Orthobiologics for Joint, Tendon, and Spine Care Today

Orthobiologics for Joint, Tendon, and Spine Care

Abstract

Welcome to our educational journey into the world of orthobiologics. In this post, I will explore the latest advancements in treatments such as Platelet-Rich Plasma (PRP) and adipose-derived therapies, drawing on discussions with leading researchers in the field. We will explore the critical importance of understanding cellular composition in PRP, distinguishing between leukocyte-rich and leukocyte-poor formulations and their impact on joint health. I’ll break down the nuances of harvesting and applying adipose tissue for regenerative purposes, highlighting patient selection and procedural best practices. We will also examine the complexities of treating subchondral bone issues and why a multifaceted approach that combines biologic interventions with biomechanical and lifestyle modifications is key to success. This exploration frames our clinic’s integrative care model, in which we combine cutting-edge regenerative techniques with holistic patient management to achieve optimal outcomes.

Our Integrative Approach: A New Era of Collaborative Healthcare

At our practice, Injury Medical Clinic PA, we believe that the future of healthcare lies in a multidisciplinary, patient-centered model. I am Dr. Alex Jimenez, and my journey has led me to earn credentials as a Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), and Board-Certified Family Nurse Practitioner (FNP-BC), among others. This diverse background allows me to view patient care through multiple lenses.

To further enhance our ability to provide comprehensive care, I am thrilled to announce our collaboration with Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a highly respected, board-certified Internist with over 40 years of experience. She will be serving as our Medical Director and Collaborative Physician. This partnership is a cornerstone of our integrative setup. It ensures that our patients receive the highest standard of care, combining my expertise in chiropractic, functional medicine, and rehabilitation with Dr. Cardenas’s extensive medical knowledge and oversight. This collaborative framework allows us to seamlessly integrate services, including:

• Medical Oversight: Dr. Cardenas provides essential medical direction, ensuring all treatments are safe, appropriate, and aligned with established medical standards.
• Chiropractic Care: We focus on musculoskeletal alignment, nervous system function, and biomechanical health to restore the body’s foundational structure.
• Functional Medicine: We investigate and address the root causes of disease by examining genetics, environment, and lifestyle factors.
• Regenerative Medicine: We utilize advanced orthobiologic therapies to stimulate the body’s natural healing processes.
• Rehabilitation and Personal Injury Care: Our team develops customized programs to restore function, reduce pain, and help patients recover from injuries.

By working together, Dr. Cardenas and I ensure that every patient benefits from a holistic treatment plan that addresses their health from every angle.

Unpacking the Nuances of Platelet-Rich Plasma (PRP)

One of the most fascinating and rapidly evolving areas in regenerative medicine is the use of Platelet-Rich Plasma (PRP). However, as I’ve observed in discussions with top researchers, not all PRP is created equal. The terminology can be confusing, and understanding the details is critical for achieving successful patient outcomes.

Leukocyte-Rich vs. Leukocyte-Poor: A Critical Distinction

The central point of confusion often lies in the concentration of white blood cells (leukocytes) in the PRP preparation. Specifically, we need to focus on the different types of white blood cells.

• Neutrophils: These are pro-inflammatory cells. High neutrophil counts in a PRP injection, particularly within a joint, can trigger a significant inflammatory response, leading to pain, swelling, and potential cartilage damage. This is often referred to as a neutrophil-rich or a truly “leukocyte-rich” PRP.
• Monocytes and Lymphocytes: These cells play a more modulatory and regenerative role. Formulations that minimize neutrophils while retaining beneficial monocytes and lymphocytes are generally preferred for intra-articular injections.

A common issue arises with commercial PRP systems in the United States. Many are marketed as “leukocyte-poor,” implying they have a low white blood cell count. However, upon closer analysis, we often find that while the neutrophil count is reduced, the lymphocyte count is significantly elevated. This results in an overall white blood cell count that may be the same as or even higher than the patient’s whole-blood count. Technically, this could still be classified as “leukocyte-rich” because the total number of white cells hasn’t decreased.

This distinction is not just academic; it has profound clinical implications. Based on expert consensus, injecting a neutrophil-rich PRP preparation directly into a joint is generally not recommended. The risk of a painful, inflammatory flare-up is high, which can lead to unhappy patients and poor results. Therefore, it’s my clinical responsibility to precisely understand the cellular mix produced by a specific PRP system.

