ORTHOBIOLOGICS DIGEST™ No. 9 Evidence, Precision, and the Questions Medicine Still Needs to Ask November 2, 2026
Deborah Westergaard, M.D.
Board Certified Anesthesiology and Pain Medicine
Physician Perspective on Orthobiologics and Precision Musculoskeletal Care
“What medicine taught us yesterday should be the foundation for what we discover tomorrow, not a boundary around what we are allowed to question.”
In This Issue of ORTHOBIOLOGICS DIGEST™
Orthobiologics is moving quickly, but speed is not the same thing as certainty. In this issue, I am looking at six stories that raise a common question: how do we remain genuinely evidence driven without allowing yesterday's assumptions to become tomorrow's dogma? We examine patient misinformation and medical certainty, a newly described biologic niche inside the hip, what PRP can and cannot be said to do structurally, needle arthroscopy as a possible precision diagnostic tool, the regulatory boundary around regenerative medicine, and Utah's supervised experiment with AI assisted prescription renewals.
My goal is not to promote every new technology. It is to separate what is interesting from what is established, what is plausible from what is proven, and what may belong in future practice from what should remain a research question today.
1. When Medical Dogma Becomes Misinformation
Patients are told to question what they see online. Medicine must be willing to question itself too.
Source: Why Your Patient Trusts Unsupported Claims but Not You — Cassie Shortsleeve, Medscape, October 19, 2026
What the article says
The Medscape article explores why unsupported claims can become more persuasive than medical advice. Trust, fear, identity, uncertainty, and a desire for control can shape decisions as powerfully as factual information. The practical lesson for physicians is that simply supplying more data may not restore trust when a patient feels unheard or when the evidence is presented with more certainty than it deserves.
For me, the larger issue is that misinformation is not defined by who says it. Information can become misleading when it is inaccurate, incomplete, stripped of context, or stated with greater certainty than the evidence supports. That can happen on social media. It can also happen in clinical practice, institutions, guidelines, government communication, or AI generated answers.
Supporting evidence: Effect of Intra articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain — JAMA, 2017
DR. WESTERGAARD'S TAKE I am strongly pro science. But being pro science means being willing to revise what we think when better evidence appears. A useful example is repeated intra articular corticosteroid treatment for knee osteoarthritis. A randomized JAMA trial found that 40 mg of triamcinolone every three months for two years produced greater cartilage loss than saline without a significant pain advantage. That does not mean every steroid injection is inappropriate. It means a familiar treatment should not become immune to re examination simply because it has been used for decades. The same standard should apply to orthobiologics. The evidence is mixed and evolving, not absent. We should neither promise outcomes that have not been demonstrated nor dismiss a field simply because it challenges older treatment patterns. The same principle applies to information patients bring from AI or the internet. A patient once questioned why I use an abduction brace after an orthobiologic procedure for a complete rotator cuff tear because the material she had read suggested a brace was unnecessary. The missing piece was context: my protocol is designed to reduce tension and maintain tendon approximation during early recovery in a specific clinical situation. AI can provide information. A physician provides context. Medicine also learned during COVID that rapidly changing evidence can be communicated with excessive certainty. That observation is not partisan. The lesson is that uncertainty should be communicated honestly, especially when evidence is evolving. What medicine taught us yesterday should be the foundation for what we discover tomorrow, not a boundary around what we are allowed to question. As Konstantin Tsiolkovsky wrote, "Earth is the cradle of humanity, but one cannot live in a cradle forever. " Scientific progress requires us to leave the cradle when the evidence tells us it is time. Patient translation: Good medicine does not ask you to choose between science and questions. Good medicine uses evidence, context, and humility to answer the questions as accurately as possible. |
2. Hip Stem Cell Research: Could the Cotyloid Fossa Fat Pad Become a Hip Specific Orthobiologic Source?
What the research actually studied
A narrative review in Frontiers in Bioengineering and Biotechnology published October 28, 2026 compared the well characterized infrapatellar fat pad of the knee with the much less studied cotyloid fossa fat pad, or CFFP, of the hip as potential sources of mesenchymal stem or stromal cells and extracellular vesicles for osteoarthritis.
