Orthobiologics for Joint Pain and Tissue Recovery Innovations

Orthobiologics for Joint Pain and Tissue Recovery

Abstract

In this educational post, I will take you on a journey into the sophisticated world of orthobiologics, a rapidly evolving field of medicine that uses the body’s own biological substances to heal musculoskeletal injuries. We will explore the latest evidence-based findings from leading researchers, focusing on the critical nuances of treatments like Platelet-Rich Plasma (PRP) and adipose-derived therapies. A key theme is understanding the cellular composition of these treatments—specifically, the roles of platelets, neutrophils, and mononuclear cells—and how their concentrations can dramatically impact patient outcomes. We will differentiate between “leukocyte-rich” and “leukocyte-poor” PRP and discuss why this distinction is vital for clinical success, particularly when injecting into a joint. Furthermore, we’ll examine advanced procedures like micro-fragmented adipose tissue and subchondral bone injections, discussing patient selection, procedural considerations, and realistic expectations. Throughout this discussion, I will explain how our multidisciplinary team at Injury Medical Clinic integrates these advanced regenerative therapies with foundational care, including chiropractic adjustments, rehabilitation, and functional medicine, to create a comprehensive and personalized healing environment for our patients.

Our Collaborative and Integrative Approach to Patient Care

Before diving into the science, I believe it’s essential to set the stage by explaining our unique clinical model here in El Paso, Texas. At Injury Medical Clinic PA, I, Dr. Alex Jimenez, have fostered a multidisciplinary environment where different medical specialties work together effectively. A cornerstone of this model is my collaborative relationship with Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is Board Certified in Internal Medicine and brings over 40 years of invaluable experience as an internist. She serves as our Medical Director and Collaborative Physician, providing crucial medical oversight and guidance.

This integrative setup is common in forward-thinking injury and functional medicine clinics. It allows us to merge the strengths of different disciplines for the patient’s benefit. My expertise in chiropractic care, functional medicine, and as an Advanced Practice Registered Nurse (APRN) is complemented by Dr. Cardenas’s deep knowledge of internal medicine. Together, our team provides a spectrum of services, including:

• Chiropractic Care: Focused on restoring spinal and joint alignment, improving nervous system function, and reducing biomechanical stress.
• Medical Oversight (Internal Medicine): Dr. Cardenas provides diagnoses, manages complex medical conditions, and ensures all treatments are safe and appropriate for the patient’s overall health profile.
• Functional Medicine: We investigate the root causes of dysfunction, examining genetics, lifestyle, and environment to develop personalized health strategies.
• Personal Injury and Rehabilitation: We develop comprehensive plans to help patients recover from accidents and injuries, restoring function and mobility.

This integrated approach ensures that, when we consider advanced treatments such as orthobiologics, the decision is made within a holistic framework that accounts for the patient’s biomechanics, systemic health, and long-term wellness goals.

The Critical Nuances of Platelet-Rich Plasma (PRP) Composition

One of the most fascinating and sometimes confusing topics in orthobiologics is the composition of Platelet-Rich Plasma (PRP). As a practitioner and researcher, I follow the literature closely, and it’s clear that not all PRP is created equal. The term itself can be misleading if we don’t dig deeper into what it contains.

A key point of discussion among experts concerns the cellular composition of the final PRP product. When we prepare PRP, we concentrate platelets from a patient’s blood. However, the process also concentrates white blood cells (leukocytes). The debate centers on which types of white blood cells are beneficial and which may be detrimental, especially for intra-articular (in-joint) injections.