Navigating PRP Systems and Preparation

So, how do we ensure we are using the right formulation for the right application?

1. Know Your System: Before implementing any PRP system in my clinic, I do extensive research. This involves asking the manufacturers for detailed data, including “white papers,” which are internal documents that outline the cellular composition of their systems. I also look for independent, peer-reviewed studies that have used the system to verify the claims.
2. Point-of-Care Analysis: The future of regenerative medicine will likely involve point-of-care cell analysis. This means having the ability to analyze a blood sample before processing and the resulting PRP concentrate afterward. This would allow us to know the exact “cellular dose” we are administering and even modify the preparation to suit a specific patient’s needs.
3. Customized Preparation: The final cellular composition of PRP can be influenced by several factors, including the volume of blood drawn, the number of spin cycles, the spin speed, and the specific kit used. For instance, for a knee injection, a larger volume draw (from 60 cc to 180 cc or more) might be necessary to obtain sufficient concentrations of platelets and other beneficial cells to achieve a therapeutic effect. By adjusting these parameters, we can create a PRP formulation that is biologically advantageous for the target tissue.

My take-home message is this: if you are considering PRP therapy, ask your provider detailed questions. Understand the type of PRP they are using and why they believe it’s the right choice for your condition. A knowledgeable practitioner should be able to explain their rationale clearly.

Advanced Biologics: The Role of Adipose Tissue and Microneedling

When PRP or other first-line treatments are not enough, we can turn to more advanced orthobiologics, such as those derived from adipose (fat) tissue. This involves a procedure called liposuction to harvest the fat, which is then processed to create a concentrate rich in regenerative cells, including mesenchymal stem cells (MSCs).

Who Is a Candidate for Adipose-Derived Therapies?

In my practice, I typically consider adipose-based treatments as a second-line option for specific patient profiles:

• Patients with Advanced Osteoarthritis: These are individuals who have exhausted other options like physical therapy, bracing, and injections (corticosteroids, hyaluronic acid, PRP) and are seeking to avoid or delay joint replacement surgery.
• Persistent Joint Effusions: Patients with chronic joint swelling, often after surgery, may benefit from the potent anti-inflammatory and regenerative properties of adipose-derived cells.
• Failure of Other Biologics: If a patient has not responded to multiple rounds of PRP, it may mean that a stronger biologic signal is needed, which adipose tissue can provide.

I’ve been pleasantly surprised by the number of patients who have responded positively to adipose therapies after failing to find relief with other treatments. While it doesn’t work for everyone—no biologic treatment does—it represents a powerful tool in our regenerative arsenal.

The Liposuction Procedure: Safety and Comfort

The idea of undergoing liposuction in a clinic setting can be intimidating for patients. However, extensive data, particularly from the plastic surgery field, shows that liposuction performed on an awake patient using tumescent anesthesia is significantly safer than when performed under general anesthesia.

Here is what the in-office procedure typically looks like:

1. Preparation: The patient is made comfortable in one of our special procedure rooms. We often play music to create a relaxing atmosphere.
2. Tumescent Anesthesia: A large volume of a dilute anesthetic solution (tumescent saline) is injected into the fat layer, usually in the flank or abdomen. This completely numbs the area and separates the fat cells, making them easier to harvest.
3. Waiting Period: This is a crucial step. We wait for 20-30 minutes after injecting the solution. This “dwell time” allows the anesthetic to take full effect and the fat tissue to become optimally prepared for harvesting. During this time, I can see other patients, which helps maintain the clinic’s flow.
4. Harvesting: Using a small cannula, the fat is gently suctioned out. Most patients report feeling only minor pressure or strange sensations, but not pain.
5. Processing and Injection: The harvested tissue is processed to produce the regenerative concentrate, which is then injected immediately into the target area (e.g., the knee joint).

This process is remarkably well tolerated and allows us to harness the body’s powerful regenerative cells safely and effectively.