What the research found
The CFFP is an intra articular adipose synovial structure located near the acetabular cartilage, labrum, and ligamentum teres. Limited existing research suggests that the region contains cells with mesenchymal stromal characteristics and osteogenic and chondrogenic potential, while also undergoing inflammatory and remodeling changes in hip osteoarthritis.
But there is an important limitation.
The review found that CFFP derived stromal cells have not yet undergone the same detailed characterization that has been performed on cells from the knee infrapatellar fat pad. Important questions remain about cell phenotype, colony forming capacity, secreted signaling molecules, extracellular vesicles, and responses to different biologic environments.
For that reason, the authors conclude that CFFP derived stromal cells and extracellular vesicles cannot yet be considered validated hip specific orthobiologic treatments.
Source: The cotyloid fossa fat pad as a hip specific orthobiologic niche: lessons from the infrapatellar fat pad for mesenchymal stem/stromal cell and extracellular vesicle therapy in osteoarthritis — Rossow RP, Polavarapu K, Naik M, et al., Frontiers in Bioengineering and Biotechnology, 2026
DR. WESTERGAARD'S TAKE What interests me most about this research is the location. This is not generic adipose tissue obtained from another part of the body. The cotyloid fossa fat pad exists inside the hip joint environment itself, adjacent to cartilage, the labrum, synovium, and the ligamentum teres. That raises fascinating biologic questions. Could a local hip specific cell population eventually prove relevant to cartilage preservation, labral biology, ligamentum teres injury, or other structures within the hip? We do not know yet. In current orthobiologic practice, I follow the growing literature involving autologous bone marrow aspirate and concentrate, including approaches that target subchondral bone in selected patients with osteoarthritis. What we do not yet have is a comparable clinical evidence base for using cotyloid fossa fat pad derived stromal cells or extracellular vesicles to treat hip cartilage loss or other hip pathology. So I see this as a biologic clue and a research agenda, not a treatment target. That distinction is important. Interesting science should make us ask better questions before it makes us offer a new procedure. Patient translation: This is promising research, not a treatment available today. The review identifies a potentially interesting hip specific biologic niche, but much more laboratory and clinical research is needed before it could become an orthobiologic therapy. |
3. Does PRP Have to Regrow Cartilage to Be Worth Doing?
A new meta analysis separates symptom improvement from structural change.
Source: Platelet rich plasma for knee osteoarthritis: a systematic review and meta analysis of structural outcomes — Archives of Orthopaedic and Trauma Surgery, October 22, 2026
What the meta analysis found
The review included 12 randomized controlled trials involving 1,200 patients with knee osteoarthritis and focused specifically on imaging based structural outcomes after PRP. PRP showed a favorable signal in patellofemoral cartilage thickness or volume and a statistically significant reduction in bone marrow edema. It did not consistently improve medial tibial cartilage measures, cartilage defect progression, osteophytes, subchondral cysts, or synovitis.
The certainty of the structural evidence was low to very low. The authors therefore concluded that current evidence does not establish PRP as a structural disease modifying treatment for knee osteoarthritis. That conclusion is different from saying PRP has no clinical value. Structural change and improvement in pain or function are different outcomes.
