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The treatment of hip osteoarthritis, like those of other joint osteoarthritic problems, is redefining itself at a pace probably not seen since the advent of hip replacement surgery. In new research doctors found that stem cells work well because they change the environment of the joint they are working on, basically they turn on the lights and call in “construction crews” of helper cells.
Researchers looked at the osteoblasts, specialized mesenchyme-derived (stem) cells accountable for bone synthesis, remodelling and healing. What they found is that these cells rebuild bones through various mechanisms including cell homing or cell signalling. This is where stem cells communicate with the surrounding tissue to help them navigate to the site of the wound and differentiate themselves into the material to build bone.6 Other research suggests positive results even in cases of Avascular necrosis. Weher the stem cells were able to call blood cells to the site.7
This research confirms other studies which speculated that not only could stem cell therapy repair bone damage in hip osteonecrosis (bone death), but it could halt the disease acceleration by correcting the decrease in the local mesenchymal stem cell populations.6Reinforcing the natural healing environment.
The use of stem cells for the treatment of avascular necrosis of the femoral head (bone death in the hip caused by lack of blood flow) has been suggested in medical research as pointed out above. In pre-clinical studies, the use of stem cells uniformly demonstrated improvements in osteogenesis (bone fragility) and angiogenesis (blood vessel formation).8 The stem cells are manipulating the healing environment.
This goes beyond bone to include the regeneration of cartilage. Rebuilding cartilage in severe osteoarthritis is considered one of the great challenges in orthropedic medicine. Stem cells provided a solution because they are plentiful, they can direct themselves to morph into collagen fillers – cartilage – and can modulate the immune response of the microenvironment of the stem cells already present in the diseased tissue. The stem cells changed the environment and revitalized the stem cells already present in the diseased joint.
Our patients are typically someone who had an arthroscopic surgery or multiple procedures with less than hoped for results. When they come into the office we will hear things like, “I had knee surgery on the left knee but do not want one on the right.” The same for the hip pain patient who does not want to repeat a surgery on the other side or someone who simply does not want surgery.
When making a decision to move forward with stem cell injection therapy for problems of osteoarthritis and painful soft tissue injury, many patients rely on research to help them make an informed decision.
As in any health condition, the earlier you treat it and how you treat it, the better the chance for successful outcome. In a new paper, doctors agree, they suggest that the diagnosis and the prompt treatment of early osteoarthritis can represent a vital step for delaying the onset and progression of fully blown osteoarthritis in many patients.
Because nonsurgical treatments such as physiotherapy, anti-inflammatory medications, and other disease-modifying drugs all have modest and short-lasting effect, the researchers reviewed the biological approaches to healing that have recently gained more and more attention.
Growth factors, blood derivatives, such as platelet concentrates, and mesenchymal adult stem cells, either expanded or freshly isolated, are advocated amongst the most promising tool for the treatment of osteoarthritis, especially in the early phases.
Primarily targeted towards focal cartilage defects, these biological agents have recently showed promising results to relieve pain and reduce inflammation in patients with more advanced osteoarthritis as well, with the final aim to halt the progression of the disease and the need for joint replacement..1
Researchers sought to provide an explanation of how stem cell injections work. Here is what they came up with: Bone marrow stem cells increases cell proliferation of chondrocytes and inhibits inflammatory activity in osteoarthritis.
In common language – stem cell injections regrew cartilage and stopped damaging chronic inflammation. 2
These healing effects of stem cells are supported in numerous studies. In one study, doctors followed patients for five years after stem cell injections for knee osteoarthritis. They found at FIVE YEAR follow up stem cell treated knees were still better than before treatment.3
Not just in the regrowing and repairing of cartilage damage but also in repairing osteoarthritic bone damage. Doctors in China who announced that in their animal studies, stem cells injected into the site of a bone fracture, promoted rapid and accelerated bone healing.4
The implications of the above research has helped revolutionize the way standardized medicine addresses problems of bone degeneration and necrosis (bone death). When the doctor says you have “bone-on-bone,” the options of joint replacement or just live with it are no longer the two only options.
As the research above shows, cartilage can be regrown, bone can be regrown, chronic inflammation (swelling) shut off – long term – stem cells provide a curative effect.
