What You Need To Know About PRP Treatment And Ultrasound | Conversations in Regen Episode 1

Are you still relying on traditional palpation techniques for joint injections? Do you wonder if MSK ultrasound can actually improve precision and patient outcomes? And what about PRP procedures—how do we determine the best formulation for optimal healing? In this in-depth conversation with Dr. Don Buford, we explore the evolving landscape of regenerative medicine, from the benefits of orthopedic ultrasound to the ongoing debate about PRP standardization. We discuss the role of ultrasound guided knee injections, ultrasound-guided joint injections, and the accuracy it provides compared to conventional techniques. You'll also hear expert insights into platelet rich injections and how to refine your PRP procedure for better patient results.

Throughout this discussion, we tackle critical questions: Is ultrasound necessary for injections? How do we achieve standardization in PRP treatment? What is a PRP injection, and should we activate it before use? Dr. Buford shares his practical approach to dosing, platelet concentration, and the potential for an "injection in a bottle"—a pre-packaged alternative to autologous PRP. He also sheds light on the future of regenerative medicine and the role MSK ultrasound plays in improving patient care. If you're looking for clarity on what is an ultrasound guided injection and its impact on orthopedic ultrasound, this video is for you.

If you're passionate about regenerative medicine and want to refine your techniques with ultrasound guided injections, don’t forget to like, comment, and subscribe. Let us know your biggest takeaways in the comments! For more expert discussions, listen to our other episodes and stay ahead of the latest advancements in PRP procedures and MSK ultrasound. Join the conversation and elevate your practice today!

Building a successful cash-based orthobiologic practice is not a single decision. It is a series of the right decisions made in the right order. The Business of Orthobiologics offers three distinct programs designed to meet physicians at different stages of readiness — whether you are just beginning to explore PRP, ready to build a full practice system, or committed to going all-in on a comprehensive transformation.

Learn More here: https://thebusinessoforthobiologics.com/programs-explanation 

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Transcript

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SPEAKER_01 0:00

I'm always shocked at how many physicians have never done orthopedic ultrasound exams.

SPEAKER_00 0:08

If you get it into the joint, whatever you're injecting is probably going to spread through the whole joint. But there are certain times when our classically taught techniques aren't going to work. Since 2008, all the PRP I've given is 100% been activated.

SPEAKER_01 0:46

And basically, uh this is gonna be uh an ask Don Buford anything or burning questions that I want to know about. So I'm gonna ask him. But ultimately, this is this time frame where I'm like, gosh, you know, where are we in regenerative medicine? You know, and and the top three things I want to know is, you know, what about ultrasound guys? Is it precision or is it overhype? Right. I think we all know the answer, but I wanted to dive into that a little bit. Can we still at this time be okay with not using ultrasound guidance? And then I think the thing that I have as a question is standardization of PRP. Like, how do we achieve consensus? How is it that we go about being really thoughtful and smart and being able to all speak the same language? And then the one that I'm really excited to delve into is you know, what is the future of orthobiologics? And we'll we'll go into that a little bit more, but let's get started. And I'm gonna just make sure everybody is here, and we're gonna be admitting a couple more people, and we'll go from there. Okay, so Dawn, tell me, I still get every day, I still get people who say, Well, I don't need ultrasound because I know where the joint is. And in this day and age, I really have I, you know, this is how we were all trained, this is how we were taught. What do you first of all, what do you tell them?

SPEAKER_00 2:37

Well, you know, all of us that that have come through orthopaedic training are taught manual palpation, bony landmarks, what the joints look like, what types of joints there are. And and so, you know, uh certainly on a on a basic science and basic anatomy level, we do know where the joints are. That's not controversial. For that matter, we should also know where the nerves and arteries are, too, right? The issue is really that having a way to be more accurate should always be better, and and I don't think that that should be a controversial statement. I haven't found anyone yet from any specialty who's 100% accurate injecting everywhere, it just can't be done. There's one paper that's been published years past where with it was a cadaver-based study with residents and attendings doing injections into the subacromial space, and the misses ranged from being subcutaneous to intra-articular and or intratendinous. And so, you know, the bottom line is we have an imaging modality that has multiple benefits. One of them happens to be that it makes you a better injectionist, if you want to use that word, because you can see the needle going into the body, and it's really not more complicated than that.