DR. WESTERGAARD'S TAKE One of the mistakes we make when discussing orthobiologics is assuming that success has to mean visible cartilage regrowth on an MRI. I do not think that is the right standard. Osteoarthritis is not simply a problem of missing cartilage. It is a disease of the entire joint environment: cartilage, subchondral bone, synovium, inflammatory signaling, mechanical loading, and the tissues that stabilize and protect the joint. If a treatment reduces pain, improves function, decreases bone marrow edema, or improves the biologic environment of the joint, that can still be clinically meaningful even if we cannot prove that new cartilage has grown. I would not tell a patient that PRP reliably regrows cartilage, because the current evidence does not support that claim. But the opposite conclusion is also too simplistic. If imaging does not show dramatic structural regeneration, that does not automatically mean the treatment failed or that nothing biologically important occurred. The better question may be: am I functioning better, is the joint less symptomatic, and are we supporting the joint environment for as long as possible? Patient translation: PRP should not be sold as guaranteed cartilage regrowth. Its value may lie in improving pain, function, and the joint environment even when an MRI does not show new cartilage. |
4. Can You Really Put a Camera Through a Needle?
Source: Needle Arthroscopy in Orthopedic Practice: Clinical Applications, Evidence Architecture, and Translational Gaps — Journal of Clinical Medicine, September 30, 2026
What needle arthroscopy is
Needle arthroscopy uses a very small arthroscope introduced through a needle sized portal to provide direct visualization inside a joint. In selected settings it can be performed under local anesthesia and can supplement imaging without a conventional operating room arthroscopy. The 2026 scoping review found a rapidly expanding literature, but much of it remains technical, cadaveric, or lower level clinical evidence. The authors describe needle arthroscopy as a complement to, not a replacement for, MRI or conventional arthroscopy.
The technology is commercially established in the United States and is also being studied internationally. Insurance coverage is not blanket coverage for a device. Payment generally depends on whether the underlying arthroscopic service is medically necessary and covered under the patient's plan. Using a needle arthroscope simply to guide an orthobiologic injection would not automatically make either component covered.
DR. WESTERGAARD'S TAKE What makes needle arthroscopy particularly interesting to me is that it sits at the intersection of two things I have spent much of my career doing: minimally invasive procedural medicine and precise diagnosis. During my interventional pain fellowship training at Texas Tech in the early 2000s, we were trained in advanced procedures including vertebroplasty, intradiscal procedures, spinal cord stimulator implantation, intrathecal pump implantation, and epiduroscopy using an endoscope within the epidural space. That background shapes how I view a technology like needle arthroscopy. I do not think the important question is which specialty traditionally owns a procedure. The important questions are whether the physician has the appropriate training, technical competency, procedural environment, credentialing, and judgment to perform it safely. We already obtain extraordinary diagnostic information from MRI and from real time musculoskeletal ultrasound in the office. Direct visualization adds another dimension. Imagine correlating the MRI, the dynamic ultrasound examination, the clinical findings, and then the actual appearance of cartilage, labrum, meniscus, synovium, or ligamentous tissue inside the joint. From an orthobiologic perspective, that could potentially improve treatment planning. At the same time, minimally invasive does not mean no risk. A needle arthroscope requires a larger portal than the 25 or 27 gauge needles I may use for some orthobiologic injections. Additional tissue trauma, infection risk, bleeding, joint irritation, cost, and the possibility that the information will not change management all have to be considered. I would not add arthroscopy simply because we can. The risk benefit equation has to make sense. But if needle arthroscopy continues to become smaller, safer, and supported by stronger clinical evidence, I am very interested in where it could fit. It may give us one more minimally invasive tool to answer the central question in precision medicine: what exactly are we treating? Patient translation: A tiny camera inside the joint may someday give physicians another way to see exactly what is injured before deciding how to treat it, but the added information has to justify the added procedure and risk. |
5. When “Regenerative Medicine” Crosses the Line
Primary source: Patient and Consumer Warning about Potential Serious Risks of Harm Following Use of Unapproved Products from Human Cells or Tissues — U.S. Food and Drug Administration, October 2026
Why the distinction matters
The FDA continues to warn consumers about unapproved products made from human cells or tissues when those products require approval but are marketed without it. The agency has reported serious adverse events, including deaths, associated with some unapproved products. Regulatory status depends on the exact product, source, processing, intended use, and claims being made.
