Introduction to Orthobiologics and Advanced Ultrasound-Guided Procedures | AMSSM MSIG Webinar

Okay, good evening everyone. Um, I'd

like to welcome everyone to our MSIG webinar, Introduction to Orthobiologics and Advanced Ultrasound Guided Procedures. We're honored to feature Dr.

Procedures. We're honored to feature Dr. Taylor North as our speaker for tonight's webinar as he shares his expertise on this topic. This session is geared towards medical students and

residents. My name is Kira Burllo and I

residents. My name is Kira Burllo and I will be serving as the moderator for tonight's webinar session. I'm the

current AMSSM MSI president and a fourth year medical student at the University of Hawaii John A. Burns School of Medicine. After Dr. North has finished

Medicine. After Dr. North has finished his presentation, I'll be the moderator for the Q&A segment. During the webinar, please enter your questions in the chat and during the Q&A, I'll ask each

question um to Dr. North and he can respond. So, now it's my pleasure to

respond. So, now it's my pleasure to introduce tonight's speaker, Dr. Taylor North. Dr. Taylor North completed his

North. Dr. Taylor North completed his undergraduate degree at the University of Utah and then earned his medical degree from Edward Via College of Osteopathic Medicine at Auburn. He

completed his residency in physical medicine and rehabilitation at the Mayo Clinic in Rochester, Minnesota, and then completed his sports medicine fellowship at Andrews Institute for Orthopedics and

Sports Medicine in Gulf Breeze, Florida.

He currently serves as a senior associate consultant at the Mayo Clinic Health System in Rochester, Minnesota and is a team physician at the University of Wisconsin Uclair. His

special interests include muscularkeeletal ultrasound, orthobiologics, and baseball medicine.

Dr. North, please begin your presentation.

All right. Thanks, Kira. [clears throat]

Um, appreciate you introducing me and happy to be here tonight. So, we are going to dive kind of right into it. And

again the title of the talk is introduction to orthobiologics and advanced ultrasound guided procedures.

Uh nothing to disclose no financial relationships. Uh throughout the

relationships. Uh throughout the conversation or throughout the talk I am going to reference a few different uh companies and their individual devices

that pertain to the lecture but no financial relationship with any of them.

All right. So just as an overview of what we're going to talk about tonight, [clears throat] we are going to start with defining orthobiologics and we're going to look at what we know about their mechanism of action. Then you know we're just going to scratch the surface,

but we will talk about some of the literature and highlighted just a few studies that summarize what we do know about biologics. Then we will talk about

about biologics. Then we will talk about some of the key regulatory principles and important clinical considerations.

And then after that, kind of the back third or so of the lecture, we are going to go into some of the more advanced ultrasound guided procedures that you might see in sports medicine and

orthopedics.

All right, so kicking things off, um you might hear about this thing in orthopedics that refers to the treatment gap between conservative and surgical

management. And it essentially refers to

management. And it essentially refers to procedures that go beyond our traditional conservative management but then fall short of you know more invasive surgery. And I really look at

invasive surgery. And I really look at this the procedures and treatments that fall within the gap as sort of filling the natural or filling this gap as is

natural progression of the non-surgical orthopedic world. So just as we see in

orthopedic world. So just as we see in other specialties, you know, there's natural progression of um new developments, new techniques, new treatments, and then we also take maybe some existing procedures or surgeries

and find out how can we do them in less invasive ways. So everything that we're

invasive ways. So everything that we're going to talk about tonight really fits within this category.

And we'll start off uh going into the biologics.

And I felt like to do this, it might help to put some context behind it and use a clinical vignette or case example.

And so imagine that you're in, you know, an outpatient sports medicine clinic and you've got a 48-year-old that comes in.

Maybe they say they're a mechanic, you know, some kind of labor intensive job with their hands and they've had this right-sided lateral elbow pain for going on a year now. and they've already seen

one provider and the provider diagnosed them with common extensor tendinopathy or tennis elbow and over the past year they've done several things. They've maybe done one

several things. They've maybe done one or two rounds of physical therapy.

They've done a short course of anti-inflammatories and then they've even tried shockwave therapy but the pain is still there and so they're coming to see you and wondering if you have anything that you

can offer.

So you want to, you know, ensure that the diagnosis is correct. We get some imaging. So we start with X-rays and,

imaging. So we start with X-rays and, you know, overall the X-rays, you know, don't show anything too telling. Um,

maybe we do some point of care ultrasound and we're looking at the lateral elbow, specifically keying in at that common extensor tendon. And, you

know, maybe we see some thickening of of some of these tendon fibers with more of a disorganized pattern. we get what's called these enthesopathic changes here or cortical irregularity where the

tendon is inserting these are kind of findings of tendonopathy and so we combine that with our physical exam and we say well yeah I think things do fit this looks like common extensor

tendinopathy and the patient says well okay you know I had a friend that recommended stem cell treatment and you know I wanted to talk to you about that see if that would be a good option for me and so we're going to talk about this

term so stem cell therapy uh really it's just a term that kind of blew up years ago and um these big hopes of being able to consistently regenerate

tissue. So this is a picture that was

tissue. So this is a picture that was taken from an article published in 2020 in science news journal that was discussing the hype around stem cell and

regenerative medicine treatments. And

you know, needless to say, the marketing outpaced the research and the evidence that we have. And over the years, we've really tried to shift our terminology from discussing this as stem cell

therapy to orthobiologics as it's a more accurate and accepted term of the therapies that we're actually providing.

So with that said, you know, what what are orthobiologics? And really the name

are orthobiologics? And really the name says it all. This is biologic therapies that are used to treat orthopedic conditions. And the three main ones that

conditions. And the three main ones that we're going to talk about tonight are plateletri plasma or PRP, bone marrow, aspirate concentrate or BMAC, and then

microfgmented atapost tissue or MFAT.

[clears throat] And you know, why would we consider using these biologics? Well, we're

essentially trying to leverage our body's ability to induce a therapeutic response. Um again the goal is not

response. Um again the goal is not necessarily tissue regeneration but more of creating a therapeutic response.

