Intro
Hey, I'm Dr. Ariana DeMers. I'm an orthopedic sports medicine surgeon, and I have successfully integrated orthobiologics into my busy practice so that I can provide a continuum of care and treat patients who are in the gap. The gap is this gray area in orthopedics where standard conservative treatments have not been effective, but surgery may not be warranted. And we usually tell our patients, come back when it's worse. What? These are your patients coming to you for help. Orthobiologics is that solution that can fill the gap and help you treat your patients who are in your office looking to you for help. Orthobiologics can also be an excellent treatment for frustrating problems without good surgical outcomes. This podcast will help you create the orthobiologics business that will make you love your job again. We will focus on value of orthobiologics, patient selection, how to talk to your patients about money, office setup, and other logistics. If this is something you've always wanted but don't know where to start, join me in "The Business of Orthobiologics" podcast.
Dr. Ariana
Hi, welcome. I'm going to be talking today about candidacy for orthobiologic treatments. Here's what we'll cover today. Who's a good candidate? And patient factors like the likelihood of success, longevity of the treatment, and risk of treatment. And we'll talk about a candidacy calculator. So patient candidacy for orthobiologics. What determines a good candidate? So we have to know the diagnosis, the patient attributes, the likelihood of success, and other treatment options as well as risk comparison. When we talk about diagnosis, we want to talk about different treatments and different success rates for arthritis, for tendon issues, for ligament issues, for nerve compression, and muscle injury. We also have to consider have patients had a biologic failure or a structural failure. Do they have partial tears? Have they not been recommended for surgery due to their other biologic issues or medical issues? Are there really no great surgeries for the diagnosis that they have? So let's talk a little bit about arthritis. So patient eligibility, patients who have mild to moderate arthritis who have not responded to conservative treatments like physical therapy and medications may have had hyaluronic acid injections and have still had problems with symptoms. Optimal candidates are individuals with early-stage osteoarthritis, healthy enough for a minimally invasive procedure, no severe joint deformity or mal-alignment, and no significant cartilage loss. That's the optimal treatment or optimal candidate. That doesn't mean that anyone with those problems can't have this procedure, but that's the optimal candidate. When we talk about tendon injuries or tendinopathy, so eligibility for the patient, patients with chronic tendon injuries who haven't responded to those conservative treatments. Our optimal candidate would be an individual with localized tendon injury without significant tears or ruptures, who are motivated to follow post-procedure rehabilitation protocols and understand that it may take quite a long time for it to fully rehab. We're talking about something in the realm of six months to have the full effects. When we talk about rotator cuff tears, our patient eligibility, our patients with partial thickness rotator cuff tears. Anybody with a full-thickness tear is not going to have as significant improvement as patients with partial-thickness tears. Our optimal candidates are individuals with small to medium-sized partial thickness tears, no significant muscle atrophy or severe degeneration of the tendon, as well as limited concomitant disease of arthritis. When we talk about ligament injuries like MCL, ACL, and ligament injuries, patient eligibility are patients with partial tears or chronic instability. This can be of the knee, this can be of the hip, of the ankle, wrist, fingers, and elbows. These are all patient-eligible candidates. Our optimal candidates would be individuals with stable knees, mild to moderate ligament injuries, and no significant joint damage to the cartilage. Next, when we talk about cartilage defects, eligible patients are patients with localized cartilage defects or early cartilage degeneration. Optimal candidates would be small to medium-sized cartilage defect, no advanced OA, and suitable joint alignment, meaning no significant mal-alignment. Next would be spinal conditions like degenerative disc disease, herniated discs, or some sort of spinal stenosis or instability. Eligibility are patients with chronic back pain with mild to moderate disc degeneration. Our optimal candidates would be individuals with localized disc degeneration, no significant nerve compression, or spinal instability. Next, we want to evaluate our patient attributes. We want to take a look at their overall health. Do they have cardiovascular disease, diabetes, cancers, metabolic syndrome? All of these have been shown to be harbingers of worse outcomes when it comes to orthobiologic treatments overall. Now, who's a poor candidate? These are items that may indicate poor candidacy for orthobiologics. That being said, this also may be an indication that they are a perfect candidate for the orthobiologics as they are not a candidate for other treatments such as surgical intervention. So, number one, advanced or severe injury or disease. Severe osteoarthritis, active infection or inflammatory disease, poor overall health. Realistic, excuse me, unrealistic expectations. This is not magic. This is not going to fix everything. This is not a drive-thru McDonald's experience. Allergies or sensitivity to the injection base that we're completing. Inability to comply with rehab. Although I would say that sometimes, low-risk, low-downtime injection-based therapies may actually be better suited for those patients who cannot comply with a strict rehab protocol, such as the case for rotator cuff repair surgery versus rotator cuff injections. Where rotator cuff injection therapy, there's very limited downtime and limited restrictions as compared to a rotator cuff repair surgery. Next would be elderly patients, although there's been some studies that show that this is actually quite beneficial with quite a bit less risk for knee arthritis. Pregnancy, although again, these are orthobiologic treatments, which are your platelets and tissues, which may have lower risk than other treatments that are not autologous. Next would be, previous unsuccessful orthobiologic treatment. And I want to talk a little bit about that because we really have to be critical on what the orthobiologic treatment was. Was it appropriate? Was it appropriately dosed? Do we know that it was done under ultrasound or X-ray guidance? And make sure that it wasn't under-dosing or poor-quality treatment rather than a failure itself. Next would be blood clotting disorders, so any kind of clotting disorder that would predispose you to excessive bleeding that would cause worsening pain, problems, or issues may be not a good candidate for injection-based therapies. Additionally, significant nerve compression may be not a good candidate for orthobiologic treatment. Then poor overall function. They may be in poor health. Like