Do stem cell injections really work? NYU's orthopedic experts explore the science of joint repair and healing injections & how to decide what's right for you.
Do stem cell injections really work? Our experts explore the science and history of joint injections, from the 1700s to today. We'll talk about the realities of injections, types of injections used, which joints respond well, and the latest research on stem cell treatments.
Narrator: SiriusXM presents an NYU Langone Orthopedics podcast. Orthopedics is just very important to the population in this country. Its ability to restore patient function. Problems related to cartilage, to someone who has more advanced forms of arthritis. Getting people back to their activities and the things that they like to do. Featuring NYU's experts in the field of Orthopedics. Trying to figure out that problem before it even is a problem. Problems with solutions. Well beyond physical therapy, to conservative pain management, to surgery. The best medical minds now come together. Applying all of our minds to solve these problems. We're here to get people feeling better so they can get back to their lives. And that's really what we try and accomplish. These are the Bone Whisperers.
Vinay Aggarwal, MD : Hi, welcome to Bone Whisperer, presented by NYU Langone Orthopedics and SiriusXM Radio. My name is Dr. Vinay Aggarwal, and I'm here joined by Dr. Laith Jazrawi, the chief of orthopedic sports medicine here at NYU Langone Orthopedics. Today we're going to be talking about a topic that is very applicable to a lot of our patients, young and old, as they go to visit their orthopedic doctors. Stem cells or scam cells? We're going to figure out which is the answer. Dr. Jazrawi, welcome.
Laith Jazrawi, MD: Good afternoon, Vinay.
Vinay Aggarwal, MD: Thanks for joining us here. Today we're going to be talking a little bit about what the stem cell situation is nowadays in musculoskeletal care. But I always like to start, in general talking about these topics that we have from the very beginning of the advent and their historical perspective of where we got to even talking about stem cells right now. Joint injections have been around for a very long time. I want you to just discuss a little bit about why, uh, people have joint pains. What are the different conditions that joint pains manifest as in your office and clinical practice?
Laith Jazrawi, MD: Great. So, historically, with injections, you can look back into the history books and see injections back to the 1600s and 1700s. Now, these were crude injections. These were typically hollow bone injections. Dirty. Not what we consider the modern age of injections with sterility the way we understand it now. So if someone had, uh, an infected joint back then, in the 1700s, they knew enough to put in these hollow tubes into, for example, the knee to drain it out if there was an infection. In the late 1800s, there was a big advance with the development of the hollow bore needle as well as the syringe. And that allowed us to start to do injections for joints. And I think that's very important because that was at the time we began to start dealing with a lot of these maladies, like you brought up osteoarthritis, et cetera. And one of the ways that they used to do it, if you can figure out a way to inject something into the joint, they started injecting everything into the joints to try to solve problems. They injected antiseptics into the joint to kill infections. They injected eventually, as we came into the modern age, even injected radioactive materials to destroy the synovium as they started to attack different type of rheumatological diseases. But really, it was the late 1800s that saw the advent of injections and the management of osteoarthritis as we know it today.
Vinay Aggarwal, MD: Well, it's really interesting to hear you talk about the evolution. I always love the historical evolution on this. Injections - even I didn't realize you can inject anything and everything back in the 1800s. When did you start to see, uh, more popularity of injections with sterile technique take off? And what did we feel like was most effective? After radioactive materials didn't work, after antiseptics may not have worked for pain relief, when did we start to evolve as for what worked right?
Laith Jazrawi, MD: So, in the 1940s was the development of something seemingly very simple, a glass tube, the glass syringe, and the glass syringe. The reason why that was very popular was because you could sterilize it, and all the components that are associated with it could be sterilized. And that's when we started to see the injections of materials like cortisone. And before even cortisone, it was the injection of saline fluid into the knee to get out all the bad humors or the bad fluid draining the knee, getting all that stuff out that was causing inflammation. And then by the time that was developed in the 1950s and 60s, you start to really see the rise in the use of cortisone and various types of cortisones being developed, short acting, long acting, that were injected in osteoarthritic knees.