That matters because terms such as stem cells, exosomes, regenerative injections, and orthobiologics are often used as though they are interchangeable. They are not. Autologous PRP and bone marrow procedures should not automatically be grouped with commercially distributed birth tissue products, exosomes, or other cell derived products with different processing and regulatory pathways.
DR. WESTERGAARD'S TAKE I believe one of the biggest problems in regenerative medicine is that the terminology has become much broader than the science. As physicians, we should be able to tell a patient exactly what we are using, where it came from, how it was processed, what evidence supports it for that indication, and what we realistically expect it to do. There is a meaningful difference between a carefully selected, image guided procedure using a patient's own platelet rich plasma or bone marrow aspirate concentrate and a commercially distributed birth tissue, exosome, or other cell derived product whose composition, regulatory status, and evidence may be very different. I am also very cautious about language. Physicians should not promise that these procedures will regrow cartilage, reverse arthritis, or cure degenerative disease unless the evidence actually supports the statement. Orthobiologics are scientifically complex enough. We do not need exaggerated claims to make them sound more impressive. The credibility of this field depends on physicians being more precise than the marketing around it. The future of orthobiologics will not be protected by broad claims about regeneration. It will be protected by evidence, transparency, technical precision, appropriate patient selection, and honest communication. Patient translation: Before agreeing to any regenerative procedure, ask exactly what is being injected, where it came from, what evidence supports it, and what the physician can realistically promise. |
6. Utah’s Experiment With AI Driven Prescription Renewals
Source: Utah’s Experiment With AI Driven Prescription Renewals — Michelle M. Mello, JAMA Health Forum, March 19, 2026
Current pilot status: Utah Office of Artificial Intelligence Policy: Authorized AI Pilots — Utah Department of Commerce
What the pilot is actually doing
Utah created a regulatory pilot allowing AI to participate in renewals of certain established chronic medications. The system cannot initiate a new prescription, change the dose or frequency, or handle controlled or addictive substances. Importantly, the pilot remains in Phase 1 as of late October 2026. A licensed medical practitioner authorizes every request before it reaches the pharmacy. Phase 2 would permit more autonomy only after Utah approves the transition for eligible medication groups.
That makes the program a test of supervised clinical AI, not fully independent prescribing. The larger policy question is whether narrowly defined, protocol driven medical decisions can eventually be delegated with less intensive physician review after sufficient evidence of safety and reliability.
DR. WESTERGAARD'S TAKE I am very enthusiastic about the potential for artificial intelligence in medicine, but it is important to be precise about what this Utah pilot represents. This is not autonomous prescribing today. The AI is being tested within a supervised system in which a licensed medical practitioner still authorizes every request in Phase 1. That distinction matters. I see tremendous value in using AI to organize clinical information, identify patterns, flag inconsistencies, and reduce some of the repetitive cognitive workload physicians face every day. But decision support is not the same thing as transferring responsibility. The physician still has to understand the patient, the diagnosis, the medications, the changing clinical context, and the consequences of getting the decision wrong. What makes this pilot interesting is that it gives us a controlled way to test where that boundary might eventually move. If AI proves consistently safe and accurate in very narrow, lower risk decisions, physician oversight may evolve in those specific settings. But that should be earned through evidence, not assumed. For me, the future is not AI replacing physicians. It is physicians using AI to make better, faster, more informed decisions while still owning the judgment and the responsibility. Patient translation: In Utah's current Phase 1 pilot, AI can help evaluate some routine prescription renewals, but a licensed medical practitioner still authorizes every request before it reaches the pharmacy. |
The Through Line: Precision Without Hype
These six stories appear to cover very different subjects, but they share the same underlying theme. Precision medicine requires more than new technology. It requires precision in language, diagnosis, evidence, patient selection, technique, and claims.
The most useful question is often not, ‘Is this new?’ It is, "What exactly does the evidence show, what does it not show, and will this information change what I do for the patient in front of me?"
