Page 10 - SMU Spring 2020

TEAM PHYSICIAN’S CORNER
that can influence the efficacy and the
safety of the injection. Specifically, IA-HA
products with a higher molecular weight
(≥3000 kDa) and those derived from
biological fermentation have displayed
superior efficacy and safety. Therefore,
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our preferred use of IA-HA is with
a high molecular weight, biological
fermentation-derived product in patients
with mild to moderate osteoarthritis.

Orthobiologics
Orthobiologics are an emerging field
of treatments that employ biologically
When available, full-length standing get them over their acute inflammatory active anabolic, anti-catabolic, and
hip-to-ankle X-rays should be performed phase and allow them to better work anti-inflammatory proteins and cell-
to evaluate mechanical axis deviation to through their weight-loss and physical based therapies in the treatment of
determine whether unloader braces may therapy exercises. We suggest exercising musculoskeletal problems, including
be helpful for your individual patient. caution when routinely including OA. At this time, the Food and Drug
Newer generation unloader braces are local anesthetic in an intra-articular Administration (FDA) has specific
lower profile and less bulky. However, steroid injection cocktail. In vitro and limitations on the use of orthobiologics
concern remains regarding cost and in vivo animal studies have found that in the United States: formulations must
compliance. Regardless of the amount of local anesthetics have a toxic effect on be minimally manipulated (simple
malalignment, patients should be given chondrocytes and synoviocytes. mechanical preparation) and for
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the option to explore a variety of brace, Our preferred cocktail for a standard homologous use (same tissue function
sleeve, and/or taping regimens to help corticosteroid injection includes 40 mg or location). The FDA prohibits culturing
alleviate symptoms, reduce pain, and triamcinolone acetonide with a 3 mL saline of cells, transporting of cells out of the
improve outcome in early arthritis. vehicle. Ethyl chloride spray is utilized clinic, sorting of cells, and adding growth
In general, the above strategies are to cool the skin but no local anesthetic is factors or enzymes to aid in the harvest.
the mainstay of treatment for early introduced into the joint. Novel extended Regulations differ across the globe
osteoarthritis. The sports medicine release triamcinolone acetonide injections where cells may be isolated and cultured
physician or surgeon may utilize have yielded promising results in clinical for later re-implantation. The current
medications and/or biologic injection(s) trials with both prolonged and improved regulatory limitations of orthobiologics in
to reduce pain and effusion so that the pain and clinical outcome scores when the United States are narrow and explicit.
patient may rehabilitate successfully. compared to placebo and standard short- Platelet-rich plasma (PRP) is a sample
Orthobiologic injections may also help acting corticosteroid injection. The of blood plasma that has concentrated
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to modulate the joint environment to extended release corticosteroids also have platelets two to seven times above the
achieve knee homeostasis. The various less systemic effect and more favorable baseline level for the specific patient 6
injection options at the clinician’s blood glucose profile in diabetic patients. according to the American Red Cross.
disposal are discussed below. These benefits must be weighed against PRP is formulated via centrifugation
and separation of blood into plasma and
concerns for increased cost and availability. platelets, which contains a host of growth
Orthobiologic Injections Viscosupplementation with intra- factors, cytokines, and other proteins
Intra-Articular Corticosteroids articular hyaluronic acid (IA-HA) responsible for decreasing inflammation and
and Viscosupplementation injections can be considered in the promoting tissue healing and regeneration.
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Corticosteroids are widely available, non-operative management of patients PRP modulates the joint environment
relatively low cost, and largely well- with early symptomatic osteoarthritis. in the setting of early osteoarthritis.
tolerated by patients. As such, these The mechanism of action of IA-HA Specifically, PRP and its biologically
are often employed as first line injection is as a chondroprotective mechanical active proteins are thought to decrease
treatment options. Short-acting lubricant that may provide analgesia joint inflammation, reduce angiogenesis
corticosteroids, such as triamcinolone and lead to synthesis of proteoglycans of the synovial membrane, and delay
2
acetonide and dexamethasone, can and glycosaminoglycans. There are cartilage degeneration while promoting
provide patients with early relief of pain important differences to recognize in medicinal signaling cell (MSC) migration,
and swelling which may be sufficient to intra-articular hyaluronic acid products proliferation, and differentiation. 13,25

 8 SPORTS MEDICINE UPDATE | Spring 2020, Issue 2