Vinay Aggarwal, MD: Cortisone is definitely a topic we're going to get into here in a second because it's one of the most popular things that we put into the joints right now. But you did mention, uh, something that I think we should tell our listeners a little bit more about. I get a patient every single day asking, doc, can you take some fluid out of my knee? Well, it's important to understand what is in the joints at baseline? And, uh, I'd like to point out that I always tell my patients, look, fluid is always present in our joints. It's called synovial fluid. It's the healthy stuff that helps keep our joints with nutrition, blood supply, and at the end of the day, it's not a bad thing to have fluid in your joints. It's the excess fluid, the inflammatory fluids that we're talking about kind of getting rid of or decreasing. So it's very interesting that draining fluid is not necessarily always the answer. It certainly is sometimes, but obviously, people have been injecting joints for a while. And listening to you talk about it, we've come a long way with the sterility, which is probably one of the most important aspects of this. Staying with the basics, what about the body parts? I talked a little bit about the knee, but what do you most commonly inject, and why are more, some joints more popular than others to inject?
Laith Jazrawi, MD: I, uh, think the most popular joints are going to be the big joints, right? They're going to be the knee, the shoulder, the elbow, the ankle, and the hip. With the advent of imaging technology and the development of fluoroscopy, which is a way to basically see the bones, that's when they started to go into the smaller joints, the finger joints, the toe joints, joints that were typically hard to get into. And also the development and the technology of smaller needles, too, to be able to penetrate that. But I would say the most common joint that we inject today is probably the knee.
Vinay Aggarwal, MD: Yeah, I agree with you, and I obviously see a bunch of knee patients being a knee doc myself. Have you noticed in your own practice that some joints are just more effective by getting injected than others? In other words, do some joints just respond better to these injections?
Laith Jazrawi, MD: Uh, absolutely. I think when you look at effectiveness, I think certainly ankle, knee, shoulder. Fairly big joints that have relatively a lot of space in them where you can get a needle into and get a lot of material into that elbow in terms of cortisone and numbing medication. The joints that I've been less pleased with or that I don't see as great of an effect is the hip joint. Whether there's a smaller space availability in there or when you have end stage hip arthritis, it's just time for the hip replacement. The injections just don't seem to work as effectively as in the other joints.
Vinay Aggarwal, MD: Yeah, and the reliability you mentioned getting into the joint, I think that's key. Everything in medicine has to be reproducible, especially surgery and procedures. And when you have a lot of people doing things different ways and not being able to reproduce getting into a joint easily, that's when I think the outcomes suffer a little bit. So we've caught up our, uh, listeners a little bit upon the speed of what is an injection? Where do we inject? Let's talk a little bit about the different types of injections in the 2000s here. You mentioned steroids. All right, that's the cortisone that everybody talks about. There's another injection type that I think we should touch on called hyaluronic viscosupplementation. Hyaluronic acid viscosupplementation, or gel injections, as we colloquially talk about. Can you talk about the differences between these two? What's the main thing that a listener should understand? The mechanism of action and maybe even the evidence behind how well they work?
Laith Jazrawi, MD: Great question. I want to start with, even before cortisone and people are doing it very commonly, is the use of saline and irrigating the joint. Most of the research studies that are out there that we look at new medications that we're injecting into the knee, the standard of care is considered still saline, which is amazing. But nonetheless, saline is one of the medications that is used to inject into the joint to basically drain it out and clean it out. Then you have cortisone. We spoke about that a little bit. Now, viscosupplementation, that's a group of medications. They typically go by the name hyaluronic acid. You brought that up as well. And they come in a lot of various forms and preparation. The first and most popular one that people know about is this thing called Synvisc. And Synvisc was not even a real hyaluronic acid. A lot of the more current ones, they look like hyaluronic acid - what you have in your normal body. Synvisc, is the merging of two big molecules. Um, and the idea was that they wanted to make this material so viscous, so they took two forms of hyaluronic acid and then merged them together. And these came from the rooster comb, so a lot of people could go, I want the chicken injection, the chicken fat.
Vinay Aggarwal, MD: We've all heard, give me the rooster comb, doc.
