1. March 26 th, 2016 Fred Hoover Sports Medicine Symposium Chris Clemow, MD, FACSM Orthobiologics: Platelet Rich Plasma, Stem Cells, and more

2. Disclosures I have no disclosures as it relates to these topics.

3. Objectives Introduce some concepts associated with orthobiologics’ use in sports medicine Describe the theories for how these procedures work Illustrate the basics of how these procedures are done Review some of the evidence Discuss the potential future

4. Many athletes have used..

5. Platelet Rich Plasma Use of concentrated platelets from an individuals own blood stream to advance healing Used in acute and chronic injury settings Typically done with guidance to an area of interest Platelets carry many of the signaling factors in the human body for healing

6. Platelet Rich Plasma: A little history… 1970’s first used 1987- Used in open heart surgery 1990’s – Used in facial and cosmetic surgery 2006 –Mishra& Poavelko (Stanford) – favorable lateral epicondylitis study 2008- Used on Hines Ward (Pittsburgh Steelers) for MCL injury before SuperBowl 2010 – JAMA article – shows comparable to saline injection in Achilles tendonopathy …..varying evidence since…..used on over 20 professional athletes and thousands of college athletes

7. The many growth factors:

8. PRP Pros Appears low risk Good lab science Relatively easy Some evidence for effectiveness in humans Unlikely to cause harm Cons Insurance doesn’t pay Variable preparation Takes time Varying evidence for indications Need ultrasound or flouroscopy experience

9. What’s the evidence?? Over 8000 published papers and 500 active studies How do you compare apples to apples?? What indication for low or high concentration? When do we use leukocyte rich vs poor? Guidance or no guidance? Acute or chronic injuries? Post procedure rehab and what type? Activated or not activated? How long should it take to get better but still show effect? Need big studies.

10. The next evolution?.. Stem cells Multipotent cells found in several places in the body Used to augment healing Designed to be part of growing new tissue from cells rather than signaling alone

11. Where do these come from?

13. Potential uses Cartilage healing and regeneration Bone healing Tendon or ligament acute or chronic healing Pain control Inflammation control Slow deterioration Tx of autoimmune diseases Tx of liver and other solid organ conditions

14. Dr. James Andrews: “We have had one big revelation in sports medicine over the past 50 years, and that was the arthroscope. I’ve been looking for the next wave, and stem cell therapy….will be it”

17. Bone Marrow Aspirate Concentrate (BMAC) Designed to obtain more multipotent stem cells Capable of being divided into many more components than mesenchymal stem cells Can be obtained from several places

18. Fat Derived Stem Cells Obtained in a procedure like a liposuction Mesenchymal stem cells separated (washed off) of fat tissue Injected back into injury sites

19. One vs the other? BMAC vs.Lipoaspirate More invasive? More multipotent cells Platelets within? More growth factors? Faster? Less invasive? Isolated mesenchymal stem Might add PRP? Less growth factors? More time?

20. What might the future hold? Chronically damaged tissue healing and/or regeneration Consistent surgical uses for healing augmentation Faster returns to play Less surgical intervention More minimally invasive repair and healing techniques

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