SPEAKER_01 3:50

So, you know, so the argument is is don't you want to be more precise? I guess is the argument that you have. Yes, is that correct?

SPEAKER_00 4:00

Yeah, and even in those situations where, you know, if you get it into the joint, whatever you're injecting is probably going to spread through the whole joint. But there are certain times when our classically taught techniques aren't going to work. In fact, I had two people today in the office that I would have struggled and turned them, unfortunately, into a pincushion, unless I got super lucky to inject their knee because there weren't bony landmarks like you would expect. And so if you don't have, if your patient population is not 100%, you know, five foot nine, you know, average male, 160 pounds, or five foot five, average 120-pound woman, then then there's going to be times when you're going to wish you had something besides just your fingers to feel the anatomy.

SPEAKER_01 4:47

Gotcha. Well, yeah, thank you so much. I I I always struggle with that conversation. Like, yes, we know where the joint is, but you know, if we have a modality, I think it is a better way to see. It's like being able to see through skin and bone and muscle and know exactly where we're going. So when we talk about PRP, I know. And then we don't have to ask for directions or fumble around in the dark. So when we're talking about PRP, I think there's been a lot of conversation about trying to characterize it. And I I think we're still kind of currently talking about, oh, this leukocyte rich versus leukocyte poor. Do you think that there is a more nuanced way to think about it? Is there a new should we be talking about it differently? What's what are your thoughts on that kind of discussion of classifying it in these two different camps?

SPEAKER_00 5:55

Yeah. I I still think in in this in this discipline, we're still at a stage where we need to continue to collect all the data because we don't really know when it's all said and done what the magic numbers and what the magic uh characterization is going to be to match and correlate with clinical outcomes. Now, there's the obvious things, leukocyte rich, you've already named leukocyte rich, leukocyte poor. I like adding a leukocyte neutral category.

SPEAKER_01 6:22

There, there's other things explain that a little bit. And there may be people on this call that don't really understand how you can have a leukocyte neutral. Like, what does that mean?

SPEAKER_00 6:32

So, so traditionally, I should in in years past, leukocyte rich PRP typically referred to PRP, where the white blood cell count was north of in the 20s, you know, 25, 35, somewhere in that range. And when you got into WBC counts that were that high, uh, a lot of us noticed that patients seemed to have more trouble with pain and discomfort around the time of the procedure. Their outcomes may be the same. In fact, a lot of recent data showing that their ultimate outcomes may match even leukocyte 4, but the issue was around the time of the injection for some of us. But that's with a white blood cell count well above the upper limit of normal human WBC count, which is maybe we'll call it 10 or 11, okay, on a typical hematology machine. Leukocyte neutral, what I call leukocyte neutral, and I don't think I'm the first, would be a clinical example where I get a CBC on a patient, their white blood cell count is five, which is well within the normal range. We make the PRP, and their white blood cell count in the PRP comes back at seven or eight. It's a little bit higher than five, but it's still within the normal human range up to 11. So I tend to call that leukocyte neutral because at that level it doesn't seem to create any flair, even though if you're going by the strict semantic, you know, criteria of is this number higher than that number? Sure, seven's more than five, but seven is still within the normal human range. So that's why I would consider leukocyte neutral. Leukocyte poor would just be starting at five, and in your PRP, you're less than where you started.

SPEAKER_01 8:01

Now, here's the the more burning question is should we be talking and should we be like thinking about which leukocytes are is that too broad of a category?

SPEAKER_00 8:16

At this stage it is. I mean, it's going to take honestly, probably a lot of computing power to correlate specific leukocytes. And you know, you get into even even even things like eosinophils and basophils and all the things we used to learn in in hematology class to try and correlate that to clinical outcome. Right now, I think the best thing we have that's the kind of easiest to access would be the platelet number and the platelet dose. It's easier to structure clinical outcome studies around platelet dosing right now. And and of course you can correlate leukocyte content, but but even with that, you know, we can still see variations in outcome and variations in in and outcomes amongst different researchers. So I think it's going to take organizations like the Biologic Association, which has their tremendous BARB repository project where they're they're storing and quantifying basically anything you can quantify coming out of blood. And then at some point that's going to go into a big supercomputer in my mind, and then some AI is going to figure out the charts and the graphs and see if they can do a regression and figure out what's correlated to what.

