What is Level 2 Orthobiologics Injection Knowledge?

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I’m down in Grand Cayman and yesterday I had a patient with a common problem that can mess up the result of an orthobiologic therapy. However, most physicians who just took a weekend course would have missed this as a problem and would not have corrected it. Let’s discuss this as a great way to discuss the different levels of quality out there.

Most Injections are Somewhere Around Level 0-1 Knowledge

Have you ever heard the adage, “you get what you pay for?”. I still get burnt by that one on consumer goods. Amazon is rife with junky stuff that looks great online, but when it arrives, you have serious buyers remorse. The same happens with orthobiologics like PRP and stem cells, but the problem is that it’s hard for you as the consumer to understand the quality of what it is you’re getting. Hence, today I’ll give you another way to roughly measure quality and I’ll use an example from yesterday.

At the top of the page, you see my scale for figuring this out. Most injections are blind, meaning that the doctor has no idea whether the orthobiologic even made it into the joint because he or she can’t see where the needle is going. This is a little like driving your car with mud or snow on the window. You can do it, but the likelihood that something bad will happen or that you won’t get where you’re going is high.

More doctors offering “stem cell” injections (most of these are dead amniotic or umbilical cord tissues and not live stem cell injections) use simple ultrasound guidance. That’s better than blind (level zero) procedures as at least you can see that you’re in the joint. However, as you’ll see below, this is still like the junk that looks good online but arrives at your door as a disappointment. Let me explain.

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Level 2 Knowledge: Yesterday’s Example

Level 2 orthobiologic injection knowledge means that ultrasound is used in a sophisticated way. That might mean that the doctor can use that ultrasound and a hands-on exam to identify damaged ligaments and tendons that also need to be injected to improve your results. Or inject deep ligaments like the ACL in the knee, which is technically complex. Regrettably, only about 5-10% of doctors using ultrasound have the knowledge to use it this way.

Yesterday’s example was a simple problem that would have been missed by doctors with only level 1 orthobiologics knowledge. Before I injected the stem cells into this patient’s knee, I performed an ultrasound exam because I knew that he had a history of effusions. This means that he can carry quite a bit of fluid in his swollen knee. Sure enough, one knee had a big effusion. Why is this a problem?

Concentration is a key issue in medicine. If a drug has a lower concentration it either acts one way or has no effect. If it’s a higher concentration, it acts another way or has an effect. We’ve known for a while that a higher concentration of stem cells on a damaged cartilage surface means better results. However, if you have a huge amount of fluid inside the knee and you inject stem cells, the concentration of stem cells per unit volume goes way down. How do you fix this?

Fixing An Effusion: Simple Level 2 Knowledge

How do you fix the effusion so the injected stem cells can be at the right concentration to have their maximum effect? Simple, drain the fluid before you inject the cells! Above you see me doing just that (left) and what I took out (right). That’s 30 ccs of fluid that would have messed with those cells.

While this sounds simple, many physicians don’t do this simple thing. Why? It’s easier to inject a joint with ultrasound if there is an effusion.

The upshot? Hopefully, this simple level 2 understanding of orthobiologic injections will give you a sense of how to start looking for quality. Tomorrow I’ll cover a level 3 technique I used this week. Again, there’s a huge variation in knowledge and quality out there!

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications. View Profile