Click here to read the Cover Story, "Standards needed for orthobiologic use in fractures."
Use of orthobiologics should be limited
The answer to the question is “yes and no.” Orthobiologics are adjuvants that are thought to improve the endogenous healing potential of the injured skeletal element. Although orthopedic implants and surgical techniques have improved significantly over the last few decades, we still encounter fractures that, despite all efforts, fail to unite. These are the situations where orthobiologics will make a difference. Unfortunately, at this stage, we are unable to predict at the time of the index surgery who will unite and who will end up with a nonunion. In addition, we can often only guess whether a growth factor is needed, a fracture site is lacking skeletal stem cells or the stem cells are less osteogenic due to an underlying medical condition. Once we are able to identify the fracture that will require augmentation with a biologic, such as bone marrow aspirate concentrate, platelet-rich plasma or others, then we will be able to recommend meaningful use of orthobiologics for primary trauma cases. Until then, the use will be limited to patients in which the past medical history or clinical appearance of the injured limb suggest suboptimal healing potential. While this is not a wrong approach per se, it will lead to overuse of these costly products.
- For more information:
- Philipp Leucht, MD, PhD, is an associate professor in the departments of orthopedic surgery and cell biology at NYU Langone Health in New York.
Disclosure: Leucht reports no relevant financial disclosures.
Promising outcomes with orthobiologics
The treatment of primary traumatic fractures constitutes one of the most common surgical procedures. The average patient with a fracture does well when treated appropriately for the injury he or she sustained. The spectrum of treatment ranges from in situ casting or splinting to open reduction and internal fixation with plates or intramedullary rods. This constitutes a significant portion of the medical budget each year. The majority of these patients do well without further treatment. There are some instances when orthobiologics do make a difference. There is literature that proves that the treatment of Gustilo-Anderson grade IIIA and IIIB open fractures is enhanced by using rhBMP-2. A study by Shunmugam Govender, MD, and colleagues was the index report that showed the use of this biologic application reduces the number of follow-up surgical procedures and accelerates wound healing compared to standard of care treatment in the tibia. The biologic therapy also reduced the number of infections that were sustained. This represents a significant cost savings to health care. There are several recent studies that show up to $6,000 per case can potentially be saved when this treatment is used. There does not seem to be any significant proof that orthobiologics should be used on a regular basis in any other common situations in closed primary fractures.
- Govender S, et al. J Bone Joint Surg Am. 2002;doi:10.2106/00004623-200212000-00001.
- For more information:
- William G. DeLong, MD, is chief of orthopedics at St. Luke’s University Health Network in Bethlehem, Pennsylvania and professor of orthopedic surgery, anatomy and cell biology at Temple University School of Medicine in Philadelphia.
Disclosure: DeLong reports no relevant financial disclosures.