• Leukocyte-Rich vs. Leukocyte-Poor PRP: Originally, the term “leukocyte-rich” often referred to PRP with a high neutrophil concentration. Neutrophils are a type of white blood cell that are first responders to acute injury or infection. While essential for initial cleanup, they are also highly pro-inflammatory. When injected into the confined, sensitive environment of a joint like the knee, a high neutrophil count can trigger a significant inflammatory flare-up, leading to pain, swelling, and potentially unhappy patients. Research from leading experts confirms my clinical observation: high-neutrophil PRP should generally not be injected into a joint.
• The Importance of the Cellular Differential: The critical takeaway is to look beyond the total white blood cell count and analyze the differential—that is, the percentages of each white blood cell type. Many modern PRP systems, particularly those used in the United States, are designed to create what is often marketed as “leukocyte-poor” PRP. However, while these systems effectively reduce neutrophil counts, they often significantly increase the concentration of mononuclear cells, including lymphocytes and monocytes. This is not necessarily a bad thing! These cells play a crucial role in modulating inflammation and coordinating tissue repair. Therefore, a more accurate description might be a mononuclear cell concentrate.

My advice for any patient or practitioner exploring PRP is to be diligent. Know the system being used to prepare the PRP. Ask the company for their “white papers” or peer-reviewed studies that detail the typical cellular output of their system. Understanding whether the final product is high in pro-inflammatory neutrophils or rich in reparative mononuclear cells is fundamental to making the right clinical decision. The future of this field will likely involve point-of-care analysis, where we can test the pre- and post-spin concentrations to know exactly what we are injecting and tailor it to the specific tissue we are treating.

Advanced Adipose-Derived Therapies: When and Why?

Moving beyond PRP, we enter the realm of more advanced orthobiologics, such as those derived from adipose (fat) tissue. One such procedure involves using a micro-fragmented adipose tissue preparation, often harvested via a process similar to liposuction.

Patient Selection for Adipose Therapies

In my practice, I typically consider adipose-derived therapies as a second-line treatment option. The ideal candidates are often:

1. Patients with Osteoarthritis: Particularly those who have exhausted other conservative options (physical therapy, bracing, standard injections) and are seeking an alternative to joint replacement surgery.
2. Patients with Persistent Effusions: Individuals who continue to experience chronic swelling in a joint, often after a previous surgery or injury, that hasn’t responded to other treatments.
3. Post-Surgical Patients: Some patients elect to have an adipose procedure to provide a biological boost to the healing environment following a necessary orthopedic surgery.

I have been pleasantly surprised by the number of patients who have responded positively to this therapy after failing to find relief with other orthobiologics. While it doesn’t work for everyone—no biologic treatment does—it possesses a significant biological power that can make a difference for the right patient.

The Procedure: Safety and Technique

A common question I receive is about the harvesting procedure itself. Drawing from extensive data from plastic surgery, we know that liposuction performed on an awake patient under local anesthesia is significantly safer than when performed under general anesthesia. We conduct this procedure in a specialized, sterile procedure room within our clinic.

The process is more comfortable than many imagine. A key technical point, as highlighted by leading experts such as Dr. Scott Brandt, is the importance of tumescence duration. We first inject a tumescent solution—a mixture of saline and local anesthetic—into the harvest area (typically the flank or abdomen). This solution numbs the area and helps to break up the fat cells, making them easier to aspirate. Crucially, we allow this solution to sit for 20-30 minutes. This waiting period is not downtime; it’s a critical step for maximizing the quality and ease of the harvest. I often use this time to see other patients before returning to complete the procedure. This methodical, patient approach ensures a more effective and comfortable experience.

Treating the Bone: The Subchondral Approach

Another frontier in orthobiologics is addressing the health of the subchondral bone—the layer of bone just beneath the cartilage in a joint. In many cases of advanced osteoarthritis, the cartilage is not the only problem; the underlying bone is also “sick,” often exhibiting edema (swelling), lesions, and increased pressure. This is known as a bone marrow lesion. The concept is similar to a building with a cracked foundation; you can’t fix the floor (cartilage) without addressing the foundation (bone).

The Rationale for Subchondral Injections

Pioneering work from researchers in France has shown incredible results by directly treating the subchondral bone. In one landmark study, injecting a bone graft substitute into the subchondral bone of the knee allowed approximately 95% of patients to avoid a total knee replacement at 15-year follow-up. These are staggering numbers.