1. de Girolamo L, Kon E, Filardo G, et al. Regenerative approaches for the treatment of early osteoarthritis Knee Surg Sports Traumatol Arthrosc. 2016 Jun;24(6):1826-35. doi: 10.1007/s00167-016-4125-y. Epub 2016 Apr 27.
2. Zhang Q, Chen Y, Wang Q, Fang C, Sun Y, Yuan T, Wang Y, Bao R, Zhao N. Effect of bone marrow-derived stem cells on chondrocytes from patients with osteoarthritis. Mol Med Rep. 2016 Feb;13(2):1795-800. doi: 10.3892/mmr.2015.4720. Epub 2015 Dec 28.
3. Davatchi F, Sadeghi Abdollahi B, Mohyeddin M, Nikbin B. Mesenchymal stem cell therapy for knee osteoarthritis: 5 years follow-up of three patients. Int J Rheum Dis. 2015 May 20. doi: 10.1111/1756-185X.12670. [Epub ahead of print]
4. Huang S, Xu L, Zhang Y, Sun Y, Li G. Systemic and local administration of allogeneic bone marrow derived mesenchymal stem cells promotes fracture healing in rats. Cell Transplant. 2015 Feb 2. [Epub ahead of print]
5. Titorencu I, Pruna V, Jinga VV, Simionescu M. Osteoblast ontogeny and implications for bone pathology: an overview. Cell Tissue Res. 2014 Jan;355(1):23-33. doi: 10.1007/s00441-013-1750-3. Epub 2013 Nov 29.
6. Calori GM, Mazza E, Colombo M, Mazzola S, Mineo GV, Giannoudis PV. Treatment of AVN using the induction chamber technique and a biological-based approach: Indications and clinical results. Injury. 2013 Sep 19. pii: S0020-1383(13)00423-3. doi: 10.1016/j.injury.2013.09.014. [Epub ahead of print
7. Hernigou P, Flouzat-Lachaniette CH, Delambre J, Poignard A, Allain J, Chevallier N, Rouard H.Osteonecrosis Repair with Bone Marrow Cell Therapies: State of the Clinical Art. Bone. 2015 Jan;70:102-9. doi: 10.1016/j.bone.2014.04.034. Epub 2014 Jul 10.
8. Lau RL, Perruccio AV, Evans HM, Mahomed SR, Mahomed NN, Gandhi R. Stem cell therapy for the treatment of early stage avascular necrosis of the femoral head: a systematic review. BMC Musculoskelet Disord. 2014 May 16;15:156. doi: 10.1186/1471-2474-15-156. PUBMED ABSTRACT
9. He M, Gan AW, Lim AY, Goh JC, Hui JH, Chong AK, Bone Marrow Derived Mesenchymal Stem Cell Augmentation of Rabbit Flexor Tendon Healing. Hand Surg. 2015 Oct;20(3):421-9. doi: 10.1142/S0218810415500343. PUBMED
9. Tetta C, Consiglio AL, Bruno S, Tetta E, Gatti E, Dobreva M, Cremonesi F, Camussi G. Muscles The role of microvesicles derived from mesenchymal stem cells in tissue regeneration; a dream for tendon repair? Ligaments Tendons J. 2012 Oct 16;2(3):212-21. Print 2012 Jul.
10. Shapiro E, Grande D, Drakos M. Biologics in Achilles tendon healing and repair: a review. Curr Rev Musculoskelet Med. 2015 Feb 6. PUBMED
11. J. B. Thorlund, C. B. Juhl, E. M. Roos, L. S. Lohmander. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ, 2015; 350 (jun16 3): h2747 DOI:10.1136/bmj.h2747
12. Pasquale MK, Louder AM, Cheung RY, Reiners AT, Mardekian J, Sanchez RJ, Goli V. Healthcare Utilization and Costs of Knee or Hip Replacements versus Pain-Relief Injections. Am Health Drug Benefits2015 Oct;8(7):384-94.