And then we s we ask ourselves you know how does this happen? Well one with orthobiologics we're hoping to be able to modulate inflammation and we'll learn about this more in upcoming slides but

uh these biologic products they release these anti-inflammatory cytoines and that goes on and can reduce local inflammation that then sensitize no receptors.

We're looking to try to improve the joint or tendon micro environment. Um we

increase local perfusion. We reduce the catabolic enzymes overall trying to create this healthier chemical millu.

The biologics they can enhance our body's existing repair response. So what

we get out with that is again we're not really focusing on tissue regeneration but more so improvement of tissue quality. And then particularly in cases

quality. And then particularly in cases of tendinopathy, orthobiologics can help break out of the kind of chronic disease state. They do this by helping with

state. They do this by helping with tissue turnover. And then subsequently

tissue turnover. And then subsequently we get stronger tendon tissue and an increased ability to uh kind of improve their load capacity.

So the indications uh include osteoarthritis and then non-arthritic cartilage injuries, tendon and ligament disorders, muscle injuries and then there's uh some other soft tissue

situations where you may consider it as well.

Okay, taking a deeper dive going into PRP now.

And again, the name kind of says it all.

So, we've got plasma that's highly concentrated in platelets and um there's maybe some different definitions out there as to what truly constitutes PRP.

And we'll talk about this in upcoming slides, but um you know, we can say maybe somewhere between two to six or three to five times the whole blood

platelet concentration um is what would maybe constitute you know, adequate PRP.

Again, more on that in upcoming slides.

Uh but how do we go about doing this this process? So it starts with if you

this process? So it starts with if you look at the picture on the right, we start with a vena puncture or peripheral blood draw. We take out whole blood. We

blood draw. We take out whole blood. We

put it into a centrifuge that then just spins down and separates out the different components of whole blood. You

then take the PRP and inject it under imaging guidance into the site of pathology.

All right. So once you inject it, what is actually happening? Well, the

platelets once injected and activated, they release cytoines. They release

growth factors that go on to regulate the phases of healing. And we're hoping to achieve this through one, the promotion of angioenesis, chemotaxis of repairarative cells, and

then imunom modulatory activities.

Okay, so this is a picture that was taken from an article published by Evers at all back in 2020 discussing the therapeutic considerations with plateletri plasma

and it shows activated platelets and how they release these growth factors and adhesion molecules that then go by go on and really perform various cell-to cell

interactions and communications. And

this then goes on to produce these amunod modulatory effects.

So if we kind of go back to our case of tendinopathy um we'll look at this illustration here which shows the different phases of tissue healing. So first we have the

tissue healing. So first we have the inflammatory phase followed by cell proliferation eventually moving into this tissue remodeling phase. And when

we talk about cases of tendonopathy, the damaged tendon gets stuck in this process and doesn't undergo adequate tissue remodeling. So when we do

tissue remodeling. So when we do something like inject PRP into a tendon, we're trying to uh for lack of better terms, hit the reset button here and restart the phases of healing, hoping to

push, you know, beyond proliferation into tissue remodeling and then obtain a satisfactory degree of tissue remodeling.

So again applying that to our case you know would PRP be a reasonable option in this situation and you know the answer is yes the patients tried several things

up to this point and it seems like a reasonable thing to do.

So uh we can do this again is done in office and the image on the left is just uh showing the common extensor tendon with a blue box around it. The blue box

is depicting the orientation of the ultrasound transducer and then the white arrow is depicting the direction that the needle would be coming in. We call

this in plane with the ultrasound transducer. So uh on the right then the

transducer. So uh on the right then the ultrasound image that we're seeing. You

see the nice uh kind of needle shaft coming in and able to deliver the plate rich plasma directly to the side of pathology with precise accuracy.

Okay. So with that background then we say well what does the literature show?

Um, this is just one of several studies looking at PRP for tendonopathy, but it's a meta analysis that was published back in 2017 in AJSM.

And this meta analysis included 18 different studies with over a thousand subjects. And they were looking at PRP

subjects. And they were looking at PRP versus other treatments for different tenonopathies. And the other treatments

tenonopathies. And the other treatments they were looking at included corticosteroid injections, saline injections, local anesthetic injections, and then dry needling.

The primary outcome was patient reported pain scores and they found that lucasy rich PRP was superior to the other therapeutic modalities.

Well, what about PRP for osteoarthritis?

We mentioned that that was one of the indications. Uh again, one of just

indications. Uh again, one of just several studies out there, but this is a recent systematic review and meta analysis published uh in AJSM authors coming out of HSS and Mayo Clinic in

Rochester. and they were looking at PRP

Rochester. and they were looking at PRP versus alternative injections for neosarththritis.

Other injections included corticosteroid and high h higheronic acid or HA and the outcomes uh again they were looking at patient reported symptom improvement and then they were also looking at any need

for further intervention you know which subjects went on to undergo some sort of reintervention in their follow-up uh period and they found that PRP s had a significantly higher rate of successful

outcomes and again this was determined by fewer cases needing to undergo reintervention and then more subjects reporting pain improvement.

Now, um good good studies, but we kind of take a little pause here and I think this is a very important slide that really determines a lot about PRP outcomes. And what's important to note

outcomes. And what's important to note is that PRP I want you to think of it that it is not a single product per se.

It's you know there are numerous preparation protocols there variable um kits and systems out there that are used that that inherently lead to variable

end products and then these go on to impact the clinical outcome. So key

variables when we are preparing PRP again include what type of system or kit we're using, what the whole blood volume is that we're starting with when we do that blood draw. You know, we talk a lot

about lucasite content in this space and if we use lucasite rich versus lucasite poor PRP and these are settings that can be adjusted on the machines. And then we want to know what is the overall

platelet count or platelet concentration that we have in our end product. And

what we do know is that dose matters.

And then also, you know, you can look at are we using any type of activation method uh which sometimes will be included with protocols.

And essentially think of it this way. So

you've got patient that walks into clinic A and they say they receive a PRP injection and then you have patient that walks into clinic B, they receive a PRP injection and it might be for the same

thing. Let's say knee knee arthritis.

thing. Let's say knee knee arthritis.

