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Beyond Reconstruction

ACL Repair - Biologics

And the Future

Steve E. Jordan, M.D.

“The Arthroscope was the first big revolution in Sports Medicine and the second will be in Biologics”

James Andrews, M.D. on Biologics in Sports Medicine

We have just

Scratched the SurfaceWhat we Do Know

Somebodyis trying to make $$$!

So - Be Cautious !

Definition of Terms“Biologics”

• Cell Therapy

• Tissue Therapy

• Growth Factor Therapy

PRP is autologous

The patients blood is drawn and centrifuged

Minimally ManipulatedHomolgous Use

Platelet Rich Plasma PRP

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Platelet Rich Plasma 101

PRP is a concentration of platelets 2-8 X normal

Centrifugation separates - the serum/platelets/WBCs/RBCsWBCs and platelets are in the buffy coat - fast spin can lower the WBC count

• Leukocyte Rich - Extra articular (?)

• Leukocyte Poor - Intra articular

Platelets have granules that release growth factors and bioactive proteins when activated: 95% within 10 minutes

Antimicrobial properties (?)

In the lab – PRP has been shown to attract stem cells and to stimulate cell proliferation which can improve healing

PRP Research Problem

Preparations Activations Applications # of Treatments Post Treatment Protocols Outcomes Reporting Measures

All Vary Wildly

PRP and the ACL

Nin, et al Arthroscopy 2009PRP and Allograft ACL Healing. No effect at 2 yrs

Cervellin, et al, KSSTA 2012

PRP at BTB Donor site. Less Pain, Same healing time

“Nin = None”

ACL Surgery + PRP

PRP gel sewn to ACL graft lead to 48% faster maturation of the graft on MRI

Radice et al, Comparison of MRI in ACL with and without PRP Arthroscopy 2010

Addition of PRP to ACL Grafts

Conclusion: Increased vascularity at the

bone tendon interface seen by 6 weeks.

No difference seen in the intra-articular

segments of the grafts (6wks and 12wks)

European Surg. Research 2010 V 45

Arthroscopy 2010

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What about that

European Treatment?

REGENOKINE - Incubated PRPMarketed for OA and cartilage problems

Manipulated?

sj1

Platelet Rich PlasmaCochrane Collaboration Review 2014

Reviewed Only Randomized Trials with Controls*

19 trials 8 types of injury: • RC repair / Decompression

• Knee Ligament / Donor Site

• Tennis Elbow

• Patellar Tendon

• Achilles Chronic / Rupture

Pain - Function - Adverse Events

Cochrane Review of the Evidence

”Overall there is currently insufficient evidence to support the use of PRT (platelet rich therapies) for treating these injuries.”

Platelet-rich therapies for musculoskeletal soft tissue injuries (Review) The Cochrane Collaboration 2014

PRP = Promising Rarely Proven

What AboutAdding a Collagen Wrap?

Second look arthroscopy

ACL with Autologous Growth Factors

ACL with AGF and Collagen

Vascularity

M. Murray, MD Harvard

Slide 13

sj1 steve jordan, 10/23/2016

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Mesenchymal Stem CellsGOT Mesenchymal Stem Cells?

:Caveat Emptor FDA

MSCs migrated into the injured ACL

KSSTA 2006

CONTROL MSCs added

Arthroscopy 2004

Achilles Tendon Repair

MSCs and Silk Scaffolds

Hydrogel and MSC Constructs …

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Journal Of Arthroscopy April 2017

“Think Inside the Box”Stem Cell Mobilization Studies

Hypoxia

Exercise

Cooling

Center for Regenerative Medicine

at Andrews Institute

ACL Surgery + MSCs

IF :• May increase healing at interface

• May increase fibroblast activity

• May migrate to injured tissue

• No adverse effects noted

• Money not an issue

• Readily Available

Why Not?

Ultrasound guided aspiration posterior iliac crest Spun down and injectedafter the procedure is done.

At Andrews Institute Gulf Breeze, FLCurrent Research Proposal

@

Prospective Randomized Blinded Trial

Wrap the ACL Graft with MSC/Collagen

Follow up with Research MRI Protocol

Current Research

Journal of Royal College of Surgeons

The Surgeon 2016

“Restitutio ad Integrum” “That’s what I’m talking about!”

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Mid Substance ACL Tears?

Mid Substance????

Type I AvulsionRepairable ✔

Repair Experience Andrews Institute

41 yo Nurse with Type I ACL Tear off femur

Desired to Avoid Reconstruction

Repair Experience Andrews Institute

ACL Avulsed from FemurRepaired and Augmented

with Internal Brace

Repair Experience Andrews Institute

7 yr and 11 yr

with ACL Avulsions

“ Bio-Enhanced “ RepairMartha Murray, MD Harvard

Repair sutures + Bio-”Sleeve” to protect from synovial fluid

Prosthetic / Synthetic Grafts

• Silk Suture 1918 (3 mos) Wire 1923 (duh)

• Proplast (PTFE) 1973 (1 yr)

• Carbon Fiber 1977 34 mos particles/rupture

• Gore-Tex (PTFE) 18-24 mos. particles/ rupture

• Dacron 1 yr then deterioration

• Leeds-Keio deteriorate after 1 yr

• Kennedy LAD stress shielding problems

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Ligament Augmentation – Again!

LARS Device Promising50 mos F/U 6% complication

“What do you think the future of ACL surgery will be like”?

Answer: “An autograft or repair with augmentation

plus biologic cell therapy”

Just Something to Ponder.

Thank You