Thank you. Sheesh bill bug me. He's a skilled cartilage surgeon. He's going to talk to us about non-operative treatment of osteoarthritis Thanks Scott My disclosures, I really have no financial interest, but that doesn't mean I have by it don't have bias I'm an orthopedic surgeon who practices the dark arts of joint replacement Enthusiastically, I'm in a health situation where we have a like Scott does we have a 15 million dollar stem Cell grant that I can't mess with by doing something stupid in the clinic and causing a legal action And I have a background as a tissue bank medical director and an FDA advisory panel So I come to us more like Scott then then then the enthusiastic front-edge practitioners So here's what happens in an arthritis practice you get someone like this it comes in. I've treated her for years did her hip replacement She's healthy active financially secure She comes in and she wants to know when she can get when she should get her knee replacement He tells me she went to one of the clinics nearby and had an injection in her shoulder and her knee and got better She was happy. She was excited. I said, what did they do? She had no idea She had no documentation nothing. So we looked on the internet and I think she got Wharton's jelly So, what do you do with this as an orthopedic surgeon? How do you get in? This is my patient This is a patient I take care of she never called me or asked me. She just went out and did this so that's why in Osteoarthritis is truly the Wild West of biologics and orthopedic practice So it's really important to understand that why is that because OA is prevalent 65 million people have doctor diagnosed osteoarthritis in the United States secondly Unlike some of the things you've heard about maybe teninopathy muscle injury. It is not curable It's not curable once that diagnosis gets on the electronic medical record It's there forever and the traditional options as you all know are palliative and not particularly effective or durable It's why surgeons exist to fix it in the end the public demand is huge and the word restorative regenerative or curative is out there and And Scott will tell you it probably shouldn't be and the medical community. That's why you're on this room we're really interested in providing more effective care options for people with Osteoarthritis and it is financially potentially lucrative because it's a cash pay situation at this stage and Everyone not just orthopedist not just surgeons wants a piece of this action and in that scenario through industry and patients and the internet its perception that regulations are open to interpretation and Enforcement is weak. So here's the perfect storm and that's why it's a Wild West So I come to think about five principles that I use with biologics in an orthopedic arthritis practice So I say one we should know the disease and not everyone does We should know the available therapies and what the treatment guidelines tell you and then know the data Of course and then know the rules I think you already know there's a lot of rules that They're hard to interpret and then you should know yourself Who do you want to be and what you want to be in the biologics arena? So first thing is Osteoarthritis is phenotypically diverse disease. There's no clinically useful biomarkers there's no single molecular target unlike rheumatoid disease where TNF alpha and IL-1 are Brilliant brilliant medicines for that and we're using a grading system to find severity of disease that was published in 1957 and It does not adequately describe the joint pathology and the biology that's happening in an arthritic joint So this is what you get if you look up treatment guidelines and you know Most of you take care of arthritis patients. You understand it, but most people that don't look up There's 35 different guidelines and most of them revolve around all these palliative care and even still opioids on this But you see where the arrow is It's an injection area where we get involved often with patients after they've been running around taking on Steroidals we have practice guidelines that aren't that helpful to us Truth be told I use a lot of steroid injections and this is a little text Messaging between me and my dentist and he comes in says he has a bad hip He needs a total joint and but he's gonna play a golf tournament So he gets a steroid injection in the hip and he gets second place in these it's a miracle Now that's I say that because not because it's biologic because that's the context in which we manage arthritis steroids are very effective Short-term and there's nothing else that makes a patient happier when they walk out of the clinic So that's the context in which you'd have this talk about biologics for your arthritis So what's the data? The data is that without a doubt PRP is the best and most studied injectable biologic for OA and you can see that here Placebo has a really good effect too, by the way. So when you talk about injections, remember there's a placebo effect PRP is better than placebo PRP is better than steroids and PRP is better than HA and these are all meta-analyses that have been done and it's clear So all the ambiguity you might hear about something else. There's really in my opinion No ambiguity about what the best biologic is for osteoarthritis based on this studies but PRP is not better than HA for severe OA so KL for disease or in people that are older So there you have to get in the cost-effectiveness discussion Is it really effective to use PRP in someone who was stage 4 disease in their 60s when you have cheaper options that might give Them by them time because you're not curing disease. Remember that so this was recently in Anna they asked for Data and I think the ESCA consensus which is going to be published soon There's a lot of thoughtful people in Europe that have more time than I do to sit down and talk about everything Yes, PRP is Supported by the clinical evidence, so I feel that's the best thing I can do But there's not enough compelling evidence for the other things BMAC Stomal vascular fraction fatty 2m perinatal tissue and the regulatory issues are unresolved and to Scott's point I don't want to mess with that if it's not more effective It's probably more expensive and I have a useful biologic in my hands that is mainstream now So finally, I know myself as an orthopedic surgeon I like performing surgery my practice is organized around that and they don't have a lot of bandwidth to compete in this marketplace I don't want to get in trouble. So I don't go there And go start doing very unusual things or things that might be edgy to compete with colleagues in the field So in the end, what do I do? I use PRP for non-operative biologic OA treatment and that's in the context of steroids and HA I discourage that use in elderly people even if they have a lot of money and and disposable income And I use BMAC as a perioperative. So I didn't have to say much about BMAC but it's very useful in the operating room as you heard I One other thing I would say is for those you injections and then do surgery there's clear evidence in the total joint literature that if you operate within three months of an injection your risk of an Infection goes up up to fourfold. So with that I tell you stick with PRP as your biologic and Watch out for the regulatory issues because it is a Wild West out there. Thank you very much

orthopedic surgeon

non-operative treatment

osteoarthritis

biologics arena

platelet-rich plasma