Well, these products, we don't know if they're necessarily the same end product. And because of these variables,

product. And because of these variables, it has led to some heterogeneity in the literature. So not every study out there

literature. So not every study out there shows clear improvement following PRP.

Now when we take maybe the aggregate of the highquality studies certainly more favorable than unfavorable u but it's still important to mention and the heterogeneity that we see in the literature again is coming

from this inherent variability that comes along with PRP preparations. So um

I think it's important to critically analyze studies and see how they might be addressing the variables here that are listed and then see how it might impact the results because it is

challenging to otherwise draw conclusions say if some of these uh details are maybe not listed in the study or um you know maybe if we look at it and we say well gosh you know um they're missing this part. And so that's

just an important thing to look at when we're talking about PRP literature, really orthobiologics in general for sure. So the take-home point with this

sure. So the take-home point with this slide is PRP is not always a singular therapy, but more a category of biologic products. And then when discussing these

products. And then when discussing these products and interpreting the literature, again, we should be focusing on the overall biologic composition rather than just the label of PRP or the

title of you know PRP.

All right. Now, with that said, we are starting to learn bit by bit um more on how we can optimize our PRP preparations. So this is a recent meta

preparations. So this is a recent meta analysis again coming in at AJSM that was looking at PRP for neo osteoarthritis and again conclusion

shows you know PRP did lead to functional improvements as well as pain relief at both short and midterm follow-ups in this study but more importantly they came to this conclusion

that hey the the concentration matters here and they were seeing that higher platelet concentrations were associated with superior results.

And then we take these three studies um that maybe go a step beyond that and say well gosh maybe beyond concentration we should be looking at the overall platelet dose and the platelet count. So

they found that the total platelet dose is more predictive of outcomes than just the fold changes in concentration alone.

So in other words there is potentially a dose response relationship between the platelet dose and the clinical effectiveness.

So again with this in mind now we kind of start to adopt this mindset that maybe PRP you know it should be treated more like a drug where we need to optimize the appropriate dose and then

once we do that we figure out well what are the protocols what are the systems that allow us to achieve that product for better results and now kind of moving on from PRP we'll

talk about some of these cell-based therapies specifically BAC and MFAP I'll explain why I refer refer to them as as cellbased therapies. But um BMAC again

cellbased therapies. But um BMAC again stands for bone marrow aspirate concentrate and then MFAT is micro fragmented atapost tissue. And these are

just illustrations of how our products are harvested.

So how do these work? Well, through the promotion of angioenesis, chemotaxis of reparative cells, modulation of inflammation, and then stimulation of matrix synthesis. Now you say, well,

matrix synthesis. Now you say, well, this looks a whole lot like what we talked about with PRP. And that's

because it is. It's there's a lot of overlap with how these biologics work.

But now where PRP is primarily working by, you know, you deliver this big concentrated burst of growth factors and cytoines and then that goes on to really

work by cell signaling and cell communication.

BMAC and MFAT well they share some of that cell signaling property but they also add additional mezzenymal stromal cells or MSC's as well as progenitors

that are proposed to have additional paracrine and amunod modulatory effects.

So MSC's you have maybe heard of these in this context referring to mezenymal stem cells but again we're shifting terminology as it pertains to orthobiologics

um to better reflect what we actually understand about these therapies and again avoid overstating how these products actually work. So we say stromal cells rather than stem cells and

again that's because the main role remains paracrine signaling not full tissue regeneration. And down here at

tissue regeneration. And down here at the bottom of the slide, uh, Arnold Kaplan, who was a pioneer in the space of MSSE use in humans, even coined this

term medicinal signaling cells. And, you

know, maybe was thinking that's a more accurate description of these drugs. You

could think of as that we're actually providing.

Okay. So, BMAC, uh, this is what the procedure looks like. Again, we start just as the name says, you know, bone marrow aspirate. So we start with

marrow aspirate. So we start with harvesting bone marrow typically from the pelvis. Once you harvest the bone

the pelvis. Once you harvest the bone marrow, much like PRP, it's placed in a centrifuge, spun down, separated. You

take your end product, inject it under imaging guidance to the side of pathology.

Okay. What does the literature show for BMAC? Again, this is just one of the

BMAC? Again, this is just one of the studies. Certainly though when you look

studies. Certainly though when you look at the the the literature as a whole it is less robust than what we have for PRP but this is a systematic review that was

published in ASM uh it was looking at BMAC for knee osteoarthritis and they found at the end that BMAC was effective in improving pain scores as well as patient reported functional outcomes.

However, it did also look at it compared to PRP and it did not necessarily outperform PR PRP and MFAT was also studied and and quite frankly the B the

BMAC again showed these beneficial effects but did not outperform the other two treatments.

So then we move on to MFAT and we'll learn a bit more about that. Uh again

this is autotogus fat that's mechanically processed. This is an image

mechanically processed. This is an image that was taken from the lipogeems website. This is a company that uh um

website. This is a company that uh um has these uh MFAT kits and processing systems. But basically, if you look at the image on the left again, you start

with a lipo aspiration or fat harvesting from the belly or flank. The atapost

tissue is then processed, washed, and rinsed, leaving with you with your end product at the end that's ready for injection.

Okay. So, what does the literature show for MFAT? Well, on the left, we've got a

for MFAT? Well, on the left, we've got a study from Mike Barriia and the team at Ohio State. This was a level one

Ohio State. This was a level one randomized control trial where they were comparing MFAT to lucasite poor PRP for nesteoarthritis.

and they found that both groups demonstrated statistically and clinically significant improvements in both pain and functional outcomes at the 12-month mark. However, they did not

12-month mark. However, they did not find a difference again between both groups. Again, going back to this

groups. Again, going back to this principle that maybe there's therapeutic equivalence, at least in this study, therapeutic equivalence between MFAT and

Lucasite poor PRP for neoarthritis.

And then on the right, we've got a study by Ken Mottner and Robbie Bowers and their team at Emery. And this was a prospective study looking at MFAT versus BMAC for neoarthritis and again found

both groups they did produce significant improvements in pain and functional scores. However, again no significant

scores. However, again no significant difference between the two groups. Again

getting back to this point of therapeutic equivalence. So in summary,

therapeutic equivalence. So in summary, BMAC and MFAT, you know, they may have therapeutic benefits, but maybe based on some of the literature that we have, it's unclear uh if it is definitively

better than PRP. Uh now there's [clears throat] certainly some nuances as to specific indications but uh this at least is is somewhat of a summary of what we know right now.

