Mar 20, 2014
Osteoarthritis is essentially joint failure because all structures of the joint undergo pathologic changes. Traditionally, OA was considered to be a disease of articular cartilage, with loss of cartilage considered to be the essential pathologic process for OA. In recent years, however, it has been realized that OA affects the entire joint structure, including the synovial lining, ligaments, supporting subchondral bone, along with the articular cartilage. Each structure in the joint plays a unique and important in the daily function of the joint. Articular cartilage, with its compressive stiffness and smooth surface; synovial fluid, which provides a smooth and frictionless surface for movement; the joint capsule and ligaments, which protect the joint from excessive excursions; the periarticular muscles, which minimize focal stresses across the joint by appropriate muscle contractions; the sensory fibers, which provide feedback for muscles and tendons; and the bone supporting the cartilage (subchondral bone), with its mechanical strength and shock-absorbing function all interact in an intricate manner to provide optimal function for the joint. Destruction of any of these structures or a disruption in the balance between them leads to the process of arthritis.
A discussion of each risk factor is beyond the scope of this Blog but they may be divided into systemic categories (advancing age, gender, genetics) and local categories (anatomy, trauma, body mass, repetitive use injury, bone density). In considering the clinical features, there is no correlation between the X-ray and the degree of pain. The most likely sources of pain in OA are synovial inflammation, joint effusion, and bone marrow edema. All is dependent on and mediated by a loss of balance in the cartilage cell (chondrocyte) mediated balance between growth factors, cytokines and enzymes that breakdown the cartilage. OA becomes an inflammatory process initiated and propagated by inflammatory mediators that lead to the demise of the articular cartilage first and damage to other structures over time.
How might stem cells change the natural history of Osteoarthritis progression? The stem cells are chondrogenic when introduced into the proper environment. Even if they do not give rise to chondrocytes that are responsible for manufacturing collagen type 2 and aggracan; The Bone Marrow Aspirate derived Stem Cells when concentrated and introduced into the arthitic joint produce the cytokines and growth factors to control the breakdown of extracellular matrix by Interleukin 1-B and tumor necrosis factor-a. Difficult to understand? Call, make an appointment, I will explain and then you decide about a stem cell intervention rather than a Total Joint Replacement.
Tags: Clinical Trial. Mitchell B. Sheinkop, Interventional Orthopedics, Orthopedic Care, Orthopedics, Osteoarthritis, Regenerative, stem cells
Feb 18, 2014
Musculoskeletal Care of the Mature Athlete
A 67-year-old man came to my office to learn more about Bone Marrow derived Stem Cells for his arthritic knees. While he had been discouraged by his sports medicine physician from seeking the Regenerative Cellular alternative, he was not ready to undergo a bilateral total knee replacement after having investigated the potential complications associated with the surgery. I started with a review of his medication profile and determined that BMAC/Stem Cells might not produce the quantity and quality potential I would want to see to justify the procedure. My concern had to do with the adverse effects of certain medicinals on stem cell numbers. I offered an alternative, Concentrated Stem cell Plasma.
The development of Regenerative Cellular interventions for the management of arthritis started several years ago with Platelet Rich Plasma. Platelets not only play a role in initiating the clotting cascade, they contain an abundance of anti-inflammatories and healing agents termed growth factors. At the outset, clinicians performed a venous puncture and filled a test tube with blood. The latter was now spun in a centrifuge and the plasma with platelets suspended was injected in the arthritic knee. Within a year, it became apparent that two or three staged PRP interventions would result in better outcomes. About a year ago, the group of physicians at Regenexx began concentrating the Platelet Rich Plasma 10X and the results of treatment have been very encouraging in that patients did better and for longer than with standard PRP. More recently, we have developed a better way to activate with a faster and longer acting release of growth factors.
Bone Marrow Aspirate Concentrated/Stem Cells remain the best possible alternative in our Cellular Orthopedic Regimen at this time. Concentrated Stem Cell Plasma (PRP 10X) is a reasonable alternative although with a shorter outcome potential and probably to a lesser extent. No bridges are burned. I have suggested the 10X PRP option to patients heavily dependent on pharmaceuticals for co-morbidities or when I anticipate a possible compromise in the quantity or quality of stem cells because of age or other factors. Primum Non Nocere, First No Harm. There is nothing lost and a lot gained by a staged approach to the Regenerative Medical management of arthritis.
Addendum: I now have several patients who were managed as above when their pharmaceutical profile excluded them from a stem cell procedure; that went on to loose weight and get fit, and minimize their medication dependency. By so doing they became reasonable candidates for stem cells; and, now are enjoying the longer term and more comprehensive benefits of Bone Marrow Concentrate Stem Cell intervention.
Tags: C-SCP, Concentrated Stem Cell Plasma, Growth Factors, joint replacement, Orthopedic Care, Orthopedics, Platelet Rich Plasma, PRP, Ultrasound Guided Injection
Dec 4, 2012
Athletics following a Total Joint Replacement is a controversial topic within the orthopedic community and varies by region and comfort level of the orthopedic surgeon. The scientific literature on the subject is quite limited. Returning to exercise after a joint replacement does not necessarily imply a return to sports. The predictors of whether a patient will return to sports after a joint replacement were the subject of an article appearing in Clinical Orthopedics and Related Research by Williams et al., in 2012:Prior high level participation in a given sport 2) Male gender, 3) Low BMI, 4) Under 50 years of age. Be informed that return to sports after a TJR may not be feasible.
Stem Cells and Joint Replacement in Sports Medicine
In a recent study, of a population that underwent a Total Joint Replacement, only 32% were active after five years. Recipients of hip prostheses were twice as active as those who had undergone a knee replacement. The limits of our knowledge in part are based on the absence of a joint replacement registry in the United States. As a result, we are dependent on New Zealand, Australia, the United Kingdom and Scandinavia for our data. Basically, your participation in sports after a total joint replacement is at your own risk. What is that risk? A revision surgery in less than five years; one out of every 75 total knee replacements undergoes revision in 3 years.
Turning our attention to sports after Bone Marrow Aspiration Concentrate for an arthritic joint, there is no available scientific data to allow for generalizations. It is just too soon. The other problem is that I am one of the few orthopedic surgeons involved in Regenerative Medicine and the Anesthesiologists and Physiatrists who pioneered this modern approach to the non-operative care of arthritis do not use the same outcome criteria as that used in orthopedic surgery. Theirs is of a subjective measurement while ours is both subjective and objective. The net result is that, while I am gathering data on the patients I treat, at this time the best I can do is anecdote. In each and every Blog, I strive to feature the outcomes of my patients. You may read about those outcomes in my Blog Archives; but let me leave you with several observations drawn from my database to date as well as the findings of a scientific study in which I was the senior author:
1) The best outcomes for BMAC (Stem Cells) in arthritis have been seen in patients with class two to three arthritis and those with a low BMI
2) Studies including Knee Joint Biomechanics During Cycling in Patients with Total Knee Arthroplasty indicate the best sport and fitness routine for hip and knee osteoarthritis whether pretreatment, treatment with BMAC or a TJR is cycling
3) Swimming works as well (personal observation)
Tags: Mature Athlete, Orthopedic Care