SPEAKER_01 9:23

Gotcha, gotcha. So is this part of the uh standardization process? Like, how do we standardize? Because currently humans are very variable. And in the morning, my blood content is different than in the afternoon. And you know, maybe my platelet count is 200 and yours is 400. Like, how does that significant variability play into this standardization?

SPEAKER_00 9:59

Yeah, I mean, I can tell you how I approach that. That's a really good question because that that is basically where we're at every day clinically. How do you decide how much blood to draw? How do you decide you know what dose? And and for me, in my practice, I simply try and match what I think is the highest level evidence for the clinical indication that I'm looking at with a particular patient. And and that comes down at this point, in my opinion, to platelet dosing, which is simply volume times platelet concentration. And you have to have a hematology machine to really know that. So that's why we have a hematology machine. That's why a lot of people on this phone call or on this webinar have a hematology machine so we can track our dosing. In order to do that properly, and because I don't often have a starting platelet count, and because it can vary, I've geared my clinical practice towards assuming that everybody is at the lowest end of normal. And so I'll say that again. I've geared my clinical practice with PRP towards assuming that everybody walks in with a platelet count of 150, which is the lower end of normal. And based on that, the one variable I can really control in the office that day is the amount of blood I draw. And so if I assume, and I can I can control my protocol and my centrifuge times and which kit I use. So if I know I have a B plus to A plus kit, one of the better kits, whether it's two spin or single spin, and I assume the starting platelet count is 150, then that tells me how much blood I probably need to draw to get to a certain dose. And that's the one variable I can control. Once I have that butterfly needle in, um, truth be told, the answer is often 120 cc's or somewhere between 60 and 120. And because the kits tend to come in 60, you know, or 120, or there's there's one kit that starts at 80, which is a nice feature. But but for most of the time, I'd rather be a little bit too high, meaning I'm drawing 120 for a lot of these clinical indications, even though the end volume of PRP may be relatively low depending on where I'm using it. I'd rather, at this stage, I'd rather be too high than too low, because I think I'll catch more people and get a better clinical outcome for more people if I'm a little bit on the high side in terms of dosing, as opposed to being a little bit on the low side.

SPEAKER_01 12:14

Gotcha, gotcha. And then, you know, there has been some conversations about the fact that monocytes are super important as an immune modulator for these treatments. You know, so what are your thoughts on the the fact that we we do think about that and we know about that? Um, and then for a long period of time, we used uh primarily um what we would call leukocyte poor, and we excluded those monocytes, yet we still had reasonable outcomes. So I don't I don't know. Like, is it is it the resident monocytes that we care about? And we're affecting change at the resident monocytes, like the in-tissue monocytes, that's why we care about them, or do we want to bring more monocytes in? Like I I actually don't know this, this is why I'm asking.

SPEAKER_00 13:08

Well, and those are all good questions, and those those may be hard, if not impossible, without some really slick studies to answer those questions. And and and I'm like you, at the end of it all, the one result I want to see in the conclusion is this patient had this dose or or you know, this treatment and and was better for this many months or years. And then I want to match that protocol. Now, if that includes a discussion about monocytes, fantastic. Tell me how you did it. But right now, with the best outcomes we have, it seems to be more tied to blood draw volume, PRP dose. And whether that, whether those platelets are being activated, you know, you know, endogenously, which is I don't activate my PRP, about to start a study with that, which we'll talk about, but I don't activate the PRP. I let the collagen and the natural tissues activate it for me, which happens pretty quickly anyway. And when that happens, whether that now creates this peracrine effect that you're hinting at and activates the macro, the monocytes, then then that may be what's happening. There may be many common pathways, many different pathways to get this common result. So it may be something where the end of it all, as long as we either put in a high enough dose to do it in-house, or we give them a drug exogenously to create the same effect, ultimately we're getting the same biological endpoint.

SPEAKER_01 14:25

Great. Now you did hint at this activation, if you will. And you know, there's some other really smart people that uh I've been talking with in the field, and there's this discussion about should we be activating our Platelet Rich Plasma? Can you what what are your what are your perspectives on that? You know, we don't some of us, you know, around the world are are always activating, some of us are never activating. Probably the answer is somewhere in the middle, but what what do you what do you think about that?