Okay. So we're going to wrap up the conversation on orthobiologics just talking about some of the regulatory basics and how we use these therapies

responsibly in practice.

This is kind of a terminology slide but maybe some principles that are worth understanding especially when you're having conversations uh with patients if it's brought up but uh talking about FDA

regulation. So the devices that we use

regulation. So the devices that we use to prepare these orthobiologic products are considered FDA cleared. However,

PRP, MFAT and BMAC are not considered to be FDA approved biologic drugs. So what

does that translate to? Well, these

essentially are these regulated products that can be used in clinical practice, but they have to meet this criteria first of undergoing minimal manipulation

and then being used for homologous use.

Minimal manipulation uh essentially means that the tissues are processed without altering the original relevant characteristics. And then homologous use

characteristics. And then homologous use saying that the product is going to be used to perform the same basic function in the recipient as in the donor tissue.

So, um, again, sometimes they'll come in and just, you know, maybe we'll talk about, you know, well, is this something that we can actually do? Is this legal, illegal? But, um, there's nuances for

illegal? But, um, there's nuances for sure, but try to just get that that point across here.

And I think this is important to talk about too again as we translate this to clinical practice. In 2021, this paper

clinical practice. In 2021, this paper was published by, if you look at the author list, there are several leaders in this space in our country. And

they're trying to give recommendations regarding the responsible use of orthobiologics in clinical practice.

And to summarize some of their recommendations, they, you know, say, well, we should start first with established and guideline supported therapies. We should only be using

therapies. We should only be using products and procedures that are allowed under the current FDA guidance.

When talking with patients, certainly be clear with the description of the procedure and then setting realistic expectations.

Use appropriate equipment. This goes

everything from the systems and kits we're using to come up with our biologic product and then again translating that over and using ultrasound or imaging guidance for

the procedures.

We should avoid hype or implying results that are not supported by the literature. And then finally, as always,

literature. And then finally, as always, you know, above all, ensure patient safety.

Okay. So, uh shifting now to the kind of latter half here of the lecture talking about ultrasound guided procedures or

advanced ultrasound guided procedures.

And uh I know previous talks um over the past few weeks have have been on uh the use of ultrasound and this piggybacks off that but we say you know why would

we use ultrasound in practice? Well it

allows for real time targeting when it comes to procedures. So we can guide a needle or a device directly to our target with precise accuracy. We can

avoid important neurovvascular structures and then minimize any tissue trauma.

So ultrasound guided procedures in orthopedics it really follows a similar trend that we've seen in other specialties such as you know use it for example interventional cardiology interventional radiology where we use

imaging guidance to come up with less invasive procedures. So again we've

invasive procedures. So again we've translated this over to orthopedics. We

can do things with smaller incisions which leads to again less tissue disruption with the overall goal of faster recoveries, improved patient outcomes and then thrown in is reduced

healthcare costs.

So some of the advanced ultrasound guided procedures we'll talk about most of these here but um a perccutaneous needle tenontomy or fasciottomy

something called tendon scraping or tendon high volume injection calcific tendonopathy a nerve hydro dissection

and then even tendon and ligament releases.

Okay. So, first up is ultrasound guided needle tenontomy. And we say a this this

needle tenontomy. And we say a this this can be performed with either a large gauge needle or a specific device. In

the bottom left corner, I have a image of a 10x device. This is just one of several uh devices out there. And how

this specific device works is at the needle tip, it creates these highfrequency oscillations that selectively [snorts] target the damaged tendon tissue. And

then it has this two-way irrigation and suction system kind of irrigating in with sterile saline and simultaneously suction so that the small little fragments of damaged tissue um can be

removed in real time. Again, there's

other devices out there uh each with their own individual nuances.

Uh and again this can also be performed with just a larger gauge needle alone and some of those mechanical fenestrations. You just physically

fenestrations. You just physically create mechanical fenestrations through the tendon and this mechanical disruption occurs at the degenerative tissue. Blood products are brought in

tissue. Blood products are brought in along with their growth factors. And

again, if we refer back to the image here of the stages of tissue healing, the whole goal with that is again, we're trying to get that tendon out of the stuck phase and push beyond that and

achieve this satisfactory degree of tissue remodeling.

So what are the indications? Uh this can be used for chronic tendonopathies, calcific tendinopathies and fasciottoies such as planter fasciitis. And uh these

ultrasound images are just uh kind of really zoomed in on a tontomy for patellar tendonopathy.

And on the top image uh the arrows are pointing to an 18 gauge needle that's being directed under ultrasound guidance to kind of the deep fibers of the

proximal patellar tendon. And then the bottom picture just shows the difference under ultrasound of what the 10X device looks like. Um, and you can see just a

looks like. Um, and you can see just a little bit larger and has some of these uh kind of hyperccoic rever reverberations kind of behind it. But

um, that's what that looks like.

So if we go all the way back to our starting case of common extensor tendinopathy uh, and applying it to this needle tenontomy principle. Well, often times

tenontomy principle. Well, often times when we are delivering PRP to the side of a tendon, we will perform that needle tenontomy as well as [clears throat]

we're kind of as we're delivering or injecting the PRP. And so again, we refer back to our image on the left. It

shows the blue rectangle showing the orientation of the ultrasound transducer with the arrow showing which direction the needle's going in. And then the

needle kind of comes in and again multiple fenestrations directed right at the sight of injury and then can inject the PRP at that time.

Okay. Another procedure that we'll talk about is ultrasound guided calcific or lavage procedure. And this is a

lavage procedure. And this is a procedure for uh calcific tenonopathy.

And calcific tendonopathy is just a form of tendonopathy where calcium hydroxy appatite deposits within the tendon tissue. Uh and then that can lead to

tissue. Uh and then that can lead to acute inflam inflammatory flares or even chronic mechanical pain.