Laith Jazrawi, MD: Right? And that was just two big molecules fused together, very viscous, very thick, that you would inject into the joint. And what was one of the problems with that? Reactions. Right. You're injecting a foreign material, the rooster's comb. As much as we cleaned it, we couldn't guarantee that there wouldn't be a reaction to the material. Synvisc is still used, and it's still fairly popular because of its viscosity being the highest one out there. The more modern ones are basically bioengineered, where they're grown in a lab by a specific bacteria that produces the material. And it looks like hyaluronic acid, it mimics it. They have these big vats, these companies, that grow it, and then they sterilize it, and then it's ready for injection. Then certainly that's one way of doing it. And then there's a third type, which is, again, getting back to more of an artificial preparation, which it doesn't really look like hyaluronic acid, but has a lot of the properties of a very viscous and, uh, lubricating material. And those come in the form of, name, Durolane, or there are many names to them, but the idea is that they don't work the way cortisone works. Cortisone drops inflammation by a specific pathway. The hyaluronic acid injections, they don't work by just coating the joint and acting as a cushion. Because we know, even with Sinvisk, that that stuff's absorbed out of the body and out of the knee pretty quickly. But it does work, interestingly enough, by blocking certain pain pathways different than cortisone. So it was really an evolution when it came out, and it certainly plays a role in the management of knee osteoarthritis, and certainly in my practice.
Vinay Aggarwal, MD: Yeah. So I completely agree with you. I think that people really come to me looking at commercials on tv, thinking they're getting this cushion pushed in their knee that's going to last them and replace their cartilage for decades to come when they're talking about the gel or the rooster comb. Now, in reality, there are hundreds of different companies now out there that provide this hyaluronic acid. Think of it like your pasta sauce in the grocery aisle. There's about 100 of them on the shelf now. And sadly, it is dependent a little bit about, uh, which insurance you have to accept, which kind of pasta sauce. But in general, in my experience, in reviewing the literature, all of these gel injections, or whatever you want to call them, rooster comb, hyaluronic acid - they work kind of variably in different patients. And what I tell my patients is it does have an effect within a little bit of an anti-inflammatory, but much more, as you talked about, a pain receptor pathway. We're still figuring out which pain receptors are responsible. But no pun intended here I always use this line in the, uh, office – if everything else fails - it's worth a shot. Okay. Because it's really now, the reactions are not that severe to them, not that many people have allergies to them anymore. They're very well tolerated. And if they're covered by insurance, or if you want to pay out of pocket, that's not a big deal, because at the end of the day, some of these patients have extraordinary responses to them. I've delayed knee replacements for well over a couple of years in several of my patients with these shots. I wanted to ask a little bit about your preference between the two. Do you have a go to that you start with, or how do you decide which one a patient is going to get?
Laith Jazrawi, MD: So I think that's a great question. I look at the patient specifically on the physical exam. If their knee is super swollen, lots of fluid, the cortisone plays a very specific role. It's very good at reducing that fluid in the knee, reducing that inflammation. It's the best thing we got out there. Hyaluronic acid works as well, but does not work when the knee is super inflamed. So if the patient comes in super inflamed, I'll start with the cortisone and then potentially bring them back for the hyaluronic acid injections. And then as I'm going through the injections, I really see which one works the best for them. Cortisone is covered by insurance. So to go right to hyaluronic acid, it's usually not my first step. If they're younger, and when I say younger, younger than 45, 40, and they have arthritis, maybe I'll start, if their knee is not that inflamed, with the hyaluronic acid injections.
Vinay Aggarwal, MD: Yeah, I would agree with that. The level of inflammation in your body tells us a lot as doctors, what we're going to give you. And, yeah, cortisone is definitely a great first step option. In general I tell my patients, when they ask me, doc, which one's better? I thought this one was better. I thought that one was better, I heard this, I heard that. I tell them, look, we're going to start you and try you on this medication, the cortisone, for example, if it doesn't work, it's not a big deal. We can always try the other one. Half of my patients, I tell them, half of them will respond to the cortisones and not the gels. The other half maybe respond to the gels and not the cortisone. There's a small subset that respond to both and a small subset that respond to neither. So it's just a little bit of patient responsiveness, and it's worth trying either or, and depending on which one you really have a good result with, you trust your doctor, and you kind of work your way up the food chain. So let's talk a little bit about the catching up to speed on the topic on hand. We're talking about stem cells, and I think that's what we need to understand here. What is exactly meant when we talk about stem cells in orthopedics? It's definitely kind of a vague term. We've all heard about stem cells since the 90s. People, your average person out there thinks of something grown in the lab with genes, et cetera. What do you think about when you think about stem cells in the orthopedic setting?
