Great, thank you. Thanks for having me glad to be here. So It's not advancing All right, these are my disclosures there are none pertinent Can you put it in the presenter view There it is All right, so although reconstruction with tendon grafts is accepted as the gold standard of an ACL reconstruction Failures and re-ruptures are still a concern in younger and high demand patients, especially returning into high-impact sports So the aim of using orthobiologics and the treatment of ACL injuries is to enhance the ligamentous healing process modulated the inflammatory response down regulating the production of Degradative enzymes after the injury and maximizing the regenerative potential of ACL cellular production population the factors that are crucial to continuing our efforts to maximize graft healing and Accelerate recover recovery to decrease these failures So we're using PRP platelet-rich fiber and ACP and MSC is derived either from adipose tissue or bone marrow aspirate And they have been widely used in the treatment of sports injuries in the last two decades Their use in efforts to accelerate functional recovery and improve graft maturation after ACL reconstruction have been increasingly studied However, the clinical benefit of these additional interventions really need to be additionally clarified their roles in Partial ACL tears continue to evolve as our techniques have revitalized interest in this outside of tenderness reconstruction First today, I will discuss PRP and review three systematic reviews related to PRP. So in 2022 a systematic review of metal analysis on PRP effects on clinical outcomes after ACL surgery Was found that it found that PRP applied alongside ACL reconstruction improved pain scores specifically with graft tunnel injection at three months post-operatively and at the BTB and Donor site before six months post-operatively it improved knee function in the short and medium term After surgery, but it did not improve clinical outcomes in the long term PRP did not improve knee stability with regard to kt1000 measurements and pivot shift testing and there was no improvement in reducing tunnel enlargement or graft characterization when injected into the graft tunnels The study did demonstrate though that PRP could be safely applied in ACL reconstruction because of the low incidence of complications another systematic review published in 2023 reviewed the effect of PRP on healing specifically vascularization Inflammation and ligament ization and the clinical outcomes in patients undergoing ACL reconstruction and they tried to compare the preparation and application of PRP It noted that PRP influences healing through early vascularization culminating in higher rates of ligament ization Long-term effects though were not demonstrated suggesting that the PRP effect is limited No consensus was reached whether the impact of PRP what the impact PRP had on pain knee stability and resultant knee function So there there are more avenues for research for this They did note on that subsequent investigation should incorporate whether multiple doses over time or more frequent Observations and comparing different forms of PRP would be necessary Again, the lack of standardization of PRP collection and the application techniques do make comparison difficult another study regarding outcomes of biologics and ACL repair and reconstruction Found that despite the attempts to improve outcomes and of ACL repair and reconstruction through biologic age agents Current evidence is still lacking sound data to approve their use Cell-based approaches have been adopted in just a few trials where PRP products have been tested much more extensively revealing potential and promoting better graft remodeling and maturation The bottom line is that no clinical superiority has been described when using PRP and ACL reconstruction however there's some interesting findings with regarding to ACL healing and partial tears and the Application of PRP has led to some encouraging outcomes both in terms of subjective scores and objective knee stability These findings do need to be confirmed with designated randomized controlled trials next platelet-rich fibrin in 2020 comparative MRI study was used to determine if PRF and ACL enhanced graft healing and maturation The study did find some positive findings with regard to its use Application of platelet-rich fibrin led to superior graft integration and maturation in the proximal third of the ACL graft There was no significant difference in the MRI signal intensity and in the morbidity or the mid-body sub-graft or at the distal tibia graft Aspiration excuse me application of PRF also resulted in significantly lower rates of post-operative hemarthrosis That needed to be aspirated. So that was an interesting finding in 2022 Retrospective case series evaluated collagen wrapping with local platelet-rich fibrin and ACL survivor rates survival rates after dynamic in a DIS excuse me, it's hard for me to say with and without augmentation So this was a little bit different, but it's the application of platelet-rich fibrin So the five-year overall survival rate of DIS was only sixty nine point six percent and they found that the collagen wrapping with the addition of PRF did not improve overall survival the patients that did not have failure of the graft and Demonstrated high satisfaction rates, but the results of this graft were actually inferior to those of established ACL reconstruction procedures So next talking about mesenchymal stem cells There have been much fewer studies on this in 2017 control double-blind randomized trial evaluating a single intra-articular injection of allogenic mesenchymal precursor cells in patients following ACL reconstruction the NPCs along with the hyaluronic acid group had reduced medial and lateral tibial femoral joint space narrowing They had less tibial bone expansion and a trend towards reduced tibial cartilage volume over six over 26 weeks This suggests that they may mod that these mesenchymal stem cells may modulate some of the pathologic processes responsible for the development of post-traumatic arthritis following ACL reconstruction ACL healing specific measurements like laxity grading or graft incorporation on MRI were not assessed in this study So scaffold enhanced repair, so we're all excited about the bear It's an extracellular matrix fold matrix Scaffold composed of matrix proteins and collagen from bovine tissue. It's hydrophilic it absorbs Five times of its weight and it's used to fill in the gap between the torn ligament ends So 65 patients were randomized for bear or ACL It was unblinded at two years and the outcomes were assessed by an independent examiner bear resulted in non-inferior patient reported outcomes and AP laxity and superior hamstrings muscle strength when compared to autograph ACL reconstruction Primarily hamstring at two-year follow-up in the young active cohort in a follow-up study in 2021 they reported earlier resolution of symptoms and increased satisfaction about their knee function as well as improved resolution of hamstring strength throughout the two-year follow-up period in Conclusion the results of the clinical work utilizing biologic augmentation with ACL repair and reconstruction have provided valuable information Regarding the biologics ability to aid in overcoming specific challenges in the injury and recovery Unfortunately as we continue these investigations a frustrating and complicating factor in Research around this is the preparation composition and dosing of these agents is not standardized Early enthusiasm for its use in ACL injuries and favorable animal studies have not necessarily translated into better clinical outcomes Orthobiologics may have a positive effect on graft incorporation and maturation and early post-operative pain scores However, their benefits have not demonstrated substantial clinical significance and do not result in better knee stability or lower failure rates We need more well-designed Controlled studies to define the exact role of these biologic agents and while more the clinical work in this field has been focused on The cellular therapy and growth factors and such the next generation of biologic strategies should include elements like scaffolds and mechanical stimuli So more research is required to further elucidate whether these approaches show The most promise and and the greatest therapeutic advantage. Thank you

orthobiologics

ACL injuries

PRP

MSCs

biologic agents