Regenerative orthopaedics: Building evidence, standardisation and precision in care

Niteen Tulpule, Treasurer and Dr Sharmila Tulpule, Chairperson, REGEN 2026 in an interview with Kalyani Sharma, discuss the evolving landscape of regenerative orthopaedics in India, the need for greater standardisation and evidence, and the role of the newly developed BMAC consensus guidelines and SKIM classification system in clinical practice

Where do you see regenerative orthopaedics standing in India today?

Niteen Tulpule: Honestly, we’re still early. Regenerative medicine isn’t practised widely across the board — even PRP, which has been around the longest, is only used by a relatively small number of orthopaedic surgeons and pain specialists. But the interest is growing, and we’re having a lot more conversations about it than we were even a couple of years ago.

This is actually the third year of ReGen. In our second year, we put out consensus guidelines for PRP, and this year we’ve done the same for BMAC. So there’s real progress happening in terms of structure and standardisation.

There’s still some hesitation among orthopaedic surgeons to use biologics even as an adjunct to what they already do. But that’s changing, as more doctors are seeing firsthand that biologics can help patients heal faster, even in cases where they’re not replacing surgery. Tendinopathies and frozen shoulder are just a couple of examples from a much wider range of conditions where biologics work well, and as more surgeons get comfortable with this, adoption will keep growing.

What are the biggest gaps in the way regenerative treatments are currently practised?

Niteen Tulpule: The biggest gap is training. A lot of doctors are not usig biologics or working with just one or two tools when they should have the full range available — PRP, BMAC, MFAT, ACS, even allogenic options and the judgment to know which one fits which patient. PRP isn’t truly regenerative in the strictest sense, but it’s very useful for its anti-inflammatory and pain-relieving effects, and doctors need to understand where each of these options fits rather than sticking with whatever they know best.

The second gap is standardisation. Guidelines on how each of these should be administered for different conditions vary a lot from clinic to clinic. That’s exactly the gap our PRP consensus guidelines, and now the BMAC consensus guidelines, are starting to close.

Patient education and counselling is another one that gets missed. This isn’t a one-off procedure — it starts in the consulting room and continues well past the treatment table. Doctors need the right blood work done beforehand to flag potential issues, clear counselling on what to expect, and a proper follow-up plan that includes physiotherapy and lifestyle guidance. Very often, the process stops the moment the injection is given.

And staying abreast of government regulations in this field really matters. It’s paramount that doctors understand what these regulations mean in practice, and practise accordingly that includes being honest with patients and not overpromising outcomes. This field only earns trust if we get that right.

What difference can the BMAC consensus guidelines make to clinical practice?

Niteen Tulpule: It gives clinicians a common reference point instead of relying on individual experience or word-of-mouth. These guidelines were built through collaboration across the US, Europe and India, so doctors now have an evidence-based framework to work from — similar to what the PRP consensus guidelines did for the field last year. That consistency leads to better outcomes, and it gives doctors the confidence to start using these treatments more widely.

How do you see the adoption of regenerative treatments evolving across Indian hospitals?

Niteen Tulpule: I think it’ll grow steadily as training improves, guidelines like the PRP and BMAC consensus documents become standard reference points, and more published evidence comes out. As hospitals start seeing peer-reviewed data and consensus protocols in addition to the individual success stories we already hear about, regenerative orthopaedics will become a standard part of the treatment pathway, especially for patients trying to delay or avoid surgery. Of course government regulations and insurance adoption will play a huge part as well.

What needs to happen to build greater trust in this field?

Niteen Tulpule: We actually have a good amount of evidence already — there are years of published data and a number of randomised controlled trials globally on PRP and MFAT, and BMAC evidence is building well too. What we need now is to build on that bank of evidence. That means more case series, more journal publications, more properly designed trials, particularly with Indian patient data. That takes support from a few directions — government grants, private investment, and doctors themselves taking the initiative to document and publish their own cases. A lot of us have valuable data sitting in our clinical records that never makes it into a study. We need more of that to actually get published and added to what already exists.

What are the biggest opportunities and challenges for regenerative medicine in India?