SPEAKER_00 15:01

I so I've never, I mean, since 2008, I've never activated, at least not outside the body. I've all so let me say that a different way. Since 2008, all the PRP I've given is 100% been activated. It's just all been activated after I inject it.

SPEAKER_01 15:17

Nice.

SPEAKER_00 15:19

I've injected has been unactivated. Okay. So the question is do you do it two minutes before or wait four or five minutes after? And there's some recent studies that show a difference in not only the immediate granule release from the platelets, but also over the next four or five days, there's some differences. And so there may be some difference there that's important scientifically, but it all comes back to this, Ariana. It comes back to the fact that the studies that I think are the best for Neo A didn't activate exogenously. The studies that I think are the best for uh lateral epochondylopathy, lateral epochondylitis, the the ones that I think are really good didn't use activated PRP. Now, that doesn't mean there may not be a good study with activated PRP that showed that it was successful as well, and that's great. I would just match that protocol. But I haven't seen anything that's significantly better in the activated PRP world that changes that for me.

SPEAKER_01 16:18

Is there any place where you would say, gosh, I really want to think about activating PRP to try to have it stay in one spot or whatever? Is there is there any application where you're like, you know what, this may we may be on to something for this?

SPEAKER_00 16:38

You know, some of our surgeon colleagues have been doing that for uh almost as long as I've been in practice trying to use a fibrin clot for meniscal repairs and sewing that in in various ways, and that makes sense. But but I'll tell you, I I think I'd have to check the registry, but I just from experience and anecdotally over the last long years, five to ten years, just by injecting my PRP at a high dose at the meniscal capsular junction, I think I'm getting the same outcome with my meniscal repairs as if I were injecting uh you know or tying in a fibrant clot. And that's a bit of extra work, as you know, that's not always easy to do when you've got a tough meniscus to repair. So, so I I prefer injecting at the meniscal capsular junction. So there may be places though where you want to create an activated version of PRP so that it stays put or so that you can manipulate it in a way that it's got more substance and structure to it.

SPEAKER_01 17:29

Sure, sure. Awesome. Okay, so now for the hard questions.

SPEAKER_00 17:34

That wasn't the hard ones? Oh no.

SPEAKER_01 17:37

Yeah, so I there's been a lot of discussions about the future of orthobiologics, autologous orthobiologics, and there's been a lot of companies that are looking for the holy grail of injection in a bottle. Number one, how close do you think those companies are? And then number two, does that make you nervous for the future of autologous therapy?

SPEAKER_00 18:08

I I don't know. I'm not real up to speed on things outside the country. I know there's always they're ahead of us in terms of already having some off-the-shelf stem cell products, some stem cell products in other countries that we don't have uh the opportunity to take advantage of in this country. But uh I have no doubt that at some point there will be kind of an allograph PRP uh version. And if the dosing is controlled and we have good dosing, you know, you know, clinical protocols, that may be the answer. I always worry, obviously, about something that's now allographed where you have to worry about a few other things. It's it's left someone else's body, it's been processed in some lab and stored in some lab and then shipped to the doctor. So we always have to worry about all those intervening steps, which is why the FDA still considers that making a drug, because I think it is making a drug. But you know, there's lots of drugs on the market. Making a drug by itself shouldn't scare us and shouldn't scare the companies. The question is, it's a tremendous financial investment. And at least in the United States, the financial investment also includes a tremendous regulatory overhang. And that's what's really slowed down development, uh, in my opinion, in this country. So our answer may very well come from overseas, and then you know, wouldn't it wouldn't it be neat if the FDA would accept some of the preliminary early studies from other countries to fast track things into this country that are biologic? So we'll see what happens. But you know, for me, it's all about the the end of the line. You know, what's the clinical result and what's the easiest, cheapest, safest, fastest way to get a patient there? So maybe not by the end of my practice career, but by the end of some people on the call, there'll be something allligraph like that where we won't even have to draw blood.