13. Smith TO, Purdy R, Lister S, Salter C, Fleetcroft R, Conaghan PG. Attitudes of people with osteoarthritis towards their conservative management: a systematic review and meta-ethnography. Rheumatol Int. 2013 Dec 5. [Epub ahead of print]
14. Orozco L, Munar A, Soler R, Alberca M, Soler F, Huguet M, Sentís J, Sánchez A, García-Sancho J. Treatment of Knee Osteoarthritis with Autologous Mesenchymal Stem Cells: A Pilot Study. Transplantation. 2013 May 15. [Epub ahead of print]
15. Barry F, Murphy M. Mesenchymal stem cells in joint disease and repair. Nat Rev Rheumatol. 2013 Oct;9(10):584-94. doi: 10.1038/nrrheum.2013.109. Epub 2013 Jul 23.
16. Diekman BO, Guilak F. Stem cell-based therapies for osteoarthritis: Challenges and opportunities. Current opinion in rheumatology. 2013;25(1):119-126. doi:10.1097/BOR.0b013e32835aa28d.
17. Berkoff DJ, Miller LE, Block JE. Clinical utility of ultrasound guidance for intra-articular knee injections: a review. Clin Interv Aging. 2012;7:89-95. Epub 2012 Mar 20.
18. Sibbitt WL Jr, Band PA, Kettwich LG, Chavez-Chiang NR, Delea SL, Bankhurst AD. A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee. J Clin Rheumatol. 2011 Dec;17(8):409-15.
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Stem cells are gently taken from the iliac crest bone of the pelvis. These stem cells are so valuable because they are undifferentiated cells, meaning that they can morph to become other, more specialized types of cells. So if a joint needs cells to rebuild tendon, ligament, and muscle, these stem cells supply the building material for joint regeneration. This is why there is so much excitement in the medical community for stem cells’ potential in osteoarthritis and other degenerative problems.
In our office we choose to use bone marrow derived stem cells because we find that we can achieve the patient’s goals of treatment using this approach. This is not to say that adipose (fat) stem cells are not as effective or even less than effective or even better. What we are looking to do is achieve the patient’s expectations and the goals of the treatment of stem cell therapy. We simply feel we can achieve this today with bone marrow stem cells.
We have used Adipose stem cells in the past and found it is more TRAUMATIC for the patient, In addition to breaking up fat tissue with a long TROCAR, a thick needle has to be used to inject.
In our experience we have not found one patient who liked this experience.
Researchers have evaluated the effectiveness of stem cell therapy and tissue engineering for treating osteoarthritis. Both bone marrow and adipose derived stem cells have the potential to provides a permanent biological solution.
Mesenchymal stem cells (MSCs) isolated from bone marrow or adipose tissue show considerable promise for use in cartilage repair. The MSCs can be sourced from any or all joint tissues and can modulate the immune response. Additionally, MSCs can directly differentiate into chondrocytes under appropriate signal transduction. They also have immunosuppressive and anti-inflammatory paracrine effects. (They change the joint environment from breakdown to healing by telling the other cells to start repairing).
Editorial January 2016 – The Journal of Arthroscopic and Related Surgery a publication of the Arthroscopy Association of North America.
In this editorial Merrick J. Wetzler, M.D. (Associate Editor), says “Harvesting of the (fat stem cells) ADSCs does require an additional procedure and the cost-effectiveness of the procedure is still under investigation, but as researchers stated in their editorials in 2012 and 2013, “we are believers in stem cell therapy” and “stem cells have substantial potential to allow 21st century physicians and surgeons . . . to achieve unprecedented tissue healing and repair.”
“We do believe that it is only a matter of time before the harvesting and growth of stem cells will become cost-effective and commercially available and will be added to our treatment options for restoration of articular cartilage.” That is a good endorsement from surgeons – however as you read in the editorial there is the added cost of the stem cell procedure using adipose stem cells to factor in and a more complex harvesting procedure getting the fat cells.
Are bone marrow stem cells the new player in non-surgical tendon repair? In the newest research doctors suggest that bone-marrow derived stem cells accelerate tendon healing in animal studies.9
Doctors know that chronic tendon injuries present unique management challenges because of the long assumed belief that these injuries result from ongoing inflammation. This thinking has caused physicians to rely on treatments demonstrated to be ineffective in the long term–anti-inflammatory medications and cortisone shots.