And so what this procedure looks like, if you look at the illustration on the left, you have a needle that's attached to a volume fil syringe, typically

composed of sterile saline and then a local anesthetic. The needle is

local anesthetic. The needle is introduced into the calcification without penetrating the posterior wall.

So that part's important. If the needle can enter that calcification but not penetrate the posterior wall, then it acts as this enclosed pressurized system

and then the injector lightly pulses on the plunger of the syringe injecting into the calcification. But because it's this enclosed space, it creates a

negative pressure. So as you push or

negative pressure. So as you push or plunge in and the plunger returns on the syringe, the negative pressure can bring the calcifications along with it.

essentially sucking them out into the syringe.

And so, uh, this is a video of that. Um,

this video or ultrasound image corresponds to what we're seeing on the left. We're looking specifically at the

left. We're looking specifically at the suppinatus and we've got the needle coming in from right to left. This, I

don't know if you can see it here. Right

here, this kind of ring of tissue is that superficial border of the calcium deposition.

and hard to make a lot of sense of what's going on, but right there kind of plunging in or pulsating in again on that plunger. And then that as the

that plunger. And then that as the plunger returns, some of that calcification is removed and broken up into smaller pieces.

All right. So, the next procedure that we're going to talk about is an ultrasound guided tendon scraping or tendon high volume injection.

And this is used for the treatment of specific tendinopathies uh mainly Achilles tendonopathy and patellar tendinopathy when there's cases of

increased neovascularization. So if we

increased neovascularization. So if we look at the ultrasound image uh it is a what's considered again long axis view of the Achilles tendon. So up here is

the tendon running from left to right and deep to the Achilles tendon is Kar's fat pad which is highly vascular.

And in certain cases of teninopathy here there will be this neovascularization that kind of sprouts up from the under surface. And there's evidence that nerve

surface. And there's evidence that nerve structures within the perendonous tissue um that are associated with this neo uh with the neovascularization that they

contribute to the pain. So with this procedure, we can use a specialized needle that under ultrasound can be guided directly at that tissue plane and

inject a large volume of fluid that essentially creates a mechanical separation and then you can move the needle. I'll show it in upcoming slides,

needle. I'll show it in upcoming slides, but essentially move the needle downward and back and forth. Again, further

creating a mechanical separation, somewhat severing that neovascularization, thereby reducing pain.

All right. So, this is what it looks like. Again, image on the left, blue

like. Again, image on the left, blue triangle showing the orientation of the ultrasound transducer.

And this is looking now at the Achilles tendon in short axis. So on the image, this is the Achilles tendon that's coming out at us in the screen, kind of running in and out of the screen. Coming

from right to left is the needle. The

tissue down here again is that Kager's fat pad. And you can see again the

fat pad. And you can see again the needle can be directed very precisely between those two tissue planes. And as

it's injected in or as it's entered in, it'll be you'll be injecting fluid to create some of that mechanical separation. And then the image here on

separation. And then the image here on the right shows you this kind of Oh, whoops. Let me go back.

whoops. Let me go back.

Let's try that again. All right. So

again, the needle's now in place. You

see pushing down creating further mechanical separation of the underlying fat pad.

Now if we rotate, so ultrasound transducer now showing a long axis view of the tendon, which we're seeing here.

With that said, now that we've rotated, we're no longer seeing the needle shaft kind in plane with the ultrasound transducer, but we're seeing it perpendicular to the transducer, which

we refer to as out of plane. So, it's

this white needle tip right here that's underneath the Achilles tendon and sitting on top again of the fat pad. And

what this Oh, goodness, it did again. What this

video shows is what we call sometimes we'll refer to as a windshield wiper effect. So, not only can you press down on the fat pad to

create separation, but again, you know, being able to use Doppler with the ultrasound and target that neovascularization, you can then enter in and kind of go up and down or right to left creating this

windshield wiper effect, further creating that mechanical separation.

All right, the next thing we'll talk about is an ultrasound guided perccutaneous fasciottomy.

And this is used for chronic exertional compartment syndrome which is a condition characterized by increased intracompartmental uh muscle pressure that occurs after exercise and it

typically leads to pain and sometimes neurologic symptoms. Now the definitive management for this is a fasciottomy and traditionally this has been performed in an open fashion

that can lead to a long a large scar and longer recoveries.

Now doing this under ultrasound guidance um has been described and is being done at some places and uh the image that I've got here on the the left the bottom

left is an ultrasound image that was taken from a paper published by Jonathan Fidoff and John or Jonathan Finnoff and Wade Johnson and they describe the

technique for performing this procedure and you use a miniscome which is shown up here. It's essentially a V-shaped

up here. It's essentially a V-shaped cutting device. All right. So down here

cutting device. All right. So down here uh V-shaped cutting device and under ultrasound guidance it can be directed down to the subcutaneous tissue shown

here with the white arrows and the star is showing the cutting tip and then the dark arrows are showing the fascial plane and I've heard Dr. Finnoff

refer to this um they're using this analogy that as that meniscot is pushed through that fascia. It is much like

scissors cutting through wrapping paper.

You know if you open scissors and then just glide them along that plane and how it slides right through. Similar analogy

that can be applied to this procedure.

Okay. Okay, we'll talk a little bit about ultrasound guided carpal tunnel release. Uh carpal tunnel syndrome, a

release. Uh carpal tunnel syndrome, a compressive neuropathy of the media nerve at the wrist. Definitive

management includes surgical release of the transverse carpal ligament. And

traditionally this has been performed with either a miniopen or endoscopic uh technique but can be done under ultrasound guidance. And some of the

ultrasound guidance. And some of the benefits with ultrasound again it includes one first when we're referring to this procedure lets us see underneath the skin. We can point out where we're

the skin. We can point out where we're going to be making cuts. So we see then cut rather than cut and then see. Again

very very small incisions here or even poke holes. No sutures needed. All done

poke holes. No sutures needed. All done

under local anesthesia does lead to quick recoveries. And again all of that

quick recoveries. And again all of that translates to reduced healthcare costs.

Okay. So, this is what the procedure looks like. Pause that. We'll come back.

looks like. Pause that. We'll come back.

