Abstract:

Point-of-care harvest and application of residence stem cells are practical and cost-effective. Tissue formerly considered waste contains these biologically potent cells, and use of such tissue may represent a big part of biologics going forward. The practical application of orthobiologics has slowed because of 3 hurdles: the regulatory requirements of stem cell technologies; the energy, time, and money required to develop a clinical evidence base; and the expense that they present to patients and institutions. Orthobiologic technologies that are simple and cheap and that leverage tissues that are already readily available at the point of care (i.e., the surgical procedure) solve many of these challenges. Cell sources could include knee synovium, shoulder subacromial bursa, bone marrow aspirate, and anterior cruciate ligament injury effusion fluid and stump tissue. A current concern is that collagenase processing and culture expansion are steps resulting in regulatory hurdles in the United States.

The practical application of orthobiologics has slowed because of 3 hurdles: the regulatory requirements of stem cell technologies; the energy, time, and money required to develop a clinical evidence base; and the expense that they present to patients and institutions. It is hard to implement into one’s surgery schedule a technique that is expensive and timeconsuming and does not have a clear return on investment. When hospitals and surgery centers consider orthobiologics, they often first consider the expense added to procedures already on the schedule. Orthobiologic technologies that are simple and cheap and that leverage tissues that are already readily available at the point of care (i.e., the surgical procedure) are going to be winners sooner and likely in the long run.

Although a potentially overused phrase, this brings to mind ice hockey legend Wayne Gretsky’s quote, “I skate to where the puck is going.” The concept still inspires and is currently applicable to the concept of resident stem cells. It is becoming increasingly clear that, for the application of biologics to make strides in everyday orthopaedic practice, it is going to have to become evidence based, practical, and cost appropriate. The concept of using repurposed, locally harvested tissue, formerly considered “waste tissue,” is going to be a big part of biologics going forward. Waste tissue has “game.”

The article in this issue by Shin, Kim, Park, Min, Yun, Chung, andMin,1 “Motorized Shaver Harvest Results in Similar Cell Yield and Characteristics Compared to Rongeur Biopsy During Arthroscopic Synovium- Derived Mesenchymal Stem Cell Harvest,” helps us take a step forward by answering a practical, real-world question: Is it better to harvest synovium and the fat pad with a shaver or rongeur grasper when we consider the viability of resident stem cells? The shaver produced a more efficient harvest, with 2.5 times more monocytes and 3.7 times more cells when cultured. The authors propose that the shaver is more efficient at harvesting because it accesses a heterogeneous population from both the synovial membrane and subintimal tissue, a location where pericytes are likely more abundant. The primary strength of this study is that it comprised a homogeneous population and a practical harvest site. One limitation is that although harvest and immediate reapplication are possible, most studies illustrating value based on this technique or similar techniques have involved collagenase processing steps prior to reapplication.^2-5 Collagenase processing and culture expansion are steps that make products high risk in the US regulatory world, a designation that opens a can of worms.⁶