SPEAKER_01 19:49

Yeah, yeah, absolutely. Well, you know, this has been great. I I think I have um a final question and then I'm gonna turn it over to our audience because now this is a very lovely, intimate setting where honestly, how lucky are we that we get to sit with you and just pick your brain? I have about like 100 more questions. So if nobody like puts them in the chat, I'm just gonna start like with my 100 question list. So, but but we'll give everybody a chance. But I did want to like ask one last question about ultrasound, ultrasound guidance, ultrasound training. Like, I feel like that's one of the biggest hurdles for for widespread adoption. And I just wanted to take your brain on, and how is it? What do you think is gonna be that stepwise adoption? Like, where it's well, of course, we use a stethoscope to listen to the heart. Like, we don't put our ear on the chest, right? Of course we use an ultrasound to look at musculostillo stuff, like you know, like that I don't why is there such a disparity? Because, like, in the rest of the specialties, ultrasound, like in the emergency medicine, ultrasound is common and standard in looking at lots of things. Why, number one, why is it like such a such a hurdle? And then what's it gonna take to have widespread adoption in our musculoskeletal education system?

SPEAKER_00 21:24

I don't know the hurdle part's a tough one, right? Because Casimus case sonography has been around for long enough for that to have have have been exposed, for people to have been exposed to it. I I think like anything else, it starts at the training level, but probably even before the residency level, you know. So even before you hit an orthopedic based residency, hopefully the medical schools, and I know this for a fact that there's many, many medical schools now that are using ultrasound in their in their gross anatomy courses. And and I think that's fantastic because that's where you start. And I think the rise of some of these portable handheld wire. Or wireless transducers that connect to an iPhone or any phone or your computer or tablet and make this modality more accessible and more cost effective for schools and training institutions to have them for their students. I think that'll just help. You know, just getting introduced to it, that's kind of your gateway modality, your gateway transducer, if you want to call it. You know, maybe something small and portable, but as you get better at it, you start to learn that there's there's higher powered devices, maybe. Um so I think at the training level, that's really where it starts. We're coming at it from both directions, right? Because we've got some very high-level clinicians in various specialties that are very, very good at sonography. And and and they're teaching kind of from the top down at a lot of high-level international and national meetings. And then from the bottom up, it's starting at the medical school level also, and and with residencies and fellowships, you know, filling in where they have appropriate, appropriate um faculty to teach. So I think we'll get there. It's clearly way better than it was 17, 16, 17 years ago when we started our course. I mean, it's night and day improved. It's basically in every orthopedic meeting there's there's lectures and talks about sonography. If you look in almost every, or just say the top 10 orthopedic journals, not only are there articles that include orthobiologics in every edition, which I think is fantastic, but there's also articles that that will include sonography if it's appropriate, either for diagnostic or or outcome measures, things like that. So we'll get to that.

SPEAKER_01 23:31

How long how long do you think it's gonna take before it's standard like using a stethoscope to listen to a heart?

SPEAKER_00 23:36

Oh gosh, it's only been 16 years since we've got probably another 15 or 16 years.

SPEAKER_01 23:43

Okay.

SPEAKER_00 23:44

It's gonna be a minute.

SPEAKER_01 23:45

Okay, all right.

SPEAKER_00 23:47

Because you have to realize everybody that's in practice now, if they want to be cutting edge, I think they have to learn how to do it. And and you have to get past the mindset that that using ultrasound is a sign of weakness when it's obviously not, it's actually quite the opposite. It makes you a much better clinician. And you none of us get ultrasound because we're scared that we can't inject the knee or the shoulder. We get ultrasound because we want to know exactly what we're doing and be able to do it better, you know. And so that mindset really starts in training when you have no preconceived ideas and there's no, you know, call it ego or whatever, attached to what you're using. You're just a student learning everything there is out there and having that open mind back then. And uh, and so I think when that next generation of orthopedic clinicians comes through that are, you know, just now coming out of medical school, but they've been in a program where they had ultrasound all the way through gross anatomy and what have you, I think those people will be even better than we are, you know, with the transducer. They'll they'll have grown up with it and they'll be even expert, even more expert at uh anatomy because it's really just applied anatomy, you know.

SPEAKER_01 24:46

Right, right, absolutely. All right, so I'm gonna open this up. Thank you so much for spending your time and really pontificating about you know all the things that we care so much. So we have some questions here, and you can you can choose not to answer or if you don't want to, but to so the question is is do you find that cervical facet PRP injection under fluoroscopy is safe, or would you recommend against it and recommend platelet lysate instead? And then there's just some discussions about volume and for example, you know, how much how much do you draw if you're gonna be using one CC per facet?