Niteen Tulpule: I honestly think India can be a world leader in this space, not just a participant. We have the medical talent, we have cost-effectiveness that most countries can’t match, and we have a government that can support this if the push is organised. What’s needed now is for all of that to come together, ie training, standardisation, evidence, policy support. All of these together working together will make the picture more complete. The opportunity is huge, no doubt. This is a chance to improve people’s lives and bring down healthcare costs at the macro level, and that’s worth getting right.

What prompted the need for a new biological classification of knee osteoarthritis?

Dr Sharmila Tulpule: This year at REGEN 2026 ( our third international conference)we proposed a new Classification System for Knee Osteoarthritis (SKIM).

Without a shared way of classifying a patient’s underlying biology, even well-designed treatment guidelines can only go so far. Knee osteoarthritis has traditionally been graded by X-ray severity alone , the Kellgren-Lawrence system , which tells you almost nothing about a joint’s actual biology or its capacity to respond to regenerative treatment. Two patients with an identical X-ray can have completely different inflammatory profiles, metabolic loads, and mechanical stresses, and therefore completely different outcomes with the same treatment. SKIM was developed to close that gap- a framework that classifies OA by biological behavior, not just structural appearance, so treatment decisions are grounded in the biology of the individual joint.

How could this classification change the way doctors approach osteoarthritis?

Dr Sharmila Tulpule: It shifts the starting question from “how damaged is the joint on imaging” to “what is driving this joint’s degeneration, and how likely is it to respond biologically.” That changes treatment selection at the root, instead of a default pathway based on age or X-ray grade, doctors get a structured, four-domain read on structure, mechanics, inflammation, and metabolic load, and can match the patient to the right intervention rather than the most familiar one. Over time, that’s how a field moves from protocol-driven care to precision care.

Where does BMAC have the strongest clinical evidence today?

Dr Sharmila Tulpule: BMAC’s most consistent evidence base is in early-to-moderate osteoarthritis and focal cartilage defects, where multiple studies have shown symptomatic and functional improvement over 12–24 months. It’s also increasingly used in tendinopathies and select non-union fractures. But one area where the evidence is particularly strong and particularly relevant right now, is avascular necrosis (AVN) of the femoral head.

Core decompression combined with BMAC has shown some of the most robust outcomes in early-stage AVN, often delaying or avoiding the need for hip replacement in young patients. This has taken on added urgency in India, where we’ve seen a rise in AVN cases in younger patients following COVID-19, linked to steroid use during treatment. The evidence is strongest when patient selection is precise, which is exactly why we unveiled BMAC Guidelines, in ReGen 2026 for the first time ever, with International Experts in the field.

How should doctors assess which patients are suitable for regenerative treatments?

Dr Sharmila Tulpule: Patient selection has to move beyond “how bad is the X-ray” to a multidimensional assessment – joint structure, mechanical alignment, inflammatory load, and metabolic status all influence outcome. This is the gap SKIM was built to close: a structured, four-domain framework that helps clinicians grade regenerative potential before choosing a treatment path, rather than relying on gut feel or radiographic grade alone.

What are the biggest misconceptions around regenerative orthopaedics today?

Dr Sharmila Tulpule: The biggest misconception is that regenerative medicine is one homogeneous therapy. That PRP, BMAC, and MFAT are interchangeable, or that they work the same way for every patient. In reality, these are distinct biological tools with different mechanisms and different ideal candidates. The second misconception is that regenerative treatments are a replacement for surgery in every case- they’re not; they’re an additional, evidence-guided option for the right patient at the right stage.

What would you like to see change in the way regenerative medicine is practised in India?

Dr Sharmila Tulpule: I’d like to see standardisation – shared classification systems, consensus guidelines, and outcome registries -replace the current fragmented, protocol-by-protocol practice. This is the direction we’ve been building toward through ReGen: we published India’s PRP guidelines at last year’s conference, and this year’s edition brought the BMAC Consensus Guidelines. That’s the goal behind bringing together clinicians from across the country around frameworks like these and SKIM: building a common clinical language so regenerative orthopaedics in India matures into a discipline with consistent standards, not isolated best practices.