1. Proof Regen Med Injections Heal Soft Tissue Injuries
Ortho Update Alleghany Hospital April 2018
Proof Regen Med Injections Heal Soft Tissue Injuries
Brian J. Shiple, D.O., CAQSM, RMSK
The Center for Sports Medicine
Philadelphia, PA

2. Disclosures Brian J. Shiple, D.O., AAOM President Elect

3. Regenerative Medicine
Since 2008 Regen Med has made a big impact in our clinics and in research. Much of the new literature shows about as much negative results as positive.
Meta-analysis conclusions are mixed with some areas like O/A of the knee and Lateral Epicondylosis showing good efficacy, but the Achilles tendon not so much.
Brian J. Shiple, DO

4. Orthopedic Surgery
The surgical experience treating advanced degenerative musculoskeletal conditions continues to show less than optimal results with failure rates in micro-fracture and rotator cuff repair at significantly high rates.
But it’s still the standard of care and it’s the best we can do, right?
Brian J. Shiple, DO

5. Regenerative Orthopedic Medicine
In O/A of the knee a tx such as PRP injections shows good efficacy up to grade 3 KL changes
Grade 4 changes- pose a greater challenge. Impinging bone spurs, loose bodies, unstable degenerative meniscus tears with meniscal protrusions complicate the chances of an optimal outcome for patients who are too young or very active for a TKA.
Brian J. Shiple, DO

6. Integration of the Two Specialties
What if we are faced with a partial thickness bursal side rotator cuff tear with an impinging bone spur on the underside of an arthritic A/C joint?
How many would treat that patient with a regen med technique such as a PRP w/ or w/o a graft injection?
Brian J. Shiple, DO

7. Integration of the Two Specialties
Failure rates will be very high, because the cause of the tendon tear is not addressed, mechanical impingement
Brian J. Shiple, DO

8. Orthopedic Surgery
That same patient would not be a great candidate for anything more than a subacromial decompression to take care of the mechanical impingement
At best the partial thickness R/C tear would be debrided but would probably not aid the tendon to return back to a healthy state
Brian J. Shiple, DO

9. Orthopedic Surgery
Full Thickness R/C tears with retraction have a surgical failure rate of % depending on the size of the tear. Full recovery can take 6 mos to 1-2 years with satisfaction rates of under 50% in patients older than 65 yrs old.
Hernigou combined a BMC injection both into the repair site and into the head of the humerus underneath the R/C foot print and decreased the failure rate to 0% at 6 months and 13% at 10 yrs.
Brian J. Shiple, DO

10. Integration of Regenerative Medicine and Orthopedic Surgery
What if we could combine the best of Orthopedic Surgery and Regenerative Medicine to be able to treat more advanced MSK cases, achieve better outcomes with shorter recovery and less complications than with the standard of care that we currently provide our patients in our regenerative medicine and orthopedic surgery practices?
Brian J. Shiple, DO

11. Integration of Orthopedics and Regen Med
There are challenges to finding the right combination of providers who can work together for the good of the patient’s MSK need
Dr Kalman is an advanced sports medicine orthopedic surgeon practicing in the Philadelphia area for yrs. He is a national expert in the art and science of hip arthroscopy as well.
He understands the healing potential of combining regen med with orthopedic surgery
Brian J. Shiple, DO

12. Integrative Orthopedics
The following three cases highlight the potential of this new integration.
All three of these cases would have failed a purely regen med approach.
I know because I’ve learned the hard way.
One case had surgery on both shoulders and regen med on one of them.
Brian J. Shiple, DO

13. First Knee Case
63yom w/ L knee pain and Medial comp O/A grade 4 w/ loose body in intercondylar notch only allowing +20°of extension. Med meniscus tear from PH to body, MCL partial tear at origin, Pat tendon defect & Baker’s cyst.
MFC with Grade 4 changes
Brian J. Shiple, DO

14. First Knee Case
Scope in 2005 found grade 3 and 4 articular surface changes in all 3 compartments. M/M and surface lesions debrided. Had continued pain after arthroscopy.
Brian J. Shiple, DO

