Orthobiologics, 3D printing, and more
Omdia Research Manager Adam Davidson believes that North America is embracing orthobiologics and regenerative medicine. In musculoskeletal (MSK) practices, biologics and regenerative medicine are used to encourage the healing of injured or non-functional tissue. In advanced markets, younger populations are eager for less invasive alternatives to joint replacement surgeries and non-traditional therapies, making biologics and regenerative medicine increasingly appealing options. Ultrasound guidance for needle visualisation has quickly become a crucial part of the rise of regenerative medicine. When injecting highly valuable biologics such as platelet-rich plasma (PRP) or stem cells, accuracy is paramount, thus making needle guidance solutions a priority for MSK ultrasound manufacturers. Needle guidance technology like this has contributed to the nearly 10 per cent YoY growth for MSK rehabilitation unit shipments and increased the popularity of ultrasound-guided injections among North American physical therapists and sports medicine physicians.
In advanced Western European and Asia-Pacific markets, a significant amount of scepticism surrounding the efficacy of regenerative medicine exists.
In Western Europe, professional athletes have popularised the use of biologics within sports medicine, but the greater MSK community is reluctant to widely adopt the treatment before it has been thoroughly scrutinised by the academic research community. In advanced Asia-Pacific markets, most of the ageing population seek traditional MSK treatments for pain management despite the invasiveness. Joint replacement surgery was in high demand in 2018, driving nearly 11% YoY growth for MSK orthopedics unit shipments in the Asia-Pacific region. Expanding the use of regenerative medicine and orthobiologics into the region will require a successful education campaign to demonstrate its positive role in pain management.
According to Professor Dr. Med Philip Schoettle, MD, PhD, Medical Director at Knee and Hip Institute Munich, stem cells are the future in treating orthopaedics. Much of the pain caused by inflammation in orthopaedics, he explains, is reduced by stem cells.
"I see stem cell treatments growing in importance, as improvements in SVF therapy, rich cell yields and precision delivery continue to speed patient healing."
Adult stem cells have multiple functions and come in different types, but ultimately what they do is lead to healing. Mesenchymal stem cells (MSC) activate the bone marrow system and other stem cells to start repairing tissue.
Mesenchymal stem cells are known as the conductor of the repair process. Endothelial progenitor cells are the foundation of building new blood vessels. They can inhibit the immune system and be anti-inflammatory, and they can activate other stem cells in the body and force them to start repairing tissue.
Stromal vascular fraction, or SVF, is a mixture of stem cells that exist in our adipose, or fat, tissue. SVF contains mesenchymal stem cells and endothelial progenitor cells as well as endothelial cells. As we age, we don’t lose mesenchymal stem cell function from fat as we do from bone marrow. There are multiple forms of SVF that vary in potency and usability.
SVF is also an autologous treatment, because the patient’s own cells are returned to them – released from the fat – and delivered by injection directly to the area in need as well as intravenously to help activate the body’s own endogenous system. Other clinics that use fat-derived stem cells often only deliver the mesenchymal fat-derived stem cells, not the SVF.
These mesenchymal stem cells have been cultured, leading to changes in the stem cells that can adversely affect their ability to induce tissue repair. Studies have suggested that delivering the mixture of the SVF is better than delivering any single stem cell type.
Currently, the Tissue Genesis Icellator is the best point-of-care system for processing enzyme-derived SVF with a safe and sterile single-use cartridge. Designed and made in the U.S., based on research by the U.S. Department of Defense and NASA, the Icellator is approved for use in Japan, South Korea and the Bahamas, all regulated medical jurisdictions.
It is also being used in multiple FDA cleared trials in the U.S., but is not yet approved for clinical use there or in Europe. Using SVF processed by the Icellator delivers the greatest number and best mixture of cells, at the highest potency, as the cells are freed from the fat matrix.
The combination of mesenchymal stem cells and endothelial progenitor cells can decrease inflammation, induce stem cells to be recruited to the joint space, and help nourish the cartilage by bringing blood supply. The goal of microfracture surgery, which is quite popular, is to get stem cells out of the bone marrow space and into the joint space to promote repair.
By delivering stem cells directly to the joint, we create the same conditions for healing, without causing more harm. The added IV infusion activates bone marrow that might sit right at the end of the bone near the joint to encourage stem cell support of that tissue.
In addition to treating knees, shoulders, hips and other joints, adult stem cell therapy can really improve or prevent severe osteoarthritis by either regrowing cartilage or decreasing inflammation of bone edema.
3D printing technology is still a relatively new area that is improving treatment for certain medical conditions.
According to Julian Callanan, Founder and Managing Director — Sinterex, orthopaedic surgery is a key area of 3D printing within the medical sector alongside dentistry and maxillofacial surgery.
Within orthopaedics itself, there are multiple areas of 3D printing.
The use of 3D printing in trauma-related orthopaedic injuries, for example - a recent concept.
Surgeons are using 3D printing to create anatomical models which offer an exact replica of a patient’s injury and trauma. These replicas aid surgeons and their team ahead of surgery.
Previously 3D printing was either too slow or located in a warehouse or factory rather than at the hospital – little use when trauma teams require accurate anatomical models quickly.