Laith Jazrawi, MD: So, with the use of the word stem cell, that's a layman's term. It's a very popularized term out there because it kind of encompasses everything that's sort of a biologic. So when we use the term biologics, we talk about these things, and we'll get a little more into PRP, platelet-rich plasma. And what exactly are stem cells? The idea of a stem cell, it's that it's a precursor cell. And when we talk about precursor cells in the body, we came from something, we came from a specific cell line, and we talk about these thing called mesenchymal cells. And these things called mesenchymal cells are really the basis of every other type of cell in our body, whether it's skin, bone, muscle, they all come from a common lineage that then branches out into more specialized form of cells. So that the skin cell has a much different function than the heart muscle cell. The same way where the Big Bang theory, where we all came from one thing, and it all shot out into different stars and planets, et cetera. But the idea is that if you can take a whole bunch of those precursor cells, those mesenchymal cells, that you can then harness their power, because they can do anything, right? They can go down any lineage. Or one of the theories are that they can potentially figure out what the problem is. People who hear stem cells, they hear, oh, the cells are going to repopulate my knee and recreate cartilage. And I think as we're going to get into this, we're going to unfortunately see that's not the truth, and maybe that's not the truth, Vinay, at this time, and maybe we just need to figure it out, right?
Vinay Aggarwal, MD: I think that's a great, super, super nice introduction as to what stem cells are. I totally understand it based on your explanation, that was fantastic. Just for our listeners, you're listening to Bone Whisper, presented by NYU Langone Orthopedics and SiriusXM radio. Here I'm joined by Dr. Laith Jazrawi, or chief of orthopedic sports medicine. My name is Dr. Vinay Aggarwal here. We're talking about stem cells versus scam cells. What's the difference? What are we actually, uh, efficacy wise talking about? I want to know the difference about something you just mentioned. PRP. That's a huge one, right? You hear about athletes, world class athletes out there getting all these types of PRP injections. Can you tell our listeners, first of all, what does PRP stand for? And as a biologic treatment, what exactly does it mean?
Laith Jazrawi, MD: Right. So, platelet-rich plasma, that's basically what it is. It's a, uh, cocktail of blood product that has three times the amount of platelets that normal blood product has. So it's determined everything by the amount of platelets that are there. But what's great about platelet-rich plasma and platelets is that the platelets in our body have a lot of these growth factors. And we learned that. So a platelet rich plasma injection typically has all the growth factors that we know in the body that the cells produce. The platelets are sort of the cells don't directly produce these materials. They have other things that produce it, and the platelets are one of them. So if you get a concoction of platelet-rich plasma, those platelets and all the growth factors are in there. And that's the good, the bad, and the ugly. It's everything in there. So you got stuff that causes inflammation, decreases inflammation, helps with healing, may even retard healing. It's basically throwing the whole thing, kitchen sink at a specific injury to try to get it to heal.
Vinay Aggarwal, MD: Are you using, uh, any of these biologics, PRP, stem cells, in your practice right now and tell our listeners what body parts, what injuries that they have kind of influenced you most successfully in?
Laith Jazrawi, MD: Right. So, when a patient comes in, we'll go through different conditions. Osteoarthritis, for example, of their knee. We start with cortisone. We build up to the lubricants. Then depending on how they respond to those injections, we then start to look at the biologics to see a different pathway to try to improve. So I'll go to PRP. These things typically have a cost associated with them. They range anywhere from $300 to as high as $3,000 and even more. And so, for me, it's challenging to force a patient to pay for something we're not even sure that's going to work. So we work up the ladder through these medications. After PRP, if that's no longer working, then we start to consider the use of stem cells, or getting more into stem cells, what they are. There's, uh, certain places that we harvest the stem cells or these mesenchymal cells. One is the bone marrow. If you look at the bone marrow, bone marrow has a certain percentage of these mesenchymal cells or these stem cells. The unfortunate thing, there's very little of it there. So when we aspirate it, all our ways of getting it out of the bone marrow, it's never as much as we'd like it to be. And I think the important thing to understand - How do they work? And I think that's something we have to be very clear on when we tell our patients. PRP works by, and you brought it up before, it's an anti inflammatory medication. It doesn't work by reproducing cartilage. There's a lot of gimmicks out there, and people who claim that they could reproduce the cartilage, they can convert a joint that's arthritic back to normal. We know that doesn't work with PRP. We know that doesn't work with stem cells. What it does is it modulates the inflammatory pathway so that you feel better. And similar to cortisone that works in one way, the PRP and the growth factor shut the inflammation down in the knee. That's one way to utilize it. And then the mesenchymal cells, or the stem cells, they sense the environment. They begin to release factors that then control the inflammation. And that's how it works for osteoarthritis. But the PRP and the stem cells also have a potential healing effect, too. Right? So tendons, right. PRP was first become popularized with the, uh, injection of ligaments and tendons to aid in speeding up healing. And there are some good studies out there which show, yeah, that's what it can do. It could take tissue that can't heal for whatever reason, and by injecting PRP, these growth factors, you can convert it along the healing pathway. So it has that ability to do that. Is it a guarantee? No, but it's something better than what we currently have, because the only other thing we have is cortisone, and that doesn't heal necessarily, just masks the pain.