Uh, now specifically on the left, this is uh one of the devices from Sonx Health. And I should I should go back

Health. And I should I should go back and explain this. So, there are several techniques that have been described in the literature. Uh, two that I've got

the literature. Uh, two that I've got shown here. First on top, this is an

shown here. First on top, this is an illustration here um using what's called the thread carpal tunnel release or a cutting thread. And it's a technique

cutting thread. And it's a technique that was described by the Go brothers.

And then the image on the bottom, this is a device uh created by Sonic and that is a company that specializes in ultrasound

guided procedural or surgical devices.

And now the image that I've got here on the left is uh one of the older models of the uh cutting knife from Sonics Health. But you can see under ultrasound

Health. But you can see under ultrasound guidance, it's guided from proximal to distal at the wrist. And what that translates to is the image on the right

showing the device here coming from right to left. And what this is is essentially has a kind of retro blade uh cutting knife that is recessed within

this device. And then again, so when you

this device. And then again, so when you enter in, everything's blunt. And then

once you are in position, you can deploy the knife and then physically retract it back and it cuts through the tissue.

This tissue right here that we're seeing is the transverse carpal ligament. And

so that's the [clears throat] target.

And again, the device is in place. The

knife is deployed right here and then slowly retracted back through the transverse carpal ligament, cutting and releasing that tissue, performing the release.

Okay. So, we're going to finish up last one here and talk about ultrasound guided trigger finger release. Much like

carpal tunnel release, um we have devices to perform this procedure. But

trigger finger is also known as stenosing teninoitis and it's where we develop this thickening of the flexor tendon or pulley system. most often the

A1 pulley. And this pulley system helps

A1 pulley. And this pulley system helps kind of anchor those flexor tendons down to bone. And when we get thickening, it

to bone. And when we get thickening, it can create painful locking or actual triggering of the finger where it gets stuck, catching, etc. And uh to perform this procedure, there's a couple again

different devices up here on top. This

right here is called a nocore needle.

It's essentially a needle with a tiny scalpel or cutting tip. And then the image on the left again is a spe specialized device from Sonics Health.

And under ultrasound guidance, the device is entered in underneath the A1 pulley. And in a similar fashion to what

pulley. And in a similar fashion to what we saw with the carpal tunnel release, a retrograde kind of cutting device is deployed once in position up here that

I'm circling. This is that A1 pulley.

I'm circling. This is that A1 pulley.

The knife is deployed and then retracted back, cutting through that pulley tissue, performing the trigger finger release.

All right. So, with that said, uh we'll wrap it up by just summarizing what we've talked about. So, orthobiologics

first, they are um increasingly being used more and more in sports medicine and orthopedics. As we expand our

and orthopedics. As we expand our knowledge on what we know, we need to continue kind of optimizing those key variables that I discussed. That will

lead to improved patient outcomes in the end. Regarding ultrasound technology, it

end. Regarding ultrasound technology, it certainly has come a long way over the past couple of decades and is now allowing us to do more and more of these ultrasound guided procedures. You know,

as with anything as it pertains to orthobiologics or, you know, you can apply this to to anything that we do in medicine, but you know, patient selection is key and then always using ev evidence-based practices. And then

above all, you know, patient safety should always remain our highest priority when considering these procedures.

several references and um want to thank you all again and if there are questions I think we open it up at this time and I'm happy to help out.

Yes, thank you so much Dr. North for um that presentation was really great. Um

so we will be moving on to our Q&A segment now. So please type any

segment now. So please type any questions in the chat. Um and again just want to thank Dr. North for sharing his expertise with us tonight. Um so first

question I believe from earlier um asking do you have a lot of chiropractors in your area um offering hila gel which I guess is amniotic stem

cell plus some other stuff in there.

Yeah, I do. Um, that that does get brought up fairly often and I think what I would say is I take all of it as a case by case. You know, I try

to ask patients about what conversations they've maybe and if if you're referring to, you know, like what happens frequent with frequently with me is where somebody might come in and and say, you know, like much like the case that we

saw where they'll say, "Hey, you know, I saw another provider. they talked about this or I you know maybe heard through the grapevine that they're doing this and that um over there and you know I I guess I take it case by case. I try to

hear out what the patient might be aware of, what kind of things were talked about with them. And um I guess in short, what I just try to say, I try to promote our practice and the way that

we do it more than kind of focusing on others. And so I just say, you know, we,

others. And so I just say, you know, we, you know, base what we're doing off the literature that exists out there. We use

the PRP system and protocols that have been studied and in the studies that have shown to be the ones producing the highest uh level of outcomes. And so um you know with that in mind again I think

I kind of point all the emphasis on just our practice and say hey here's what we offer um rather than kind of talking about other practices. And um I don't know if that necessarily answers your

question, but the answer to that is yes.

It comes up often and I just kind of try to point people back to the evidence and again going and that's why maybe understanding some of the FDA regulations and so forth is important because it certainly helps when we're

talking with patients about these situations.

Thank you. Um next question is when would you choose BMAC or EMPAT over PRP?

as you mentioned the evidence shows similar outcomes.

Yep. Um again case by case and what I will say is the I mean I do significantly higher

cases of PRP. Um and depending on the case again with the most common being the most common you know things like tenonopathies and osteoarthritis um you know I'll I'll talk to them.

There's many things that come into it, right? It's more than just the condition

right? It's more than just the condition that we're treating, but there's other factors. You know, one, the financial uh

factors. You know, one, the financial uh obligation that comes along with it. So,

these are typically going to be outofpocket cost procedures. And so, in our practice, PRP is significantly cheaper. So if I think that maybe the

cheaper. So if I think that maybe the outcomes, let's say we're treating knee arthritis is going to be equivocal, then I might be kind of at least saying that,

hey, here's what we know again about the studies. PRP shows this, you know, BMAC

studies. PRP shows this, you know, BMAC shows this, MFAT shows this, some of these other procedures again theoretically have some of these messenymal stromal cells and more kind of these this, you know, cell signaling

or more than beyond just a cell signaling response. But still kind of

signaling response. But still kind of going back to the literature and ultimately using that and then maybe the patient factors like out-of- pocket costs and so forth to make that

decision. But I'd say overall vast

decision. But I'd say overall vast majority of times I'm using PRP as the first orthobiologic that I'm going to for those exact reasons. Cheaper and

then the evidence um is much more robust with it. And again don't definitively

with it. And again don't definitively know in most situations if the BMAC or MFAT are superior to PRP. Um so

certainly some nuances. You'll have

patients that might come in and um are specifically looking for one or the other. maybe they've had PRP in the past

other. maybe they've had PRP in the past and they've talked to somebody else about BMAC and they're saying, "No, I've kind of already came to the conclusion.

