Regenerative musculoskeletal orthobiologics are a game-changing and paradigm-shifting treatment option. They require a new set of standards in terms of diagnosis, treatment regimen (moving from single joints or individual structures to treatment of the entire kinetic chain), rehabilitation protocols, and expectations. These interventions and therapeutic regimen afford physicians the ability to heal injured tissues and return them to a more normal and, in some cases, a native uninjured state. In this manner, they have also set new standards in preprocedural and postprocedural imaging.
Regenerative therapies are powerfully compelling, but consistently successful results require precision diagnosis, and delivery with the use of image guidance ( Fig. 38.1 ). There is clear and repeatable evidence that a precisely placed image-guided injection of regenerative materials, including autologous cells, changes the tissue appearance back to a more normal morphology.
In today’s practice, there are many conventional treatment modalities that provide for improved function and reduce pain. These include palliative treatments such as corticosteroid injections, and nerve ablation. Surgeries are focused at removing the diseased tissues, whether it be a meniscus, labrum, or joint. However, the modalities all fail in regard to their ability to change the disease process of the injured tissues. Orthobiologics have shifted the perspective from palliative to restorative, further confirmed as magnetic resonance imaging (MRI) and ultrasound evidence shows return to a normal tissue morphology. Follow-up imaging allows the clinician to correlate clinical success with structural tissue improvement, further validating the source of pain and dysfunction.
Most case reports, abstracts, and white papers in orthopedic, musculoskeletal, and regenerative medicine focus heavily on pain scores and functional outcome measures such as the Oswestry Disability Index, visual analog scale (VAS) score, and Knee injury and Osteoarthritis Outcome Score (KOOS). Imaging has been used as an outcome measure to a much smaller degree, but it is a crucial and highly objective measure of outcome. Imaging is a powerful modality because it can be used in precisely defining injuries, inflammation, and dysfunction, but this does require a specific skill set by the practitioner. In many instances, imaging studies are misinterpreted because of the disconnect between physical exam and diagnostic imaging interpretation. The cause for the patient’s pain or dysfunction, otherwise known as the diagnosis, is present on imaging but is not interpreted as critical or important or sometimes is simply not recognized. Another reason for the disconnect is the lack of interpretation skills of the treating physician, or solely relying upon the report of the radiologist who has never seen or evaluated the patient. The pressures on the radiologists to read high volumes of cases and meet relative value units (RVU) quota further reduce the quality of imaging interpretations because the priority becomes ruling out catastrophic findings (i.e., cancer, surgical emergencies) rather than finding subtle diagnoses.
The field has matured with the advent of improved point-of-care ultrasound and postinjection-limited MRI. Physicians now can reimage patients after the procedure and demonstrate healing of the tissue by delineating the morphologic difference between injured tissue versus healed tissue. This can be best accomplished with the use of MRI, ultrasound, x-ray, and computed tomography (CT) scans, which provide a detailed image of all structures and the ability to see regeneration of native tissue on a larger scale. This is a major shift in thinking compared with orthopedic and neurosurgical models, where the tissues are often severely disrupted and where postoperative imaging is less than ideal in demonstrating improvement. The tissue is often obscured by metallic artifacts; therefore the repaired tendon or tissues are poorly visualized. Artifacts may be related to screws, anchors, or even simply filings from shavers used during surgeries or arthroscopies. Postsurgical scarring involving the soft tissues, epidural space, fat pad, and other areas are also commonplace. In stark contrast, imaging in the regenerative medicine setting can demonstrate resolution of tendon tears, reformation of ruptured ligaments, healing of annular tears of discs, improved alignment of the spine, resolution of joint effusions, and even reversal of bone marrow lesions, cysts, and intraosseous edema ( Figs. 38.2–38.10 ). Moreover, an updated imaging study prior to treatment is crucial because it focuses therapy to all the regions that require intervention. In addition, it is most ideal to reimage the patient at approximately 3 to 6 months and 12 months after orthobiologic therapy. Practitioners should use consistent methods, imaging modalities, and imaging sequences. Local imaging centers and radiology groups are usually able to offer discounted pricing for limited sequence exams that focus on the previously injured and treated tissues. This may dramatically reduce the extent of imaging required, scan times, and costs and improve patient comfort. Imaging is beneficial in gauging the response of the injured tissue and to document the outcome, both for documentation and for research purposes. It can also dramatically improve practitioner and patient confidence that the treatments are working toward their intended outcome.