15. Knee O/A Lacking Extension
Sent to Dr K for arthroscopy and loose body removal. Immediately experienced full range of motion.
2.5 mos later returned for BMC stem cell tx with intra-articular fat graft
He received a saph nerve block plus local anesthesia to facilitate a comfortable procedure
BMC TNC 2X10e8 at 4cc from 80cc BMA (not great)
Brian J. Shiple, DO

16. First Knee Case-Athroscopy
Patellofemoral Joint
Brian J. Shiple, DO

17. First Knee Case-Athroscopy
Lateral Joint
Brian J. Shiple, DO

18. First Knee Case-Arthroscopy
Fixed Loose Body in Front of ACL
Brian J. Shiple, DO

19. First Knee Case-Arthroscopy
Bone Removed=Return of Extension
Brian J. Shiple, DO

20. First Knee Case-Arthroscopy
Loose Bodies
Brian J. Shiple, DO

21. Knee O/A Lacking Extension
Dx US revealed MCL sprain, small effusion, Horizontal defects of the M/M from AH to PH. Baker’s cyst.
Pt received an I/L epidural block w/ Fluoro for BMA and to tx LBP
All soft tissue structures injected w PRP/fat graft and BMC placed in the joint and M/M tear with part of the fat graft.
Procedure tolerated very well
Brian J. Shiple, DO

22. MCL Post Treatment
One of our principle RIT tenets is to treat any stabilizing structure needing tx
The Medial Meniscus tear is difficult to heal with a regen med tx
Here the MCL looks nml after tx and clinically the patients valgus stress test was nml as well
Brian J. Shiple, DO

23. Knee O/A Lack of Extension
Post procedure he experienced early pain relief.
He was placed in an unloader brace to protect the M/M for 6 weeks
He began weight bearing on day 3
F/U at 12 weeks with 90% pain relief and return to near full function
Now at 26 months- no pain, full function, does not think about it
Brian J. Shiple, DO

24. R/C Tear w/ Impingement
65yof with 1 yr hx of B/l shoulder pain and loss of ROM. Difficulty sleeping on shoulder and doing ADLs.
Exam shows loss of ROM in Abd/ Flex/ Horiz Flex/ ADD/IR and weakness and pain w/ R/C testing. She had signs of impingement with Hawkins and Neers and O’Briens was (+).
Brian J. Shiple, DO

25. Full Thickness R/C Tear
US evidence of Rt S/S FT tear w/ 8mm retraction and partial thickness tears to the I/S and Sub Scap tendon insertions. She also has evidence of a SLAP tear, O/A of GH jt and A/C jt.
MRI shows evidence of A/C spur impinging the S/S tendon w/ PT tear and causing cortical bone cyst and marrow edema in her Humerus with a loose body in the axillary recess
Brian J. Shiple, DO

26. R/C Tear w/ Impingement
Tx plan- try to help heal her soft tissue injury to her S/S tendon.
We will not be successful if the torn R/C tendon is suffering from mechanical impingement that potentially caused the tear in the first place!
Major reason a regen med tx alone will not work
Must prepare the injury for healing and remove all barriers that will cause it to fail!
Brian J. Shiple, DO

27. R/C Tear w/ Impingment Arthroscopy Glenohumeral Joint Loose Body
Brian J. Shiple, DO

28. R/C Tear w/ Impingement
Arthroscopy
Partial Cuff Tear Seen In Joint
Debriding Partial Cuff Tear
Brian J. Shiple, DO

29. R/C Tear w/ Impingment Arthroscopy Subacromial Bursa
Subacromial Bursa Debridement Followed by Decompression of Acromial Spur
Rotator cuff
Brian J. Shiple, DO

30. R/C Tear w/ Impingement
Pt sent to Dr K for acromioplasty and loose body removal
Returned 3.5 weeks later to begin her BMC stem cell tx
Injected a BMC/ fat graft into her GH Jt and S/S tendon tear and injected BMC intraosseous into the Humerus as per Hernigou’s work.
Post-op abduction pillow sling for 4 weeks prior to starting her rehab
Brian J. Shiple, DO

31. R/C Tear w/ Impingement
12 week f/u reports 85% better in pain and fct.
Began PT at the 12 week mark which is late
One year out and she has 90% pain relief and excellent function improvement.
Brian J. Shiple, DO

