Over the last few years there has been a virtual explosion in interest in stem cells and the concept of using stem cells from a person’s own body to rebuild and regenerate damaged or degenerated structures. As far as orthopedic applications go, stem cells are being used for a wide variety of conditions ranging from persistent tendonitis, chronic back pain or rotator cuff issues to full blown “bone-on-bone” osteoarthritis of the knee or hip. These regenerative orthopedic therapies are attractive in that (if done properly) there is very little risk of complications, minimal downtime, and with quality stem cell processing as well as an experienced and skilled injection specialist, there is over an 80% chance of success for a long-term resolution of a problem.
What is the downside of stem cell therapy? The therapy involves a same-day mini liposuction office-based procedure usually from the abdominal region (most of us are willing to part with a little belly fat!). Also, depending on the joint involved and the skill of the injector, there is usually some mild discomfort with the injections. Finally, since this therapy is so new and cutting-edge, Medicare and insurance companies do not yet cover it so patients have to pay out of pocket. (The costs of the therapy will vary according to which joints and regions are injected with the stem cells.)
The good news is most people respond to a single therapy session and discomfort associated with the injections usually passes in a day or two. It is however important for people to realize that there is a wide variation in the quality and hence effectiveness of a stem cell therapy session. For optimal results it is most important that the final stem cell preparation has a high total number of free stem cells (usually in the order of 200 million+). Also it is crucial that people select a Regenerative Orthopedic Injection Specialist who is experienced and expert at a detailed palpation exam so they can properly identify the precise structures that are damaged and the root-cause of the pain and problems.
As far as stem cells go, there is debate in the regenerative orthopedic community whether we should use stem cells from bone marrow as well as those from abdominal fat. In our opinion, fat is much superior in that it represents a far richer store of adult mesenchymal stem cells. Also, we feel that a mini-abdominal liposuction is less invasive and better tolerated than bone marrow aspiration.
Although many protocols use only 20-50 CC’s of fat at our center we like to take around 150 to 200 cc’s of fat to work with (which will yield about 5-7x the total number of stem cells). In addition, we then use a proprietary enzymatic process to dissolve the fat and release the stem cells. Since stem cells are like little workers that have homing characteristics to damaged tissue it is most important that they be free so they can do their thing. Also, PRP (Platelet Rich Plasma) should be mixed with the stem cells prior to injection to activate and energize them. Stem cells can be considered as the seed while PRP can be thought of as fertilizer.
In short, the way the stem cells are harvested and prepared makes a huge difference to the effectiveness of the therapy. At our center we have a dedicated General Surgeon to harvest the fat properly as well as a dedicated stem cell scientist to make sure the stem cell preparation is optimal in number and quality (and do the counts to verify it) prior to injection.
Regarding the criteria of choosing the right Regenerative Orthopedic injection specialist. Once you have the stem cells, the second crucial parameter is to put them as close as possible to the damaged or degenerated structure(s). This begs the question of exactly how do we know which structures are involved and precisely where the problem is?
It is important to understand that injecting joints, joint capsules as well as ligament and tendon attachments, is a sub-specialty onto itself. It is most important that the specialist has superior palpation skills since palpation and looking for the “jump sign” is by far the most important diagnostic test to find exactly which structures are damaged and properly diagnose the “primary pain generators”. Unfortunately, MRI is of limited value in Regenerative Orthopedics since it is not sensitive enough to pick up the subtle sprains and strains that are so often a major part of the problem. Ultrasound is very useful for certain situations such as intra-tendinous tears, but in the absence of palpation skills, ultrasound used on its’ own may be quite misleading. Regenerative Orthopedics is primarily a hands-on specialty. After hearing some history, an experienced specialist should be most interested in palpating suspected regions and structures in order to make a correct diagnosis and treatment plan.
When a joint or region is addressed it is vital that not only the joint be injected but also the supporting joint capsule, ligaments and tendon attachments since they are very often a very important part of picture. These accessory connective tissue structures are highly innervated tissues that are the major pain generators in the musculoskeletal system. Unfortunately they are commonly overlooked. In our opinion these structures must be addressed as well as the joint itself for an optimal outcome. In our experience the best injectors have a background in Prolotherapy, which is the science and art of assessing and injecting joints and connective tissue structures.
So, can stem cells regenerate your joints? The answer in most cases is a resounding YES. If they will or not, no one can predict for sure, but if you find a good regenerative injection specialist who uses a good protocol (i.e. high count of free cells) your chances of success improve dramatically. Stem cells are the power of nature that, if properly placed, can help heal a whole host of musculoskeletal and orthopedic conditions in a most efficient and elegant manner. In our opinion, we feel that in many cases orthopedic stem cell approaches will heal conditions faster and better than the traditional approaches of surgery, steroid injections and NSAID therapy. We are convinced that stem cell therapy is the medicine of the future and, as we learn more and more, will become ever more effective at fixing common orthopedic conditions. It is exciting for us to see what stem cells can do. At times the results far surpass our expectations and we stand in awe at what these little workers can achieve.
