In the last few years there has been a virtual explosion of interest in the use of stem cells to address many orthopedic conditions such as knee osteoarthritis, rotator cuff, hip arthritis and chronic back pain. Emerging is the new discipline of Regenerative Orthopedics. In the hands of a good Regenerative Orthopedic specialist, stem cell procedures can be highly effective as well as being very safe and minimally invasive. In our opinion, stem cells should be considered as an option by anyone with persistent pain or debility from an orthopedic condition.
However, as a new emerging specialty that has yet to set standards of care, there is a vast difference in the quality of Regenerative Orthopedic treatments with stem cells. This will of course have a huge impact on the success and outcome of the stem cell procedure. If a patient is interested in exploring the stem cell option, it behooves them to understand what to look for in terms of both stem cell technology and injection techniques, so they can make an informed decision when they choose their doctor.
There are two major determinants of the effectiveness of an orthopedic stem cell treatment. First, the potency of the stem cells used i.e. the number and quality of stem cells. Second, the expertise of the injection specialist to deliver the stem cells as closely as possible to the damaged or degenerated structure.
Quality and Counts of Stem Cells
As far as stem cells for regenerating orthopedic structures go, by far the richest source is a patients’ own (i.e. autologous) fat. We feel that bone marrow aspirations are unnecessarily invasive and yield no significant advantage. For most patients we recommend low-pressure syringe aspiration of at least 60 ccs of abdominal fat. In our opinion this aspiration technique needs to be done gently in order to preserve the viability and vigor of the mesenchymal stem cells. There is nothing to be gained by refining and injecting dead cells. (In addition, while we’re taking the fat, we like to offer patients the added bonus benefit of targeted bodysculpting.)
Also, how the stem cells are separated from the fat makes a huge difference. For maximal impact you need free stem cells that can migrate to the precise damaged structures as needed. The best stem cell technicians have their own techniques to gently coax the stem cells to separate from the fat. A highly purified extract of stem cells yields the best results. Since fat has many imbedded toxins it is important not to inject fat with the stem cells.
The second major determinant of a stem cell treatment is the experience and expertise of the injection specialist. To be effective, the stem cells have to be injected as closely as possible to the pain generators and damaged structures. This specialty of Regenerative Orthopedics is the art and science of learning to inject orthopedic structures in order to stimulate healing and regenerate them. It should be understood that Regenerative Orthopedics as an emerging specialty is separate and distinct from Surgical Orthopedics, which represents a totally different approach. Regenerative Orthopedics is a minimally invasive injection specialty that addresses the subtle sprains and strains of connective tissue structures as well as cartilage and bone abnormalities. Surgical Orthopedics’ main purview is using surgical approaches to address grossly damaged bone, cartilage, nerves and torn ligaments and tendons.
In order to properly address the source(s) of pain it is very important to identify the primary pain generators. The most effective and in many cases, indeed the only way to determine all the pain generators involved is to use a Prolotherapy*-type methodology to palpate all the structures in the area and look for the “jump sign” to confirm precisely what structures are involved and need to be regenerated. In the musculoskeletal system, many pain generators are due to a very subtle stretching of ligamentous and tendinous attachments which are highly innervated and can be very problematic. Unfortunately, these subtle sprains and strains are not picked up by MRI, xray or ultrasound, leaving a thorough palpation exam by an physician expert at a Prolotherapy-type methodology as the only option to identify and address all the pain generators involved.
(*Prolotherapy is a discipline that has been around for over 70 years and used the injection of various substances, the most common being dextrose, to stimulate the healing and regenerating of ligament and tendon attachments)
If a doctor only addresses the obvious structural abnormalities as seen on xray, MRI or ultrasound and fails to address all the surrounding connective structures of a joint, we feel that in many cases the doctor will fail to identify all the primary pain generators and the results will be less than optimal. As a general comment, in order to be complete, we find that most patients require not only an intra-articular injection but also several injections to the appropriate trigger points in the supporting capsule and surrounding ligaments and tendons. For example, a patient say with moderate OA of the knee and cartilage loss may have 40% of the pain from the joint line but also 40% of the pain may come from the Medial Collateral Ligament and capsular complex and another 20% from the Pes Anserine complex. The latter two pain generators have their epicenters at least 1 or 2 inches below the joint line and require direct stem cell injection for healing since the stem cells will not be able to migrate to these sites from inside the joint.
With stem cells, we stand at the gates of a new and exciting era in medicine. As far as Orthopedic conditions go, stem cells can have a significant beneficial effect and may indeed solve many problems outright. In order to optimize a Regenerative Orthopedic procedure with stem cells we recommend that patients find a doctor that has had specialized training as a stem cell scientist or who utilizes the services of a stem cell scientist. In addition the regenerative injection specialist should be well versed and expert in a Prolotherapy-type palpation methodology and injection techniques so he can properly diagnose and inject all the pain-generators involved.
Using advanced stem cell technology and proper injection techniques, the healing power and impact of stem cells should not be underestimated. Although it will be quite some time before medicine fully understands how these little marvels can repair and regenerate structures at a cellular level, for the time being we often stand in awe as we observe what they can achieve.