Living Orthopedics

Most everyone has heard of stem cells and growth factors and regenerative medicine in some fashion. Stories abound of professional athletes traveling to Europe for stem cell therapies in an almost secretive fashion. Truly the perception of stem cells has been mystical.

As we all know, every tissue in our body is made up of cells. In fact, each tissue is made up of specialized cells, e.g. bone, muscle, skin, heart, brain, etc. Stem cells are simply early-stage cells that have not differentiated into these “specialized” cells but have the potential to do so. For musculoskeletal medicine for orthopedic surgery we are most interested in mesenchymal stem cells (MSCs) as they may become bone, cartilage, tendon, ligament, and muscle.

Stem cells have been highly scrutinized here in the U.S. primarily for ethical reasons. Human embryonic stem cells, from unborn babies, is one potential source that has sparked a great deal of criticism. Their use is not approved for our applications in the US. Instead, we rely on adult stem cells, present in abundance, in all of us. Adult stem cells, especially when trying to maximize MSCs, are found in our bone marrow. When used in an autologous fashion (meaning that they are used on the same person from which they are derived) there are no compatibility or rejection issues and they may impart amazing healing potential to tissue that is otherwise unable to heal.

In the United States, the only approved living stem cells for human use our autologous adult cells that are minimally manipulated. This means that there are no chemical or replication processes allowed to be performed on these specimens. Basically, this is living tissue that is transferred to the areas in need of healing. What is allowed is concentration of the stem cells are growth factors to deliver these potent healing agents with simply less volume. Consequently, techniques of harvesting and preparing these agents are exceptionally important to their function.

Though the science around stem cells and growth factors has been flourishing for years, clinical studies have recently been showing their great potential for the treatment of multiple musculoskeletal pathologies and ailments. Early and mid-stage degenerative arthritis, chronic tendon problems such as rotator cuff disease were tennis elbow, and degenerative disc disease are just a few of the common problems that may be well treated with these techniques. Truly, regenerative medicine with the use of stem cells and growth factors to treat common orthopedic problems is here to stay. There will always be a need for orthopedic surgical procedures such as joint replacement and spinal fusion but many patients will be able to avoid such surgery with skilled and proper re-generative medicine techniques.

Many orthopaedic and musculoskeletal ailments result from tissues that simply do not or cannot heal. Degenerative osteoarthritis for instance has no ability to regenerate articular cartilage in the joint and hence the process is considered hopelessly progressive only worsening over time. The same is true for degenerative disc disease of the spine. Chronic tendinopathy is like rotator cuff disease or tennis elbow lack sufficient blood supply and nutrients to heal the tendon injury. This is where growth factors and stem cells can play a role.

Our bodies contain a multitude of various growth factors, molecules that help our tissues heal, and stem cells which manufacture these growth factors. This is part of our normal homeostasis and well-being. Unfortunately, these growth factors in cells cannot always get to the areas of injury on their own. Advances in regenerative medical science now allow us to harvest and concentrate these substances from our own bodies and apply or inject them to where they are needed.

Growth factors and stem cells, more potently, stimulate signaling mechanisms to increase blood vessels, nutrition, and the healing activity of the tissue. Since they are living cells, stem cells have the added advantage of being able to manufacture more growth factors and replicate themselves potentially becoming functional cartilage, bone, or tendon cells depending on the environment.

For adults, mesenchymal stem cells are most abundantly found in bone marrow with the highest density or concentration in the iliac crest. Harvesting techniques involve aspirating bone marrow through a needle. MSCs are found in the bone marrow aspirate. Aspiration technique is decidedly important to maximize the number of cells collected. The bone marrow aspirate (BMA) not only contains the stem cells but growth factors and platelets as well.

Unlike stem cells, growth factors and platelets may be isolated from peripheral blood hence no bone marrow aspiration is necessary but no stem cells are obtained either. Processing of this blood yields a material called PRP (platelet rich plasma). PRP contains growth factors without cells but is high in platelets that act as “packages” of growth factors.

Although there is little question that bone marrow aspiration with living stem cells and platelets/growth factors is theoretically a better healing stimulus then PRP alone, it may not always be necessary. In most cases of soft tissue pathology such as tendinopathies, PRP yield similar results to BMA. However, with cartilage injury such as arthritis, stem cells healed superior results overall.

Large clinical studies now show clear advantages to orthopedic regenerative medicine. Largest series of patients with knee arthritis and PRP injection show markedly decreased pain, increased function, and no disease progression and 73%. Stem cells provide an even more robust and sustained effect. Stem cell injections with low back pain patients due to degenerative disc disease show a greater than 65% reduction in pain with sustained improvement. These results are all achieved by simply providing our own bodies with our own natural biologic substances to stimulate and direct successful healing.

We Can Heal Ourselves.
Stem cells, growth factors, and PRP or not magic bullets though. Like any other tool for the treatment of orthopedic problems such as surgery, the retrieval, processing, and application of these substances must be done by physician most knowledgeable and adept in orthopedic musculoskeletal diagnosis and treatment.

Living Orthopedics is an orthopedic practice devoted to regenerative medicine with the use of stem cells, growth factors, and PRP. Dr. Donald is a board certified orthopedic surgeon and Medical Director of Living Orthopedics and NJ Spine Group.