I want to try this." So, at that point, you just make sure that it's actually clinically indicated and safe. Um, and

then that might be a reason to proceed.

All right, next question. Um, how about D5W versus PRP for planner fascia and Achilles tendon? Um, and also, what are

Achilles tendon? Um, and also, what are your thoughts on ERCP shockwave for calcifications?

Yeah, really good questions. Um, I think overall to summarize those, [clears throat] all of them I think are reasonable things to do. Um, there are

studies out there that would support maybe all of them being used. Uh, so

again, coming down to which do you select? I I can't say that I know of

select? I I can't say that I know of enough literature out there that shows one to be superior to the other. So then

again, we kind of take into factors, you know, what are the costs? You bring in something like shockwave and you say, well, [clears throat] shockwave is non-invasive. So if we're looking to

non-invasive. So if we're looking to kind of go in this least invasive to more invasive, you know, fashion or algorithm, then that might be a good starting point. Um, but I think to

starting point. Um, but I think to answer the question, you know, potentially all good treatments, um, probably all have reason to pursue each of them, but then you just use those

other factors, cost, you know, explain the procedure, what the recovery might be like, um, and then allow the patient maybe to help with the decision-m on on what seems to be the best option.

Okay, next question. um for some of these cutting edge procedures discussed particularly ones based on fascial disruption how robust is the body of literature for results is it considered

standard of care now um I wouldn't say it's considered standard of care and there's probably multiple factors that

go into that for sure um I guess I can speak to I I mean yes there's there is there's uh you know a lot of there is literature for each of those procedures I talked about, there

are certainly studies uh talking about each of them.

And I guess the short answer is probably not considered the standard of care.

Again, many factors um that go into that. This is still considered

that. This is still considered relatively, you know, new territory and certainly should be things that are done on a collaborative effort with our surgical colleagues. Um, and so because

surgical colleagues. Um, and so because of that, I think you can still while several of these, you know, and I'm I'm maybe I'm excluding 10X from this or uh the needle tanottomy, um, that has been

around long enough to that is maybe you could consider that as part of a treatment option for the standard of care. Um, but some of the other more

care. Um, but some of the other more advanced things with tendon and ligament releases, um, it's going to be kind of more situational based and maybe even

institutionally based as to what the true standard of care is.

Okay. Um, do ultrasound guided carpal tunnels still require an O to perform or can they be done outpatient in clinic?

Um, also have you heard of any similar technique for Gon's canal?

Yeah. Um,

so the the first part of the question this can be performed in an operating room, outpatient procedure suite or in a clinic. A lot of that again comes down

clinic. A lot of that again comes down to individual practice setups, but it is at least designed to be able to be

performed in an outpatient clinic. Um

the second part, so for Gon's canal, um not specifically that I know of for that condition, uh you can

apply some of the principles with, you know, ligament releases and apply them to other parts of the body. not that

I've seen in particular for Gillon's canal. Um, and we we see that one in

canal. Um, and we we see that one in clinic less. It's it's less common of a

clinic less. It's it's less common of a pathology. And so [clears throat] going

pathology. And so [clears throat] going to have, you know, kind of maybe lower on the on the totem pole as far as people that are looking into this is, you know, like what should we look at

next as far as what we can do?

Um, next question is, how expensive is 10x or tenjet? Um, how many patients do you need to make the cost worthwhile?

Uh, good question and uh I honestly unfortunately I don't think I can give you a a good answer on that.

The billing that's that's I think probably not not that I'm trying to evade the question here. Uh, one I I I don't actually know the definitive answer because it's going to come down

to each individual practice. So for us at Mayo um how we build for it, we essentially have built-in systems to our EMR where we put in the description

where we essentially just order the procedure to be done. It gets sent to our billing uh team. But the topic of billing codes for 10X is certainly a

topic of discussion. Um, and it's it is somewhat institutionally based as to what the cost is, what the insurance coverage is, and therefore translating it to what that looks like from a

revenue standpoint in practice. Uh, so I I I don't have a specific answer to give you to that. It's a little more nuanced than just saying it charges this much or it bills for this much right now and you will earn this much because it's it's

really going to come down to the practice environment.

What sort of training would you recommend for residents who are interested in becoming proficient in these procedures?

Yeah, it's uh it's practice, practice, practice practice practice practice.

So, any way that you can achieve practice and I would say highle practice. So, um

practice. So, um you know, certainly courses at AMSSM. I

think if you can go to AMSSM, that's a great a great opportunity. There are

several ultrasound courses throughout the um [clears throat] throughout the course that have you know basic level um up to advanced levels and really you're

kind of putting together a lot of the the top synographers in the world in this space uh at that meeting and and teaching and so I think that's a great place to start. There's some, you know, online

start. There's some, you know, online resources, textbooks that are also fantastic and um I'm happy to I mean, if somebody if we need to get more specific

about it, I'm happy to share those recommendations with you. But um I'd say practice, but practice in a good way and and the the proper way. Um and if you're kind of starting from scratch, then

there's a few textbooks that I' I'd re recommend and um courses. Courses if

you're kind of getting your feet wet.

And then if you're going into sports medicine um and you truly want to do more with ultrasound, then certainly um sometimes selection with your your training programs comes into play with that too. And you just try to get as

that too. And you just try to get as much practice and good practice as you can. And then I'll tell you, I mean I'm

can. And then I'll tell you, I mean I'm not too far out into my practicing career and uh it remains to be a very humbling skill set and I'm doing it

every day and um continue to grow a ton with it. So it's just practice and time.

with it. So it's just practice and time.

