How regenerative medicine can make a difference to orthopedics in light of the challenges of traditional bone and joint treatment?

Accidents and injuries happen which is inevitable in life. Even if accidents can be avoided, theoretically, the aging of the joints leads to osteoarthritis.

While young people may recover from injuries with conventional treatment, joints do not respond in the same way, especially with age. Tissues such as cartilage, ligaments, and tendons do not have the ability to regenerate and heal on their own as well as other tissues, which worsens with age. We often resort to joint replacement and surgical procedures to repair and straighten joints because our bodies can’t.

An estimated 150,000 knee and hip replacements are performed in the United States each year, and the number is expected to triple by 2040.

The choice is usually between conservative management, physical therapy, mobility aids, steroid injections, and surgery, including joint replacement. Conservative procedures may be less effective, while surgery comes with pain and medical risks. The question comes: Should you risk your health?

Is regenerative medicine the solution?

Regenerative medicine is a new field of medicine in which orthopedic surgeons aim to move away from replacement and toward joint preservation. Using Orthobiologics, the body can be supplied with cells and materials and stimulated to heal without a surgeon’s knife.

Taken at face value, it seems to be a perfect solution to all our problems. The promise of regenerative medicine in orthopedics can delay joint replacement for as long as possible and may offer an alternative while long waiting for an implant procedure in other specialties of medicine. As with any new form of treatment, regenerative medicine is not without controversy. The main debate in orthobiologics is whether the body of evidence currently supports the incorporation of regenerative medicine techniques into conventional treatment strategies.

There is a lot of evidence supporting regenerative medicine techniques in certain conditions such as osteoarthritis and tendinopathy. However, there needs to be a broader evidence base before these treatments are accepted as standard practice in orthopedics.

What is regenerative medicine?

We also cannot expect larger studies to demonstrate the efficacy of these treatments, as some meta-analyses show only the marginal efficacy of the plasma-rich plasma and advise against its use as a conservative treatment.

The History of Regenerative Medicine

The idea behind regenerative medicine is not new. The oldest story detailing the body’s ability to regenerate comes from Greek mythology around the god Prometheus, who was punished for stealing fire and giving it to humanity. Prometheus was chained to a rock for Zeus’ eagle to eat his liver, day after day, with his liver regenerating overnight. This story leads us to believe that the ancient Greeks were aware of the liver’s ability to regrow and regenerate at this point in history. In orthopedics, the first known “regenerative” procedure came in 500 BC, where Roman soldiers with joint locations were treated with hot needle therapy.

Modern orthopedic therapies have advanced in regenerative medicine over the past 80 years, focusing on modifying the healing response in the body. Magnuson described a treatment for osteoarthritis by extensive debridement of the knee. This well-established treatment was later replaced therapies including inducement of healing by irritation to the joint via injection of saline (prolotherapy – Hackett et al. 1956), drilling into arthritic cartilage (Pridie 1959), and micro fracturing cartilage (Steadman 1984).

Recently, regenerative medicine has focused on implantation cells to initiate healing, with the introduction of modern interventions such as platelet-rich plasma, mesenchymal stem cells, and injections of biomaterials that can induce a healing response.

Regenerative Medicine and Orthobiologics in 2022

Modern orthopedic regenerative medicine therapies are still struggling to find a place within standard practice and large healthcare institutions, due to controversy over whether the evidence base currently supports their use. Treatments such as platelet-rich plasma and injections and fat-cell derived stem cells often require patients to pay out of pocket as insurance companies refuse to cover these forms of treatment.

However, there is an increasing number of physicians who are using orthobiologics as part of their practices. As the growing evidence base for therapeutic feasibility expands, conditions such as osteoarthritis and tendinopathy are being treated, and treatments are offered including injections of:

• Plasma-rich platelets taken from the patient’s blood.

• Stem cells are taken from adipose tissue, bone marrow, umbilical cord, amniotic fluid, and placenta.

• Biomaterials such as autologous chondrocytes (cells taken from the patient that produce cartilage), bovine collagen, bone matrix, and proteins.

Orthobiologics are generally considered conservative treatments, as a less invasive alternative to surgery or as an additional option when other treatments have failed.

Orthobiologics is becoming increasingly popular, in part because of the media coverage of famous athletes undergoing these procedures. It has added enthusiasm to the debate about regenerative medicine.

If the goal is to move away from joint replacement and joint surgery, we are not there yet. However, we see the use of orthobiologics expanding and advancing.

The future of regenerative medicine

Regenerative medicine holds promise for delaying and possibly reducing surgical intervention in patients with degenerative joint diseases and musculoskeletal injuries. Shortly, we may see orthobiologics used as a middle-ground for arthritis cases, sitting somewhere between conservative treatment and surgery.

In the future, we may see another form of how to replace joints such as moving away from metal and ceramic joint replacements towards biological replacement and regeneration. We can also anticipate a move toward orthobiologic injections as a preventative measure for degenerative joint conditions.

Some hurdles must be overcome before orthobiologics can take a real place among conventional treatments. Some of these obstacles deal with the controversy behind stem cell research and the lack of a solid foundation of evidence. Other obstacles include difficulties in developing currently available treatments to promote symptom improvement, long-term efficacy, and safety. We are still struggling with how to store stem cells, grow cells rapidly for grafting, and prepare the musculoskeletal system for transplant and regeneration of new tissue.