The procedure involves using fluoroscopy (live X-ray) to guide a needle into the diseased subchondral bone. The simple act of creating a channel into this high-pressure environment can provide relief through decompression. We then have the option to inject a biologic substance, such as bone marrow concentrate, to stimulate healing within the bone itself.

Managing Expectations and the Bigger Picture

While the results can be remarkable, it’s important to maintain a balanced perspective. Across the breadth of subchondral literature, there is a consistent 20% failure rate. This means that while the procedure works very well for about 80% of patients, one in five may not achieve the desired outcome and may need to proceed with a different intervention.

This brings me back to our core philosophy of integrative care. The success of a subchondral procedure, or any orthobiologic treatment, doesn’t just depend on what happens on the day of the injection. It depends on what we do to change the joint’s biomechanical and biological environment afterward. As a chiropractor and functional medicine practitioner, this is where my focus intensifies. We must ask:

• Can we offload the joint through a custom brace or by correcting gait mechanics?
• Can the patient achieve meaningful weight loss to reduce daily stress on the joint?
• Are the patient’s quadriceps and supporting muscles strong enough to provide dynamic stability?
• Can we address systemic inflammation through diet and targeted supplementation?

Sticking a needle in the bone is only part of the solution. The “magic” is limited if we don’t also treat the whole person and the environment that contributed to the joint’s decline. The patients who fail are often those with persistent biomechanical issues, like severe malalignment or muscular weakness, that continue to overload the treated area. True, lasting success comes from combining advanced biologic procedures with dedicated, comprehensive rehabilitation and lifestyle modification.

Conclusion: A Personalized and Evidence-Informed Path Forward

The field of orthobiologics is incredibly promising, but it requires a profound understanding of the science, a commitment to evidence-based practice, and a personalized approach. As we’ve discussed, the details matter—from the specific cellular composition of a PRP injection to the critical need to address underlying biomechanical and metabolic factors.

At Injury Medical Clinic, under the medical direction of Dr. Cardenas and with our integrated team, we are dedicated to navigating this complex landscape with our patients. We combine foundational chiropractic and rehabilitative care with cutting-edge regenerative therapies to not only alleviate symptoms but also to fundamentally change the trajectory of our patients’ health. By staying at the forefront of research and applying it within a holistic, patient-centered framework, we can offer hope and tangible results for those seeking to heal and reclaim their quality of life.

References

1. Hernigou, P., Auregan, J. C., Dubory, A., Flouzat-Lachaniette, C. H., Chevallier, N., & Rouard, H. (2018). Subchondral stem cell therapy for knee osteoarthritis: A 15-year-old prospective study. International Orthopaedics, 42(8), 1779–1786.* This reference is a proxy for the discussion on the French subchondral study, as the specific paper mentioned in the transcript was not named. Hernigou is a leading figure in this area.
2. Laudy, A. B., Bakker, E. W. P., Rekers, M., & Moen, M. H. (2015). Efficacy of platelet-rich plasma injections in osteoarthritis of the knee: a systematic review and meta-analysis. British Journal of Sports Medicine, 49(10), 657–665.* Provides a broad overview of PRP efficacy in knee OA.
3. Mazzocca, A. D., McCarthy, M. B., Chowaniec, D. M., Cote, M.P., Romeo, A. A., Bradley, J. P., … & Beitzel, K. (2012). The positive effects of different platelet-rich plasma methods on human muscle, bone, and tendon cells. The American Journal of Sports Medicine, 40(8), 1742–1749.* This study explores the cellular effects of different PRP preparations, touching on the importance of composition.
4. Gentile, P., Scioli, M. G., Bielli, A., Orlandi, A., & Cervelli, V. (2017). Concise Review: The Use of Adipose-Derived Stromal Vascular Fraction Cells and Platelet-Rich Plasma in Regenerative Plastic Surgery. STEM CELLS, 35(1), 117-130.* Discusses the science behind using adipose-derived cells and PRP in tissue regeneration.