Vinay Aggarwal, MD: Right. And a lot of our patients are looking for that holy grail. Like you mentioned, they're trying to get back to their youthful exuberance, if you will. Trying to get to their younger years, in the case of arthritic patients. But in the case of injured patients, also, they're trying to get back to their pre injury state. What are those tendons that you think, uh, work the best for you when you're injecting biologic, like a PRP?
Laith Jazrawi, MD: I think tennis elbow. So that's what we call lateral epicondylitis, or on the side of your elbow. That's been confirmed in studies to have a better effect than cortisone. So for me, that's my go-to. Sometimes, just because of the cost, I'll still give patient a cortisone injection. One doesn't hurt. But for me, PRP is a go-to in the elbow. I've had less success around the knee joint for, like, jumper's knee. I've not been happy there. And it seems to work pretty well for any type of insertional hip tendinopathy. I tend to do it for that as well. It works nicely. So those are the conditions pretty much I use.
Vinay Aggarwal, MD: Got it. So just to recap, lateral epicondylitis, the outside of the elbow, that's tennis elbow, works pretty well. Patella tendinitis plus, minus the front of the knee, maybe not so much. And then around the hip joint on the lateral or the outside area of the pants pocket, abductor tendonitis works pretty.
Laith Jazrawi, MD: I would add hamstring, too, and hamstring, yeah, that was one of the ones. It was originally described for.
Vinay Aggarwal, MD: Good good. I want to go back to something you mentioned - the marketing, right? The marketing on what? This is direct to consumer, whether it's an advertiser, whether it's the companies. A lot of doctors at this point are seeing patients that come in with marketing. And this may be why we were talking about this in the first place with the title of this, uh, conversation “Stem cells or scam cells”. Some docs think that these are a total scam. And so we need to understand why that's the case. In your opinion, you touched on it a little bit, it's because they're falsely advertising that they restore structure, restore cartilages. Can you expound on that? Is there any reason that this has gotten such a bad name?
Laith Jazrawi, MD: Yeah, I think the idea of claiming that the stem cells are the bone marrow aspirate. There are other places you can get stem cells. There are also from your fat that there's certain liposuction procedures where you could harvest fat and use those precursor stem cells to inject. But the concept is very clear that when someone's trying to market this or the companies are pushing it, they're falsely advertising, in certain cases, that they can restore the joint. Why have a knee replacement? Why have a joint replacement? And I think the orthopedic community, with the terminology that we use with replacing the knee, patients, the first thing they think about is that you're cutting my knee out and putting metal in plastic. Who wants that? And I think that that's the challenge that we deal with when there's a big thing that needs to be done to get you better, that if you have something else that's easier, you can do it in a day, it's ripe for fraud. And I think that's where the problem is. Whereas if you said, hey, this is a way that we can help with your knee joint or hip, and it can give you a little extra time and decrease the inflammation, but eventually, you'll probably need a joint replacement if your knee is pretty bad. Most patients won't go for that. They're not going to pay the extraordinary amounts of money that some of these places are requesting when they're given these materials.
Vinay Aggarwal, MD: Right. I had a mentor once tell me, when you're offering treatments, there's nothing that patients hate more than over promising and under delivering. And I think that's where these stem cells kind of can get into trouble. You have to be very clear with the patient what they're getting injected, and, um, what the expectations are, what the current science and literature outcomes are. It's much better, in my experience, as a metal and plastic guy, under promising, over delivering, great feeling for both the patient and the doctor. So we like to set expectations. I think that's how patients do extremely well. And sometimes, because this gets out of hand, the docs over promise. That's why these stem cells may have gotten that “scam cell” terminology, but I think there's a lot of opportunities still right for the use of them in the right patient population. I think that the science is obviously evolving as we speak. It has been for the last several years and certainly the last decade. Are there any non-injectable forms that you're seeing stem cells used in orthopedics? Whether it's in your practice or not? Some other applications - Talk about bone marrow aspirates is it anytime used in your surgeries?