Treating the Bone: The Importance of the Subchondral Environment

A critical concept that is often overlooked in the treatment of osteoarthritis is the health of the subchondral bone—the layer of bone just beneath the cartilage. In many cases of joint pain, especially in advanced arthritis, this bone becomes stressed, developing edema (swelling), microfractures, or lesions. This is sometimes referred to as a “bone marrow lesion.” Think of it as a sick foundation under a house; if the foundation is weak, the house above it (the cartilage) will inevitably suffer.

The Challenge of Subchondral Injections

Research, particularly a landmark French study, has shown incredible results with injecting the subchondral bone to treat these lesions. In that study, a high percentage of patients avoided knee replacement surgery even 15 years after the procedure. The procedure involves decompressing the bone by drilling into it, then injecting a biologic agent, such as bone marrow concentrate or a synthetic bone substitute, such as calcium phosphate cement.

However, as I’ve seen in my clinical practice and in reviewing the broader literature, there are several key considerations:

• The Decompression Effect: A significant portion of the benefit may simply come from drilling a hole in the bone. This act of decompression can relieve the high pressure within the bone, which immediately reduces pain. The question remains: how much of the success is due to decompression, and how much to the “magic” we inject?
• The 20% Failure Rate: Across nearly all studies on subchondral procedures, there is a consistent 20% failure rate. This means that while the treatment can be highly effective for 80% of patients, one in five will likely not see a lasting benefit and may need to proceed with surgery.
• Treating the Whole Environment: Simply injecting the bone is not enough. We must address why the bone became sick in the first place. This requires a holistic, integrative approach that considers the patient’s entire biomechanical and metabolic status.

A Holistic Strategy for Bone and Joint Health

To improve the odds of success beyond that 80% and create lasting change, we must modify the patient’s environment. This is where integrative chiropractic care becomes indispensable.

• Biomechanical Offloading: For a knee, we need to reduce the compressive forces on the joint. This can be achieved through:
  • Osteotomy: A surgical procedure to realign the bone.
  • Offloading Brace: A non-surgical option to shift weight away from the damaged part of the joint.
  • Chiropractic Adjustments: Correcting misalignments in the spine, pelvis, hips, and ankles can change the way forces are transmitted through the leg, reducing stress on the knee.
• Muscle Strengthening: Weak quadriceps and gluteal muscles are a major contributor to knee pain. If these muscles aren’t providing adequate support, the joint is subjected to excessive pressure. Our rehabilitation programs focus on strengthening these key muscle groups.
• Weight Loss: Every extra pound of body weight places 4-6 extra pounds of pressure on the knee joint. Weight loss is one of the most powerful things a patient can do to change their joint environment.
• Metabolic Health: Systemic inflammation, poor blood sugar control, and nutritional deficiencies can all hinder the body’s ability to heal. Our functional medicine approach addresses these underlying issues to create an internal environment conducive to healing.

No orthobiologic treatment, however advanced, can overcome poor biomechanics. As my surgical colleagues often say, treating the “foundation” (the bone) is useless if the “walls” (the muscles and alignment) are still crumbling. The patients who fail these advanced procedures are often the ones whose underlying biomechanical and metabolic issues were never addressed. By integrating chiropractic care, functional medicine, and targeted rehabilitation with our biologic treatments, we provide our patients the best possible chance for a successful, long-term outcome.

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References

• Hernigou, P., Auregan, J. C., Dubory, A., Flouzat-Lachaniette, C. H., Chevallier, N., & Rouard, H. (2018). Subchondral bone or intra-articular injection of bone marrow concentrate: what is the best choice in knee osteoarthritis? International Orthopaedics, 42(10), 2293–2301. https://doi.org/10.1007/s00264-018-3932-9
• Housman, T. S., Lawrence, N., Mellen, B. G., George, M. R., Scott, J. R., & Fleischer, A. B., Jr. (2002). The safety of liposuction: results of a national survey. Dermatologic Surgery, 28(11), 971–978. https://doi.org/10.1046/j.1524-4725.2002.02129.x
• Kon, E., Di Matteo, B., Delgado, D., Cole, B. J., Dorotei, A., Filardo, G., & D’Amato, T. (2021). Platelet-rich plasma for the treatment of knee osteoarthritis: a comprehensive narrative review. International Journal of Molecular Sciences, 22(8), 4057. https://doi.org/10.3390/ijms22084057