Today, Sinterex is working with Rashid Hospital in Dubai in support of the trauma team at Dubai Health Authority.
The team is having to deal with challenges such as highly complex foot structures comprising many different bones. In the event of a complex fracture, the surgeon must identify what missing shards and bone fragments correspond to. 3D printing can help answer this question, resulting in more efficient surgery.
Second, 3D printing is used to produce cutting guides. These are helping surgeons to execute quickly and accurately.
An example of this is in knee surgery. TKR – total knee replacement – is complex, involving bone, ligaments, cartilage and more.
Third, implants themselves are 3D printed.
A custom knee or hips, as opposed to an off-the-shelf equivalent, will benefit patients more – who fit different categories (short, heavy, thin and more) - offering better performance and rotation over the long term.
Callanan expects to see further developments in software allowing for the design of more patient-specific solutions.
This, along with a fall in printer prices, will bring down the cost of 3D printed medical devices, allowing them to become more cost-competitive with their off-the-shelf equivalent.
As an example, a Canada-based business is offering a custom-designed 3D printed knee at less than the price of a standard off-the-shelf equivalent offered by the traditional medical device companies.
Pushing the envelope further in 3D printing is titanium technology, enabling greater freedom in design.
Through this approach a lattice structure can be produced to create spinal cages for replacement vertebrae. A titanium lattice is both light, owing to its hollow, empty structure, and strong. It also allows the other vertebrae to integrate and grow around it in a process called osseointegration.
Immersive media includes virtual reality (VR) and augmented reality (AR).
VR is a computer-generated simulation of a 3D environment that can be physically interacted with using a helmet or screen, while AR is an interactive experience that blends computer-generated information into the real world.
Tech giants including Google, Microsoft, Apple, Facebook, Amazon and others have invested heavily in AR and VR technology.
Recently 15 surgeons from 13 different countries undertook 13 mixed reality orthopaedic operations as part of a 24-hour event. In the United Arab Emirates, the surgery was carried out at Burjeel Medical City in Abu Dhabi.
The surgeons collaborated virtually using Microsoft HoloLens 2, allowing them to visualise and operate via hologram; share their real-time view of the surgery; benefit from remote peers’ expertise on different clinical cases; and train peers remotely, enriching their surgical practices.
HoloLens 2 is a wireless, holographic mixed reality headset that connects with apps and solutions to enhance or enable collaboration, innovation and productivity. Hand and eye-tracking technology detects where the surgeon’s gaze is, allowing them to operate with greater precision.
Despite technological advances, barriers to their adoption remain according to Maine-based ‘Google Glass explorer’ Dr Rafael Grossmann. “The main problem is regulators and hospital administrations not welcoming true innovation; they are fearful of liabilities, fines and reprimands,” adding that the floodgates will need opening for innovation to flourish.
eSports is a form of a sports competition that uses video games and has turned into a big business. According to Newzoo, global esports revenues will grow to $1,084 million in 2021, a year-on-year growth of +14.5%, up from $947.1 million in 2020.
It's also rapidly growing in viewership. Globally, the total esports audience will grow to 474.0 million people in 2021, a year-on-year growth of +8.7%.
Sports medicine consultant Dr Kirill Micallef Stafrace is seeing an increase in upper limb, finger, wrist, elbow, shoulder, neck and spine issues among eSports participants, in addition to posture problems generally, citing third reasons.
With more than 200 movements per minute of gameplay, even minor pain can derail a career
One, more people are practising eSports worldwide. In the United States alone, there are more than 4,300 active competition players.
Second, eSports is growing as a profession and athletes are dedicating more hours to it. Some are training for up to 14 hours a day, while competitions can go on for three days, almost non-stop (especially those involving role-playing games).
Lastly, eSports’ popularity has exploded over the past two years, to the extent that support services have not kept up (in contrast to traditional sports, which have developed over decades).
While the management of eSports injuries is no different from traditional sport, Dr Kirill believes that there should be no delay in treatment.
At professional level, where there are more than 200 movements per minute of gameplay, even minor pain can greatly affect performance, with 10 milliseconds meaning the difference between coming first and coming 10th. A debilitating injury will end a career early, with the typical athlete managing no more than five years.
ESports athletes should focus on stretching and strengthening through preventative exercises that use “squidgy balls” and elastic bands, while also ensuring that gaming equipment is properly fitted.
To ensure that eSports athletes practise safely, better education is required to promote awareness, and Dr Kirill also calls for self-regulation. In rugby, for example, when the ‘sin bin’ was implemented and a framework introduced for high tackles, the number of traumatic injuries was markedly decreased.
The ongoing pandemic means that air travel is not currently feasible for many international patients.
Orthopaedics however remains a key service in the United States offered to inbound medical tourists.
According to the US Cooperative for International Patient Programs (USCIPP) - an organisational membership programme of the National Center for Healthcare Leadership – orthopaedics is currently the fifth most common service line for adult outpatients and the third for paediatric outpatient visits, dropping from second as reported in its 2018-19 survey of 56 member hospitals and health systems in the US with international programmes. While inbound medical travel is likely to remain impacted for months to come, USCIPP and parent organisation National Center for Healthcare Leadership believe that global consumer confidence in the US will recover faster than previously expected, pointing to the following evidence: