I returned from Bologna Italy Inspired. First I had the opportunity to tour the world famous Rizzoli Orthopaedic Institute. A tour included a mind blowing look at the 16th century building containing one of the rarest collections of orthopaedic literature in the world. I saw original books by Epicorates and the first anatomy textbooks ever written from the 1500’s. There was a globe in the library that did not have Australia on it because it was not discovered by Cook yet! I was amazed by the intelligence demonstrated over 500 years ago, which is still very accurate and relevant today.
The conference brought together over 350 physicians & industry leaders from over 43 countries. I lectured on the Orthohealing Center USA Experience: Intra-Articular BMC Bone Marrow Concentrate for Cartilage Disease.
– Observing live surgeries with meniscal synthetic scaffold (Actifit) followed by bone marrow concentrate with Peter Verdonk from Belgium . A biodegradable acellular scaffold may recruit stem cells from the synovium to heal a meniscus tear. 12 mo re-look data showed new meniscus tissue on histology. (note: this is not approved in US).
– Overall there was a great emphasis on subchondral bone. It seemed that a majority of lectures including mine emphasized the importance of addressing this with cartilage repair.
– Perhaps the most impressive lecture was by Arnold Caplan a leading stem cell researcher. He termed MSC’s “Medicinal Signaling Cells” that live on blood vessels and with a trophic effect secrete healing properties like “injury specific drugstores” responding to trauma and reduce scarring. They are called “Pericytes” and he showed some impressive imagery of them of them along with various cell markers to identify them. PDGF releases the pericytes which mobilizes the cells driving the trophic/medicinal effect.
– Every second 15million blood cells expire and are replaced.
– MSC’s contain LL37 which functions as an “antibiotic” and may explain why BCM may reduce surgical spine infections.
– We still cannot engineer cartilage and have to look back into embryology for answers.
– Overall PRP with micro fracture seems to have a favorable effect.
– In a study comparing leukocyte rich vs poor prp, there were no differences in outcomes although there was increased inflammation with the L rich PRP initially, but increased endogenous hyaluronic acid production. Still no conclusion in debate of WBC rich vs poor PRP.
– Biomarkers! This was the most exciting topic for me. The field is growing but not ready for prime time. In the near future serum, urine, synovial lab tests may demonstrate early OA before radiographic findings to allow for early intervention. Studies have shown that you can predict # of cartilage lesions post ACL repair based on biomarkers. Surgery increases catabolic activity with a spike in IL1. A previous paper in AJSM was discussed on West Point Cadets that had elevated biomarkers prior to ACL tears. Perhaps in the future athletes could undergo preventative screening to predict ligament tears and serious injuries that generally occur without warning.
– BMC used in microfracture resulted in faster results at 6mo & 12mo follow up which may be important in athletes.
– Alberto Gobbi from Milan described his data with BMC for OA and described a surgical procedure termed, “Biologic Arthroplasty.” A sticky clot like chewing gum (Batroxobin) was added to the BMC intra-operatively as an alternative to thrombin. Single lesions and patients <60 y/did better and 15mo re-look showed good tissue re-growth. 12,24,36 mo f/u data showed decreased pain scores and significant improvements. They also treat co-existing issues with meniscectomy, HTO etc. This is becoming a more popular option in Italy as a cost effective alternative to other surgical procedures. - Hyaluronic acid (HA) maintains joint homeostasis for cartilage metabolism. Several papers were reviewed that demonstrate that HA is effective in OA for controlling the disease process & providing symptomatic relief. Overall the conference was a delight to attend. I encourage anyone interested in learning more about some of the latest in tendon and cartilage repair to attend the Orthobiologic Institute (TOBI) 5th annual PRP and Regenerative Medicine Symposium in Las Vegas NV June 6-7, 2013. Many thought leaders will be in attendance to help advance our understanding of biologic based therapies.