I tell my patients, their body, we want to optimize their biology because this is the drugstore, this is the pharmacy we're going to for the medicine, and we want to have the best pharmacy and the best medicine available. So if we have poor health and poor overall function, this may not be the best treatment for them. Now, let's talk about the likelihood of success. We really have to delve into the literature and look at different success rates for each diagnosis. But overall, there's an overarching success rate of about 50% to 75% success rate with appropriate candidacy, appropriate selection, and appropriate treatment protocols. Now, let's look at that as compared to standard treatments like cortisone or surgery. We know that some of these standard treatments are not successful at all, and some of them are quite successful. So for a long-term treatment, cortisone is not going to be successful. And we know that this is successful in only about 6-12 weeks, with all effects being mitigated by 26 weeks in most cases. Now, surgery, on the other hand, from a longevity standpoint, we know that hip replacement surgery is an excellent procedure with an excellent outcome and efficacy as well as long-term success. So we really have to be clear on what treatments we're comparing the orthobiologic treatment against and looking at the expectations of each treatment as compared to standard treatments. And then we talk about this longevity. So in treatments for arthritis, longevity treatments such as the standard treatments, cortisone, 6-12 weeks, hyaluronic acid, 6-9 months, and orthobiologic treatments appear to be longer than that, at least 12-18 months for platelet-rich plasma and may be longer for other cellular therapies. When we looked at tendon tears, this becomes quite a bit more interesting because, in some studies, this does appear to be curative instead of a band-aid procedure. This is actually causing healing of the tendon itself, the same with ligament injuries. When we talk about nerve irritation, there may be longevity of the treatment if we can actually treat the underlying reason the nerves is irritated, either a little bit of degenerative dysdisease or spinal instability or compression of the carpal tunnel. And we can inject this area and decrease the irritation, but also stabilize the underlying reason that we're having nerve irritation. This may be curative, again. And so the longevity of the treatment for curative treatments is quite acceptable and desirable. When we talk about spinal degenerative disc disease, we do know that even using platelet-rich plasma epidurals, this can actually reverse the bulging of the disc and decrease the compression of the nerve. And this does appear to be a significant longevity of the treatment, as well as decreasing the risk of adjacent segment disease. We know when we have a high spinal fusion that the risk of adjacent segment disease is real and can be quite problematic. Whereas if we are improving the functional segment of the spinal disease, this decreases that risk of adjacent segment disease and so decreases the overall need for further treatments and may actually cause improved longevity. Now, next part, we want to talk about risk comparison. When we talk about the risks of physical therapy, bracing, and supplements, these are low-risk procedures. They're non-invasive. Medications are the next step up with some side effects and some risks associated with it. The next would be injection-based therapies. We talk about the risks of steroid injections and hyaluronic acid injections, and then we talk about those risks of the orthobiologic injections. One, we'd compare orthobiologic treatments to minimally invasive surgeries. The risks may be quite equal or the same across the board. When we're talking about the risk of invasive major surgery like a joint replacement or spinal fusion, then we have significantly less risk with orthobiologic injections and more risk with those surgical injections. So those are all things to take into consideration when we're talking to our patients about whether they're a candidate for orthobiologic treatments. Next, we'll talk about a couple of candidacy calculators. There's this intuitive calculator where it's just your brain and based on your diagnosis, patient variables, likelihood of success, and longevity. Then we go ahead and talk about what we know from the outcomes in the literature. This takes into account our patient's values and goals as well. Next is the Malanga Outcomes Calculator. This is a really cool calculator. It's based on safety, efficacy, durability of the effect, number of required treatments, cost, level of invasiveness, limitations post-procedure, expected time to improvement, and expected time to activity or sport. And this is used, and then you get to score each one from least invasive to most invasive, lowest cost to highest cost, least limitations to most limitations, most safe to most risk, low efficacy to high efficacy, and they all get scored on a 50-point score. And then we also use this to take into account what our patients value as well, and it's to be used as a shared decision-making tool. And so each treatment has a different score and different weight from the patient's values. And so you can calculate the score for an orthobiologic treatment versus surgery. You can calculate the score of one orthobiologic treatment as compared to another orthobiologic treatment for the same diagnosis based on the differences of limitations and invasiveness and cost. And it's really cool, helpful tool that I've been using for a bit, and I'm pleased to be able to talk about that today. Next would be what we call the Buford "Chalk Talk". This is his way of talking with his patients. He has a chalkboard in the consultation room, and they go through all of these risks, benefits, and options, and there's no one right answer. So his conclusions are, there's no one right answer for the given clinical diagnosis and/or patient. It has to do with all of the combinations that we see together. And then we educate the patient with the information that's relevant and looking at the peer-reviewed literature and supported by registry data or expert opinions. Then unless the decision is clearly a medical error, then we proceed with what the patient-selected treatment is. These are a couple of ways to think about patient candidacy for orthobiologic treatments. So how do you decide? Is my patient a good candidate? Consider all the factors, including diagnosis, individual patient attributes, and likelihood of success, as well as the other issues such as longevity of treatment, cost, invasiveness, risk stratification, and then what the likelihood of success is as the patient considers it to be success. Hopefully, this has helped you guys. Thank you so much for joining me. I'll see you next time when we talk about money. Take care.
Outro
This has been "The Business of Orthobiologics" podcast. Thank you so much for joining us today. If you want to know more, please join us on the website, "PRP-Now.com", and click on the FREE masterclass. Also, don't forget to "SUBSCRIBE" to this podcast to get more guidance on integrating PRP in your busy practice. Bye for now.
