1. Orthobiologics in sports medicine: an overview of the market
Catherine Coveney
Biosport Project, University of Sussex

2. Aim
To identify the range of emerging biomedical sport-related diagnostic and repair technologies, and their producers, in musculoskeletal and sports-related specialties

3. Orthobiologic: a biologically derived material used in the regeneration and repair of musculoskeletal tissues.
Alshameeri, Z., & McCaskie, A. (2015). The role of orthobiologics in hip preservation surgery. Journal of hip preservation surgery, 2(4), 339.

4. Methods
Survey of companies/products – research, development and/ or marketing
company websites, press releases & related documents (Jan - June 2015)
observations, discussions & materials at exhibitor stands of various sports medicine conferences (in UK, Denmark, Italy and India 2014 – 5)

5. Technology
Cell type/ biomaterials
Intervention type + purpose
No. of Companies
No. of Products
Injury
Autologous Chondrocyte Implantation/ Transplantation (ACI/ ACT)
Autologous chondrocytes
(+ stem cells, PRP)
Surgical -
Cartilage regeneration 16 28
Cartilage tears/ degeneration (Knee & ankle)
Cartilage allografts
Donor chondrocytes (cadaver) 7
Cartilage tears/ defects (Knee)
Biological scaffolds
Equine - tendon, pericardium
Collagen – Porcine, bovine
Cadaveric skin cells, amniotic tissue, placental tissue
Hyaluronic acid
Surgical implants, some used with ACI or microfracture
- Cartilage and bone regeneration 12 18
Osteochondral defects
Cartilage lesions
Wound healing
Soft-tissue injuries
Donor and synthetic ligaments and tendons
Donor ligaments & tendons (cadaver)
Bovine collagen
Synthetic biomaterials
Synthetic materials
Surgical – Tissue regeneration 10
Ligament and tendon injuries (e.g. meniscus, ACL, hamstring, patella tendon, Achilles, rotator cuff).
Bone grafts and bio-absorbable fixation systems
Equine tendon + bone cells
Collagen – bovine, porcine
Autologous bone cells
Bone cells from cadavers + living donors
(+ Stem cells, PRP)
Surgical - Bone regeneration 22
65 (+)
Bone defects, fractures
Platelet Rich Plasma (PRP)
Platelets + growth factors from autologous blood
Injection or adjunct to surgery – Tissue regeneration 23
Tendinopathies,
Muscle injuries,
Ligament & tendon injuries OA
Bone repair
Cartilage repair
Stem cells
Mesenchymal stem cells (MSCs) from Bone marrow aspirate/ concentrate
Donor MSCs
Haemtopoietic stem cells (HSCs)
Injection or adjunct to surgery, combined with other surgical techniques & products -
Cartilage and bone regeneration 30 35
Musculoskeletal injuries – general
Pain & inflammation

6. Technology
Cell type/ biomaterials
Intervention type + purpose
No. of Companies
No. of Products
Injury
Hyaluronic acid
Hyaluronic acid – avian (derived from rooster coxcombs) and non-avian sources
Injection (viscosupplementation), combined with other products (e.g. biological scaffolds), adjunct to surgical procedures
- To stimulate tissue repair; for pain relief and joint mobility 14 26 OA
Chondral and osteochondral lesions
Other cell therapy products
Tenocytes
Autologous blood
Autologous adipose Derived Regenerative Cells
Placental cells
Osteoblasts
Osteoprogenitor cells (donor)
Gene-therapy
Injection, surgical 9
Tendon injuries
Muscle injuries
Fractures
Actovegin
Bovine blood
Injection, gel or tablet – speeding up tissue regeneration 1
Prolotherapy
Dextrose injection – stimulate repair and tissue regeneration
Stretched or torn ligaments and tendons
Chronic musculoskeletal pain
Traumeel
Homeopathic injection, tablet, gel – to stimulate tissue regeneration and repair
Promote healing and reduce inflammation in the joints
Orthobiologics and other regenerative therapeutics on the market/in development (2015): summary table

7. Autologous Chondrocyte Implantation (ACI)
First generation ACI – a two-step procedure. Autologous chondrocytes are harvested, cultured & re-implanted, held in place using a periosteal patch (from shin bone).
Second generation ACI – a two-step procedure as above. Autologous chondrocytes held in place using a collagen membrane.
Third generation ACI or MACT/MACI– a two-step procedure. Autologous chondrocytes are harvested & cultured within a collagen matrix or scaffold, which is then implanted.
IMPACT – a one-step procedure. Autologous chondrocytes are mixed with donor MSCs, the cell mixture is applied to the damaged area during the same operation.
AMIC – a one-step procedure that involves microfracture used to obtain MSCs from bone marrow, held in place over the defect by a cell-free scaffold. Some scaffolds incorporate biological factors.
ACIC – microfracture with the use of an injectable atelocollagen matrix, performed arthroscopically.
MACH – a one step procedure that involves injection of autologous MSCs into the injury site, covered by a PRP enriched collagen membrane.
Left, large pan-patellar cartilage defect. Right, ACI cells being injected under a collagen membrane. Image: Mayoclinic.org

8. Biological Scaffolds
Surgical implants to promote healing of cartilage or osteochondral defects
Made from various biomaterials (e.g. Equine - tendon, pericardium; Collagen – Porcine, bovine; Cadaveric skin cells, amniotic tissue, placental tissue; Hyaluronic acid)
Used in the treatment of: Osteochondral defects, cartilage lesions, soft-tissue injuries & wound healing
12 Companies, 18 products

9. Platelet Rich Plasma (PRP)
Platelets & growth factors from autologous blood
Injected directly into injury site; sometimes combined with other products/ surgery
Range of uses e.g. tendinopathies; muscle/ligament/tendon injuries; OA; bone & cartilage repair, wound healing
18 companies, 23 products

10. Stem Cells
Incorporated into different medical devices e.g. seeded into biological membranes or mixed with cartilage cells in ACI.
Bone marrow aspirate concentrate (BMAC): aspiration from patient, centrifuged, concentrated & injected back into the patient
30 companies; 35 products
Image above: Example of bone marrow aspiration procedure

11. Complementary & Alternative Therapies
Actovegin- made from calf’s blood. Used to speed up recovery times in muscle injuries.
Prolotherapy- sugar & water solution.
Traumeel- homeopathic remedy.
- Used to stimulate the body’s own repair responses & speed up tissue regeneration.

12. Summary
77 companies active in the ‘orthobiologics’ field (orthopaedics market) (2015); 200+ products
27 targeting sports medicine market specifically
29 companies had a UK presence
Commercial interest & activity :
Bone grafts and bio-absorbable fixation systems – most established market sector (22 companies, 65+ products)
Stem cells – 30 companies, 35 products
PRP – 18 companies, 23 products
Hyaluronic acid – 14 companies, 26 products