Questions Patients and Physicians Are Asking
Does PRP regrow cartilage in knee osteoarthritis?
Current randomized imaging evidence does not establish PRP as a reliable cartilage regrowth or structural disease modifying treatment. PRP may still improve pain and function in some patients, which is a different outcome from demonstrating new cartilage on MRI.
What is the cotyloid fossa fat pad in the hip?
It is an intra articular fat pad in the acetabular fossa near the ligamentum teres. Early laboratory research suggests it contains biologically active stromal cells, but it is not currently a validated injection target or clinical stem cell treatment.
Are fat derived stem cells better than bone marrow derived cells for joints?
There is no universal winner. Tissue source influences cell behavior, and clinical evidence varies by indication, processing method, and treatment strategy. The cotyloid fossa research is especially interesting because it studies tissue that naturally resides inside the hip.
What is needle arthroscopy?
Needle arthroscopy uses a miniature camera through a small portal to look directly inside a joint. It may complement MRI and ultrasound in selected cases, but it has not replaced conventional arthroscopy or routine imaging.
Is needle arthroscopy covered by insurance?
Coverage depends on the medically necessary arthroscopic service, diagnosis, payer rules, place of service, and documentation. Insurance generally covers a procedure rather than a particular camera system, and coverage is not guaranteed.
Can needle arthroscopy be used with PRP or BMAC?
The concept is technically interesting because direct visualization might improve lesion assessment, but routine needle arthroscopy solely to guide orthobiologic injections is not established by current evidence and does not automatically make an orthobiologic procedure covered by insurance.
Are all regenerative medicine injections the same?
No. PRP, autologous bone marrow procedures, birth tissue products, exosomes, and other cell or tissue products differ in source, processing, regulatory pathway, evidence, and intended use.
How can a patient evaluate a regenerative medicine clinic?
Ask what exactly is being injected, where it came from, how it was processed, what evidence supports that product for your diagnosis, whether the use is FDA approved or follows another regulatory pathway, and what outcomes the physician can realistically promise.
Is AI prescribing medications without doctors in Utah?
Not in the current Phase 1 pilot. As of late October 2026, a licensed medical practitioner authorizes every prescription renewal request before it reaches the pharmacy. The AI is limited to renewals of established medications within the pilot's rules.
Can AI replace physician judgment?
AI can organize information, identify patterns, and support decisions, but clinical responsibility still requires context, examination, diagnosis, and judgment. Current medical AI programs are testing where limited delegation may be safe, not proving that physicians are unnecessary.
Why can medical recommendations change over time?
Because science is iterative. New trials, better imaging, new technologies, and longer follow up can change what we know. Updating a recommendation when stronger evidence appears is a feature of evidence based medicine, not a failure of it.
What should patients ask before an orthobiologic procedure?
Ask what diagnosis is being treated, what tissue is being targeted, why that biologic was selected, what evidence applies to your specific condition, what imaging guidance will be used, what rehabilitation is expected, what risks exist, and what outcome is realistic.
About the Author
Deborah Westergaard, M.D., is board certified in Anesthesiology and Pain Medicine and has nearly three decades of experience in interventional pain management. She completed anesthesiology training at UT Southwestern University Medical Center in Dallas and fellowship training in Pain Management at Texas Tech University, where her training included advanced image guided and minimally invasive spinal procedures. Her current work emphasizes precise diagnosis, image guided interventions, orthobiologics, and joint and spine preservation strategies grounded in evidence, anatomy, and individualized patient selection.
Orthobiologics Digest™ is a physician perspective series by Deborah Westergaard, M.D. It is educational content and does not constitute individualized medical advice. Treatment decisions should be based on diagnosis, examination, imaging, evidence, patient goals, and an individualized risk benefit assessment. Results vary.
Primary Sources
ORTHOBIOLOGICS DIGEST™ NO. 9
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