This is why the great excitement in stem cell therapy, says one study:
“Tendon injuries represent even today a challenge as repair may be exceedingly slow and incomplete. Regenerative medicine and stem cell technology have shown to be of great promise.”10
Most recently studies have indicated the potential effectiveness of bone marrow (stem cells) and its positive effects on Achilles tendon healing, particularly during the early phases.11
A recent article appeared in the British Medical Journal – this is what it said:
The article is part of The BMJ‘s Too Much Medicine campaign – to highlight the threat to human health and the waste of resources caused by unnecessary care.
A new study from the journal American Health and Drug Benefits suggest that patients over the age of 70 should just have a knee replacement and not even explore steroid or hyaluronic acid (viscosupplementation injections) to save on national health care costs.13
In recent research doctors noted that healthcare interventions for knee osteoarthritis are poorly perceived and that patients expect the inevitable joint replacement. The expected failure of conservative treatment to manage pain and symptoms is common partly because clinicians trivialize osteoarthritis.14
This is almost paradoxical, the patients are too old for other treatments and some doctors suggest that they should simply proceed to the most invasive treatment that requires the most healing and recovery time? What is too old for a knee replacement? Evidently there is no limit. But what is too old for the extensive recovery and rehabilitation?
In another recent study researchers reported the results of Stem Cell Therapy in patients that showed rapid and progressive improvement (in function) with improvement of knee cartilage quality. Says the research ” (Stem Cell Therapy) may be a valid alternative treatment for chronic knee osteoarthritis. The intervention is simple, does not require hospitalization or surgery, provides pain relief, and significantly improves cartilage quality. “15
Another study says that stem cells should be considered a reservoirs of repair cells that fix damaged joint tissue, strengthen healthy joint tissue and also repair the problems associated with chronic inflammation *(swelling and stiffness),16 “viable even in elderly patients who may still display significant chondrogenic (cartilage regrowing) potential”17
By identifying the general area where the injections need to be given, then applying ultrasound imaging we can see the joints, ligaments and tendons moving in real time. This allows us to pin point the area that needs to be treated and guide the injection exactly where it can provide the greatest healing benefit to the patient.
This is especially important in Platelet Rich Plasma Therapy when we want to deliver the maximum number of platelets to the painful area, and Stem Cell Therapy when getting the stem cells to the exact site is of paramount importance.
Now the research in support:
“ultrasound guidance of knee injections resulted in better accuracy than anatomical guidance (95.8% versus 77.8%). Ultrasound guidance notably improves injection accuracy in the target intra-articular joint space of large joints including the knee. The enhanced injection accuracy achieved with ultrasound needle guidance directly improves patient-reported clinical outcomes and cost-effectiveness. 18
Research in the Journal of Clinical Rheumatology says that “(Ultrasound) Sonographic needle guidance reduced procedural pain and improved the clinical outcomes and cost-effectiveness of intra-articular injections of the osteoarthritic knee.” 19
The researchers found that ultrasound guided injection over conventional palpation-guided methods resulted in 48% reduction in procedural pain, a 42% reduction in pain scores at outcome, 107% increase in the responder rate and with higher accuracy, less need for procedure, significantly reducing patient cost.
Knee and hip osteoarthritisare mainly about two things – the loss of or “no” cartilage and the associated bone lesions and damage from the missing cartilage causing a “bone on bone” situation.
When someone comes into our office with a recommendation for joint replacement surgery, it is usually on the recommendation that the bone in the joint — the ball and socket of the hip, the thigh bone (femur) to the shin bone (tibia) of the knee joint for example–are damaged enough that repairing or providing treatment options other than replacement surgery are not practical or warranted.
In research, investigators have shown that stem cell therapy can repair and rebuild bones. This was strongly documented in a study on diabetic patients. Doctors reported that by adding stem cells from human bone marrow to a broken diabetic bone enhances the repair process and increasing the strength of the newly formed bone.
Bones of diabetic people are known to be more fragile than non-diabetic people and take longer to heal after fracturing. What’s more, diabetic people are more likely to sustain fractures as a result of fall than non-diabetics as they often suffer from impaired vision and reduced sensitivity in their feet.5
The researchers found that stem cells healed broken bones more and that the healed bones resulting from stem cell treatment were found to be significantly stronger and able to withstand more stress than those in a control group.