SPEAKER_00 25:26

So so right out of the gate, I have to I have to stay in my lane because I do some lumbar spine things under ultrasound. I don't do any philosophy, and if I was going to be up around the cervical, uh, I think pharoscopy is still the gold standard. So I would say that is safe. I think pharoscopy is safe. I think that's the way, again, the gold standard. But you can do some things with ultrasound. We could all get on YouTube right now and type in ultrasound guided cervical facet injection. There's going to be some very high-level videos showing how to do that, but recognize that those people are experts and like anything else. If you're going to do that, uh, you want to get some good training to do it. Um, in terms of volume, I can just correlate that to other areas in the body where we inject one CC, like maybe I did a carpal metacarpal joint today, base of the thumb. Uh, at our course we just had, we injected the great toe MTP joint, which is a low volume. And in those low volume injection situations, I typically draw, I honestly I typically draw 60. 60 is kind of my ante to to get in. And but when you concentrate down to one CC, if we can't find anything else to inject, it's obviously going to be very highly concentrated. You know, you may you may have platelet counts in the 3800 range for that one cc, you know. So you're putting in 3.8 billion platelets in one cc, but but uh just know that that can be done. I just I just again, if I'm going to draw and concentrate down that much, I still want to have a high enough dose that it makes sense.

SPEAKER_01 26:52

Sure, sure. We have a a note from Alan Mucha. Thanks, Dr. Buford. I've been teaching uh ultrasound to the Stanford Ortho residents and sports fellows for many years. They love it. And you know, Alan says he thinks it should be a part of every training program. And, you know, I 100% agree. And I'm just I'm always shocked at how many physicians who come from really great programs across the board have never done ortho orthopedic ultrasound exams or injection-based therapies, or you know, maybe they've done like two, um, but it's not standard of care.

SPEAKER_00 27:30

Yeah, and I and I love that. I mean, uh, those of you that don't know Dr. Mishra, he's he's one of the original, one of the original gangsters in this in this gang, right? And and the fact that Alan, Dr. Mishra, takes his time to do that is what we all need to do whenever possible. I mean, that's just my bias, but but I I think we all need to do that. And so that's why we have a course, that's why we have seminars, that's why we try and reach out to uh whoever wants to learn. We try not to be really, you know, our courses aren't just for orthopedic surgeons, they aren't just for doctors. We we cover anyone that wants to learn this, this, this, this imaging modality, and I think it can only help all of us. So kudos to Dr. Mishra, too.

SPEAKER_01 28:05

Yeah, he also says your course is amazing, and I'm gonna kudo, I'm gonna second that because that's where I learned, you know. I was fresh out in brand new resident and fellow right out of sports medicine fellowship, and I had no idea. I'd never used an ultrasound in my entire training. And so I went through your course and I was like, oh my gosh, and my eyes were open, and I was like, you can see so much, it's great. No more guessing. So, with there was a question with all the recent flurry of papers, do you have a minimal total platelet amount per joint? And then what happens if you don't reach that threshold? What do you do?