32. R/C Tear w/ Impingement
Patient originally was planning on doing the same tx to both shoulders, acromioplasty and then stem cell tx
Because the right shoulder went so well, she decided to try just the acromioplasty without the stem cells after to the left shoulder.
At the time of P/C follow up, her left shoulder was over 6 months post op and was still quite painful
Brian J. Shiple, DO

33. Knee Pain w/ Loose Bodies
40YOM navy officer in charge of his country’s special ops. He c/o B/L knee pain and could walk with a limp but could not run any more. He was post op in 2014 for his Lt knee for M/M tear trimming and debridement of his MFC and Tibia medially for advanced O/A. Never really got sig pain relief from his surgery in a foreign country despite several visco injs
Rt Knee was post ACL reconstruction in 2006 w/ O/A
Medial Joint
Medial Joint
Brian J. Shiple, DO

34. Knee Pain w/ Loose Bodies
Ist tx was one year prior to the integrative surgery.
His exam showed medial joint line pain and posterior medial joint pain with an obvious mass in his popliteal fossa
MRI- showed a M/M tear, Bone on Bone O/A and BME in both the tibia and the MFC. He also had numerous small calcific loose bodies in his popliteal cyst as well as in his joint
MFC
MTP
MMT
Brian J. Shiple, DO

35. Knee Pain w/ Loose Bodies
U/S showed loose bodies in Popliteal Cyst, M/M defect and post horn para-meniscal ganglion cyst and mild effusion
He was treated with a PRP/ Fat graft to his joint and M/M tear. He was given a FN block and was offered 5cc of PRF into his MFC and his medial tibial plateau with 11ga X 4” Jamshidi trocar and cannulas as per Anitua/ Sanchez’s PRF protocol.
Brian J. Shiple, DO

36. Knee O/A Case
Brian J. Shiple, DO

37. Knee O/A case
Brian J. Shiple, DO

38. Knee Pain w/ Loose Bodies
He had exc pain relief - 11 months
Due to his job duties of jumping out of airplanes and landing hard, his pain relief was not long term. He presented back to me the following summer with return of his medial jt line pain.
US showed M/M and L/M defect with Baker’s cyst full of loose bodies, small effusion and medial JSN and prox MCL defect
Sent to Dr. K for loose body removal.
Brian J. Shiple, DO

39. Knee Pain w/ Loose Bodies
Patient presented 4 days post op for his BMC stem cell tx
He still had a sig effusion from his surgery so this was drained and his joint was irrigated until all signs of post op hemarthrosis was removed
He received a BMC/ Fat graft to his medial PF jt, M/M and L/M and MCL origin defects.
Brian J. Shiple, DO

40. Knee Pain w/ Loose Bodies
His post op recovery took about 3-4 wks. His pain dropped and ROM returned w/out swelling
Now 6 mos post op and has no pain, full ROM, no swelling and can run and walk all day without pain or swelling.
His government is trying to figure out how to make our treatments more available to their people
Brian J. Shiple, DO

41. Integration of IROM and Orthopedic Surgery
There are Surgical Options for Treatment of Cartilage Injuries
Unfortunately, These Options are for Focal Lesions
Most of the Patients we Treat Have Diffuse Changes Along with Treatable Pathology in Many Cases
The Cases we Presented are Representative of a Team Approach
Traditional Orthopaedic Surgery Treats the Joint…..BUT we Know that Extra-Capsular Structure are Also Pain Generators
WE MUST TREAT the ENTIRE JOINT!
The Future of Orthopaedic Medicine Is the Biologics and Collaborative Efforts from All of US to Make IT Happen
Brian J. Shiple, DO

42. Integration of IROM and Orthopedic Surgery
In Conclusion the cases that we have high lighted here would all have failed if we had not combined the two treatment techniques of using orthopedic surgery to remove all impediments to a successful recovery from our IROM treatments.
The future of IROM will be full of integration of other techniques from hormone replacement, nutrition and prehab to well timed surgical techniques to optimize the patient’s chances of an optimal outcome.
Our challenge is find the common ground to work together across specialties for the best interest of our patient’s care and outcomes!
Brian J. Shiple, DO

43. Brian J. Shiple, DO

44. Brian J. Shiple, DO