New Research & Publications

Vangsness Article

Consequences on Private Insurance Coverage: The AAOS Clinical Practice Guidelines and Hyaluronic Acid Injections

Congratulations to TOBI Faculty, Dr. Vangsness and colleagues, on this important new publication in the Journal of Bone and Joint Surgery.

Researchers recently reviewed the conclusions of the 2013 American Academy of Orthopedic Surgeons (AAOS) Clinical Practice Guideline (CPG) on the use of intra-articular (IA) hyaluronic acid (HA) injections and how their position has impacted private insurance coverage of these injections. The significance of such a review is warranted due to the continued high cost of hyaluronic injections as an out-of-pocket expense to patients who are not eligible for coverage through their private insurance carrier.  The AAOS does not recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. This publication authored by TOBI Faculty, Dr. Vangsness and colleagues, outlines the inherent biases of the meta-analysis conducted by the AAOS and its flawed methodology, acknowledges recent studies conducted, and endorses reconsiderations for a modified and comprehensive guideline for nonsurgical treatment of knee pain due to osteoarthritis (OA), specifically reevaluating the AAOS CPG on IA HA treatment. Dr. Vangsness and colleagues support a substantial body of evidence outlined in this review in support of IA HA injections as a valuable treatment option for knee pain due to OA.

To summarize, private insurance coverage as a consequence of the 2013 AAOS CPG recommendations negatively impacts nearly 30% of insured US citizens seeking insurance coverage for IA HA injections to effectively manage knee pain due to OA.  Researchers support a more judicious approach to OA treatment with the adoption of more recent recommendations from published sources to optimize outcomes of IA HA treatment. Furthermore, researchers identify the need for definitive clinical selection criteria and a consistent technique of injection to improve patient-outcomes and cost-effectiveness. Current recommendations by the AAOS restrict the safety and effective treatment of chronic knee pain due to OA and limit clinical intervention.  Dr. Vangsness and colleagues urge the reevaluation of the AAOS CPG on IA HA treatment. Read the article here and join us at the 11th Annual TOBI Orthobiologics Symposium in Las Vegas, NV to hear more from Dr. Vangsness.

Leukocyte-rich PRP for Knee Osteoarthritis: Current Concepts.

Osteoarthritis is one of the most debilitating degenerative conditions affecting more than a third of the population of active individuals over the age of 65. Upon onset of clinical manifestations, osteoarthritis (OA) may become increasingly destructive regarding disease progression with respect to the microenvironment. Investigations into the leukocyte concentration in PRP formulations and its effect on the healing process in OA has created some controversy in evidence-based practice. It is well known that the inflammatory phase is integral to the process of wound healing.  TOBI Faculty, Dr. Lana and colleagues, have published an article in the Journal of Clinical Orthopedics and Trauma that investigates the presence of leukocytes in PRP formulations and highlights the interactions between neutrophils and activated platelets in the release of anti-inflammatory molecules as an effect of leukocyte-rich PRP (L-PRP).

In conclusion, leukocyte concentration from the buffy coat layer during PRP processing may contribute some positive immune modulation effects towards the regenerative phase in the inflammatory process. Alpha granules secreted by platelets provide a source of growth factors that aid in the appreciate outcomes of tissue repair, while interactions between neutrophils and activated platelets elicit an anti-inflammatory shift within the healing cascade. Lastly, a phenotypic switch from M1 to M2 macrophages also provides an important shift towards repair mechanisms within the microenvironment.  Although the overall effectiveness of L-PRP in the treatment of OA has shown some positive results, more investigation is needed to analyze the outcomes for varying degrees of OA and usher in a general consensus.

Congratulations to TOBI Faculty, Dr. Lana and colleagues, on this important publication. Access the article here.

Kirchner Article

Vertebral Intraosseous Plasma Rich in Growth Factor (PRGF) Infiltrations as a Novel Strategy for the Treatment of Lumbar Pathology

TOBI Faculty, Dr. Kirchner and colleagues, have recently published their case presentation of a novel strategy for the treatment of degenerative low back pain in a recent issue of the Journal of Orthopedic Surgery and Research.  A primary motivation to adopt minimally invasive cell-based therapies in the field of Orthobiologics to treat degenerative conditions of the spine led this team of researchers and clinicians to present the first reported case description of the utilization of Vertebral Interosseous and Intervertebral disc infiltrations of leukocyte-free PRP.  The technique was adapted from previous published clinical applications of combined intra-articular and intraosseous PRP infiltrations in patients with knee and hip osteoarthritis for the treatment of chronic pain. In a recent publication, Dr. Kirchner and colleagues present a clinical case of a 40-year old man with a 10-year history of chronic low back pain that was unalleviated by conventional methods of pain management. Clinical findings upon evaluation showed several spinal alterations indicative of degeneration and herniation. The patient underwent a series of three treatments, two of which were intraosseous infiltrations performed in a operating room and the third dose being administered to the paravertebral lamina in an adapted out-patient operating room

In brief summary, disc and endplate regions of the lumbar spine present functional units susceptible to degeneration.  Spontaneous regression of disc herniation is widely known, but the mechanism of regression is poorly understood. Dr. Kirchner and colleagues provide evidence-based clinical results showing aspects of disc degeneration being reversed by the use of an entirely autologous platelet-rich plasma system that mimics the physiological repair process through the release of growth factors in PRGF infiltrations. We congratulate TOBI Faculty, Dr. Kirschner on the success of a novel strategy, which is published in the Journal of Orthopedic Surgery and Research.  Read the full article here.

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