Laith Jazrawi, MD: So, we do it to aid in healing. So, there's some data that suggests that PRP may work for aiding and meniscus repairs. Some have added it to ACLs and even rotator cuff repairs. But I would say there's no definitive data that any of these materials improves the healing rate compared to nothing. So, again, to charge a patient for something that's not yet shown in the literature or through studies to be definitively better, I find difficult for me, and I find it unethical in certain cases to have, uh, patients pay for these things.
Vinay Aggarwal, MD: Yeah. And again, you have to go back to what you said. If the patient wants the kitchen sink thrown at them and they're willing to undergo that expense or discomfort or additional procedure, et cetera, I think that's one thing. But certainly we are trying to get more promising outcomes for the long term, and I think eventually these stem cells do show some promise. And with that, I want to make sure that our listeners are reminded that there's always a positive note to end things on. So, as far as the future of stem cells, is there anything that decades away from now that you see where it's really showing great promise, or where you really just don't think it's ever going to get to where we want it to be with stem cells, where you think it wouldn't be recommended for routine patient care?
Laith Jazrawi, MD: I think we're at the tip of the iceberg, Vinay. This is something that we know that these cells are there. We know that we come from these cells. These are our basic starting point. So they have all the knowledge, they have the ability to do anything. They just have to be targeted in the right way. And I think that's one of the things - figuring out the targeting pathways and what drives them down a specific lineage and what drives them to produce cartilage, in maybe in an unhealthy joint like we described. Maybe we figure out that there's a certain pathway and a certain material that needs to be given at the same time that will then force these cells to produce the cartilage that will then cover the ends of the joint. We're certainly not there yet. Then the other thing is replication of the cells, right. There are not that many of them, certainly with the bone marrow cells. So all of the data is suggesting that maybe we need more of them and maybe having more of them - so in a lab, taking your cells, replicating them, and then injecting. There are certain companies that are doing these overseas already. Again, we don't know if it works. Is more better? Not all the time. But I think as we begin to understand the way these cells work and what factors they're releasing, I think it's going to be important that there are certain factors that drive them down a certain pathway to do the job that they're intended to do in terms of the joint, to hopefully not only decrease inflammation, but maybe eventually to reproduce cartilage. And I think, look, everyone talks about stem cells, youth and all that other stuff. There's a whole other pathway of research now that's looking at ways to figure out the time clock in your bodies. Your cells start to undergo senescence. Why is that? Is there a way, if we understand that process, to slow aging down, not your physical appearance, but the way your joints degrade over time and the mechanics and the weight along your joints and how they break down your joints, maybe there's a way we can slow that process down. And by slowing it down, then maybe we don't need stem cells. Maybe we could slow the aging process down, and then our joint problems are not so bad in our hundreds, so we don't end up getting the arthritis that we were destined to get.
Vinay Aggarwal, MD: Well, that sounds like a, uh, nice goal for me. I love to go back and we started this conversation in the 1600s and we're ending it here in the 2020s. We went from radioactive injections and antiseptics into our joints, but we're certainly at a point with stem cells and with other injectables and treatment on the research horizon that shows a lot of promise. I think the point of this conversation is in science and medicine, we're always going to be trying to keep pushing the envelope and trying to keep learning on how to keep our patients’ joints healthy and functioning. And once again, thanks again for joining us here on Bone Whisperers, presented by NYU Langone Orthopedics and SiriusXM Radio. You've been listening to Dr. Vinay Aggarwal, interviewing Dr. Laith Jazrawi, the chief of sports medicine at NYU Langone Orthopedics. Thanks, Leith, for joining us. It's been a pleasure talking.
Laith Jazrawi, MD: Thank you. I had a great time.
Narrator: The Bone Whisperers is a co production of NYU Langone Health and SiriusXM. The podcast is produced by Scott Uhing, sound design by Sam Doyle. SiriusXM's executive producer is Beth Ameen and senior operations manager is Emily Anton. Narration and additional sound design by Michael Luce. Don't miss a single episode of the Bone Whisperers and subscribe for free wherever you listen to podcasts. To hear more from the world renowned doctors at NYU Langone Health, tune into Doctor Radio on SiriusXM Channel 110 or listen anytime on the SiriusXM app. For the Bone Whisperers podcast, I'm Michael Luce. Join us next time for the latest advances in orthopedics on the Bone Whisperers.