SPEAKER_00 28:46

So that's a great question. And and the short answer is yes, I have an idea in mind. What I'd like to do for soft tissue applications is get above 3.5 billion platelets, and remember that that that the dose is volume times concentration. So you could do that with three cc's at you know 1100 or 1200 platelet count, or you could do that with one cc and a platelet count of you know 3,500. So, so, but that's based on some work that was spearheaded by Dr. Peter Everts and others in a collaborative kind of multi-center trial where the soft tissue papers, looking at PRP outcomes, the soft tissue papers that had doses under 3.5 billion, 14 out of 14 had um outcomes that were not statistically significant. And if you go above three and a half billion in a single injection for soft tissue applications, and this was a summary of all the different ones that are out there, you know, from tennis elbow to Achilles to rotator cup, if you were above three and a half billion, nine out of eleven papers showed statistically significant outcomes. The disparity between that number, you know, obviously three and a half billion is arbitrary, but but using that as a cutoff, the disparity between papers below that dose and papers above that dose was unexpected and striking. It wasn't just a gentle curve, it was like horrible, horrible, good, good. Okay. And so for soft tissue, I want to get above three and a half billion. For joints, it's a little bit different. And let me back up and say one more thing. There's some independent research just for rotator cuff that suggests you want to get to five billion or even higher. Okay. And and back to that initial conversation, if you have somebody with the lowest normal platelet count of 150, and you draw 60 cc's of blood, with a reasonable machine, you ought to be able to get to 5 billion platelets for most soft tissue applications. Inside the joint, you know, a lot of people talk about Bansall's paper out of India that has a dose of 10 billion platelets for a knee. Uh, fewer people are familiar with Choose study, which is a three-injection protocol, one injection a week, and weekly the dose was 4.2 or 4.3 billion, don't quote me. But the total dose after three weeks was 12 billion, pretty close to Dr. Bonsal's 10 billion. So, question is what do you do if you make a PRP injection, it comes in at 7 billion, and you're planning on doing a single injection? I've found I've found that they do okay. If I'm close, I would hesitate, and again, that's partly because uh we're drawing so much blood. Now, remember what I said also, because I don't want to be in that situation as much as I can avoid it, I often will draw 100, often, if not always, will draw 120 cc's, because then even if they're at 150 platelet count, if you do that math, we are starting at such a high initial platelet volume, you know, 18 to 20 billion platelets, that even with a mid-level PRP making protocol, we're still going to end up at 10 billion. Even if you lose 50% of the platelets in the process of making PRP, we're still going to end up around 10 billion if that's your target. If I really thought 10 billion was my target and I only ended up with five or six, yeah, I would probably go back and draw more blood, to be honest. But that hasn't been a concern. I don't, I don't think we're fine-tuned and and you know, sophisticated enough to say 9 billion is not going to get the same result as 10 billion. I think that's just I think there's a margin of error there.

SPEAKER_01 32:09

Yeah, absolutely. Now we have a question, and this is a question that comes up very, very often, and it has to do with local anesthetics. Um, and she says, I read that xylocaine 2% doesn't negatively affect the platelet, and it's okay to use to numb the surface of the tendon, for example, in lateral bochondylitis. Do you agree? And then how do you control pain during the procedure?

SPEAKER_00 32:32

So I don't necessarily agree, but I don't know everything. It's just my opinion. And so as a result, I don't use lidocaine, xylocaine, bupivacaine, any of the canes when I'm doing a lateral epochondylitis injection because it's just too close. I don't want to do anything that could potentially have a negative impact on my procedure. And so the second part of her question is really the key because it's the same question I had when I said, okay, if I can't use lidocaine, I mean, you know, and I'm not going to do a general anesthetic, there's got to be something in between. And and the answer for me, which and for most of us, is I use a lot of ethyl chloride. Okay. And I use, I can often use a 25-gauge needle for laudar lipochondylitis. And then the key for me is I also can concentrate the volume down. So patients' pain for these relatively superficial soft tissue injections or for small joint injections is directly related to volume in addition to some other things, you know, other technique items, but but the volume makes a big difference. And so, you know, many, many, many years ago, and it'd be great to have Dr. Misha's opinion on this, but many, many, many years ago, I I would inject three cc's and kind of flood the zone for lateral epochondylitis. With ultrasound, I can be much more precise. I can target that hypoecoic defect, I can needle a couple times, and I can put in one and a half cc's, get the same clinical outcome based on my registry, and far less pain.

SPEAKER_01 33:55

Great, great.

SPEAKER_00 33:56

And then use ice after. I haven't found ice to be a negative thing to use after. That comes up also. So we use ice after.

SPEAKER_01 34:01

Yeah, perfect. Awesome. Thank you so much. I think this is another really great question. What sites or specific journals are your favorite? Uh, what that are your favorite? What do you go to for the latest studies and articles on orthobiologics and regenerative medicine? I think that's a really great question because there is an a burgeoning amount of data coming out. And it's really hard to wrap your mind around and wrap your arms around the sheer volume. And if you're just getting into the game, it's like, how do you figure out where the right stuff is?