Is there any prep that you advise your patients prior to orthobiologic injections? For example, stopping

injections? For example, stopping medications, increasing hydration, or certain diets. I've heard NSAIDs need to

certain diets. I've heard NSAIDs need to be stopped for PRP, but does that also apply to the other cell-based therapies?

Yeah, excellent question. And the answer to that yes, especially with NSAIDs. Um

so a couple things some of the GLP1 agonist too that like uh ompic and so forth some kind of recent things that we should um you know you have the conversation at least with a patient as to whether or not you stop that or not

but maybe some um some kind of new emerging evidence that that may interfere with our orthobiologic therapies. The same goes with NSAIDs. So

therapies. The same goes with NSAIDs. So

yes, you do want to try to stop these for a period of time before the procedure and then after. And again,

we're trying to give the platelets the best chance that they can to go on and do their thing. And so, if we're taking medications that maybe interfere with their production, we might not get the

level um of success or results that we want to see. Uh more on diet. Yeah,

there's certainly something to that. Uh

again, I think with what we know, we can maybe simplify it and generalize it and say anti-inflammatory diets. So, you know,

anti-inflammatory diets. So, you know, take that for what you will. Um but

whole food you know whole foods and less processed foods again what is the overall impact of the clinical outcomes um we maybe don't know fully but there

is some reason to think that uh having an anti-inflammatory diet or so uh is beneficial and then I can't remember was there something else with the question that was asked

I think the other aspect was increasing hydration oh yeah um increasing hydration well I'll tell you that helps with blood draw. Uh sometimes we're taking pretty

draw. Uh sometimes we're taking pretty large volumes of blood. Um we always tell patients to come hydrated and a big part of that is for

uh the blood draw. But yeah, certainly I think there's probably something to that, right? Um I think probably

that, right? Um I think probably following general what we call health principles and nutrition principles would would only help your chances with the outcomes. But so yes to the diet

the outcomes. But so yes to the diet changes, it can only help. Yes to

hydration. And then yeah, there are a few select medications that we you know maybe talk about avoiding prior to performing the procedure.

Okay, great. I believe those are all the Oh, one more. Um any specific contraindications to PRP or cellbased

therapies?

Yep. So um there are some you know maybe strict contraindications or absolute contraindications and then some relative contraindications.

Um so things like bloodbased cancers you know leukemas um maybe a discussion that you would want to have again if this is something that is in the kind of active phase then

I mean for me that's a that's a big contra indication. if it's maybe a

contra indication. if it's maybe a history of uh it's a conversation that I have with oncology. Um, [clears throat] and then you know, so I I think not only

just bloodborne cancers, but I think plant cancers in general, if I have patients that have cancers or maybe they're undergoing chemotherapy or other types of treatment, I will reach out in

those situations that are maybe uh gray areas where we we don't fully know and I'll run it by those providers and say, "Hey, here's what we're doing from your end. Are there any risks associated with

end. Are there any risks associated with this procedure?" Uh, so those are big

this procedure?" Uh, so those are big ones that I'm thinking of. And then uh some of the other things that that would fall into it um apply with

just other standard injections and it sounds basic but cellulitis or you know skin infections at the site. Um knowing you know if it's

PRP or if you know if you're going to be doing a tontomy with it and you want to make sure there's no allergies to things like lidocaine or local anesthetics. But

um so yeah, there are a couple of those maybe absolute contraindications and then several relative contraindications or things that you should um you might need to consult on before proceeding.

Okay. Um let's see. Is there anything you're personally curious about or looking into regarding orthobiologics or these procedures?

Um yeah, I mean personal interest kind of in all the above. Um and both are a huge part of my practice. As far as current research goes, um I'm not

actively involved with something pertaining to one of these, but have been in the past. Um specifically with some of the ultrasound guided procedures. So yeah, but I I would say

procedures. So yeah, but I I would say all of it is a big interest of mine and this talk really encompasses a lot of what I talk about with patients on a

day-to-day basis.

Okay, great. Um so I believe that was all of the questions. Um before we conclude tonight's webinar, I want to um express our gratitude to Dr. North again for taking time out of his evening to

share his expertise in orthobiologics and advanced ultrasound guided procedures with us medical students and residents attending tonight's session.

Um, thank you to everyone who attended tonight's webinar as well. I want to encourage everyone to join us next Tuesday, December 16th at 8:00 p.m.

Eastern time for the last MSI webinar for this year. It will be the third webinar of this three-part series on sports ultrasound and orthobiologics hosted by our medical student interest

group. This three-part webinar series

group. This three-part webinar series has built from one session to the next and culminates in the webinar session next Tuesday um for an interactive Jeopardy game where charter medical

schools connected to the MSI have been invited to register a team of current medical students and it'll have a team captain and up to four members. Um, and

they'll compete against other charter medical schools in an interactive Jeopardy game. There will be questions

Jeopardy game. There will be questions on sports ultrasound basics, anatomy of the shoulder, knee, and hip, and questions um on orthobiologics and ultrasound guided procedures like we

learned about tonight. At the end of this 1-hour interactive Jeopardy game, the medical school um interest group team with the highest number of points will be the winner and will be given the

opportunity to host an MSIG webinar in 2026. They'll select a sports medicine

2026. They'll select a sports medicine topic as well as faculty from the medical school that are AMSSSM members to be featured as the webinar speakers.

All AMSSSM member or student members should receive an email from Joan Brown.

AMSSSM membership manager with the link to register your med school interest group team for the interactive Jeopardy game. All team registration forms must

game. All team registration forms must be submitted by next Sunday, December 14th, to be contestants in our MSIG interactive Jeopardy game. So, it's with

pleasure that we'll announce that Dr. Robin Patel and Dr. Georgio Negron will serve as the co-ame hosts along with Jenna Suzaki, who's a AMSSM MSI officer,

as the moderator for the interactive Jeopardy game. So, we hope you will join

Jeopardy game. So, we hope you will join us for our exciting year-ending um Jeopardy game. It has been my pleasure

Jeopardy game. It has been my pleasure to serve as the uh moderator for tonight's webinar and this concludes the webinar. Thank you again Dr. North.

webinar. Thank you again Dr. North.

Yeah, thank you all.