National Academy of Sciences, 112(47), 14452–14459. https://doi.org/10.1073/pnas.1508520112
About Dr. Pamela Mehta, MD
Dr. Pamela Mehta is a board-certified orthopedic surgeon in San Jose, California, and founder of Resilience Orthopedics. She is an expert in the treatment of sports injuries and osteoarthritis, as well as modern regenerative medicine therapies.
Dr. Mehta graduated from the University of Southern California with honors in 2006. She was awarded the Order of the Palm and Laureate, and the Order of Arete, during her undergraduate and medical studies – both awarded for excellence in leadership, academics and service.
She then completed her residency at Columbia University where she was trained by Dr. Louis Bigliani, the inventor of modern shoulder replacement. Since then, she has worked for major healthcare organizations in California for 5 years, before founding her own orthopedic practice – Resilience Orthopedics in San Jose. During her career, Dr. Mehta has had the privilege of serving as Chief of Orthopedic Surgery and National Director of Orthopedics for a large orthopedic hospital group, as well as serving as a medical advisor to various companies including @FIGS and @TheGoodFeetStore.
Disclaimer: This article has not been peer reviewed and is presented as the personal view of a qualified subject matter expert pursuant to the News-Medical.Net Terms of Service . Dr. Mehta has no conflicts of interest to declare.