SPEAKER_00 34:37

And it's hard because although there's there's journals out there like like I'm co-editor with Alan, Dr. Mishra, and Bill Merle on a journal this ortho biologic specific, but good papers come from all over the place nowadays. And so you're exactly right. So just having a subscription to one or two isn't enough. And by the same token, you don't want to have to buy every single article for $25 or $45. And so what I do is I've set up some search parameters on Google. So this is a hot practical tip. I've set up some search parameters on Google and particularly on Google Scholar for any paper that has particular words in the title or in the keywords, and the obvious things for generative medicine, orthobiologics, PRP, Lucas I Rich PRP, you know, just anything you can think of, you can create a search criteria on it. And I have it set up to just email me weekly with any new articles that meet that criteria. Sometimes the list can be pretty darn long, um, but you can wade through them. I also try and limit what I do where I start is with the human outcome studies, because those are the ones that may have a chance to initially impact my practice the quickest. And then I'll backtrack and look at animal studies and basic science things just because they're interesting to me. But you know, beyond the journals that are part of my specialty, so the orthopedic journals that have specific ortho biologics content, to capture everything else that happens across the planet, I think you have to use search parameters. And and now with ChatGPT, I'm kind of interested to see if there's a way to use that just to create some search, you know, kind of robots that go through and as things get published, if they have the keywords that you're looking for, it emails you.

SPEAKER_01 36:12

Brilliant. I'm sure we're gonna find a bot really, really soon to get that. Yeah, yeah. Oh, Atiba says there is a way, Don. There is a way. So we'll be working on that bot for everybody. Oh, he's already working on it. So when I say we, I mean somebody else is going to be working on that, and hopefully we'll get that in everybody's hands soon. Awesome. Well, hopefully this has been very helpful for everybody. I really appreciate the the opportunity to be a part of this, and I'm so glad that everyone's taken uh time out of their day. I just wanted to share a couple of things, and uh so I'm just gonna share my screen. This is we have questions, right? And the our slideshow is gonna be basically this. We'll just do this. Okay. I'm sure you can, this is not exactly right, but we'll just go ahead. And I wanted to just this is the conversations in regenerative medicine, and I really appreciate everyone being here. This I started this series because I really wanted to pick everybody's brain and I didn't know a better way. So if I'm gonna do it, I'm gonna share all of the um answers with um my friends and my colleagues and and and really put it out there because this is an exciting field. Obviously, we know who I am. I'm uh, you know, an orthopedic surgeon and uh been working with interventional orthobiologics, and I'm obsessed with helping doctors to add orthobiologics to their practice. So we had a lot of great questions. I really appreciate everybody really joining in and asking those hard questions and not being afraid to ask those questions that we all are wondering about. And after this, you will receive an email for an opportunity for the PRP Power Play. And so integrating strategies on how you can add or improve your offerings for your patients and really deliver results and grow your practice in a meaningful way for both your patients and for practitioners. If you want to continue the conversation, uh, we are continuing this conversation next week. We'll have Dr. John Farrell, we'll have Dr. Mary Ambok, hopefully Dr. Alan Misha will join us. I'd be uh honored. So if you want to scan that QR code, we do have that available. Um, and then we just want to bring to your attention if anyone's going to IOF map max in February for any reason, Phoenix, Arizona, one of the best, best, best, best annual events, IOF Interventional Ortho Biologics Foundation. I have am going to be bringing you a day of business. So you're bringing, bridging that gap between your skills and your knowledge and turn your expertise into a thriving practice that you absolutely adore. And and then anytime that happens, we have some other opportunities, but we also have a BA summit. So save the date if you're interested in the BA summit, May 7th. Yes, it's in the middle of the week. Yes, it's gonna be amazing. Uh, so definitely save the date. And then finally, uh, we have women in orthobiologics and wellness, and I'm here to help. I have a newsletter that discusses how you can take these research papers and apply them to your practice. How do you talk to your patients? How do you use all this data that John Don just spewed out from all of these different studies? And how do you actually use this to help guide your patients in whether they should be uh choosing other, you know, PRP? Should I what should I do? And how how can we guide our patients using the best, newest, latest research? So I just wanted to bring that to your attention. But I I just I'm so thankful that we are able to be here and have the ability to host Dr. Don Buford. Thank you so much for your time. If there's any other questions, let's see here. Great, great, great, great. Yes. Looking forward to seeing you both at Biologics. Thanks, Dr. Mishra. Thank you all for joining us. I really appreciate it. We're gonna wrap this up and uh we will see you next week, hopefully, with Dr. John Farrell. Uh, keep your eyes peeled for that. Uh, and please let me know if I can help you. Thanks so much for coming. I appreciate you all.

SPEAKER_00 41:13

Thank you all. Bye bye.