Orthobiologics research has come a long way since the earliest reports of platelet rich plasma (PRP) in the 1980s and stem cells in the 1960s.There has been exponential growth in the number of published scientific studies on PRP and stem cells in orthopedics over the past 10 years.
Regenerative medicine is a new medical specialty that uses advancements in the study of cells and tissue engineering to understand how the body heals itself. In the field of orthopedics, regenerative treatments have evolved to capitalize on the unique healing qualities of our own cells to stimulate healing, reduce inflammation and decrease pain for a variety of musculoskeletal conditions.
The demand for regenerative treatments continues to grow as patients discover how these treatments are successfully being used to treat acute musculoskeletal injuries and degenerative conditions.More and more patients have benefited from such therapies with reduction in pain and significant improvement in their quality of life.
Regenerative Medicine in 2020
Clinical trials and research in regenerative medicine has provided more ever increasing evidence for the safety and efficacy of cell based therapies when used in orthopedics such as osteoarthritis, tendon tears, ligament injuries, low back pain, sciatica and several others conditions.
The choice of regenerative treatment depends upon multiple factors including the type and severity of injury, medical comorbidities and other issues unique to each patient. San Diego Orthobiologics Medical Group offers a number of regenerative medicine options such as:
Platelet Rich Plasma Therapy: Growth factors and proteins in the platelets and plasma of the patient’s own blood promote tissue repair and reduce inflammation. Specific PRP formulation is customized to joints, tendons, ligament or nerves for maximum results.
Adipose Derived Stem Cell Therapy: Fat tissue derived from your own body enables regenerative cells (such as stem cells) within your own fat tissue to work together and repair, reconstruct and replace damaged or injured tissues.
Bone Marrow Aspiration Concentrate (BMAC): Utilizes regenerative cells that are contained within your own bone marrow. The marrow contains a rich reservoir of anti-inflammatory molecules, platelets and stem cells to stimulate your body’s ability to improve circulation, decrease inflammation and regenerate tissues.
Prolotherapy: Medications that help regenerate tissue and relieve pain are injected into injured ligaments, tendons or joints to strengthen and improve stability in patients with osteoarthritis, ligament sprains and sports-related injuries.
Moving Forward
The field of regenerative medicine is continuously evolving and expanding.Cell based therapies are getting acknowledgement in orthopedic surgery and have been used to accelerate healing and improve outcomes. The combined use of cells and protein scaffolds (tissue framework) are utilized for cartilage, tendon, ligament and bone tissue engineering to accelerate healing and long lasting results.Surgery to repair bone fractures or bone defects have been supplemented with cell therapy to increase bone healing and mineralization.
Many other exciting potential applications for stem cell therapy are currently being studied, not just in orthopedics, but in other specialties. The idea that a patient can bank their own stem cells to store for future use is already a reality.
However, there is still more work to be done in order to make significant progress on this field.Although there are thousands of studies published in peer-reviewed scientific journals, there is a great need for more high-quality studies and clinical trials.Continued work on standardization of processes, reporting and treatment protocols is vital.Collection of data through registries is not only important to track patient complications and outcomes, but also to guide future decisions made by insurance companies and regulators.Collaboration with a multidisciplinary team of experts in physical medicine and rehabilitation, orthopedic surgery, sports medicine, cell therapy, molecular biology and others will continue to move the field forward at a rapid pace.
Drs. Christopher J. Rogers and Mary A. Ambach of San Diego Orthobiologics Medical Group are experts and leaders in the field of regenerative medicine. They are involved in clinical trials using cell-based therapies for knee osteoarthritis and disc degeneration in the lumbar spine. They have published in multiple medical journals and Regenerative Medicine textbooks.They serve as faculty members and lecturers at national and international medical conferences and serve on the board of directors for several regenerative medicine organizations.
Bone marrow is a rich source of many types of cells.Red blood cells, white blood cells and platelets are manufactured in the marrow and released into the blood.Stem cells, were discovered in bone marrow in 1988 and have been shown to have the remarkable potential to develop into many different types of cells and promote healing.
Bone marrow contains at least two kinds of stem cells.One population, called the hematopoietic stem cell (HSC), forms all the different blood cells in the body.A second population, the mesenchymal stem cell (MSC), has the ability to transform into different cell types such as:
Bone cells (osteoblasts and osteocytes)
Cartilage cells (chrondrocytes)
Fat cells (adipocytes)
Fibrous connective tissue cells (fibroblasts)
Stem cells not only have the ability to become other types of cells, they also have powerful anti-inflammatory and immune system modifying properties to influence the healing response of injured tissues.
What is Bone Marrow Aspiration Concentrate?
Bone marrow aspiration concentrate (BMAC), is a concentration of cells that is obtained from a patient’s own bone marrow.Bone marrow aspirate is collected using a minimally invasive procedure that uses a needle to obtain bone marrow from the bone, commonly in the pelvis. The procedure is performed under local anesthesia or light sedation for comfort. The bone marrow is minimally processed in our lab to separate and concentrate the cells using centrifugation.Bone marrow processing protocols vary widely and influence the number and quality of the cells.The resulting biologic product is then injected into injured tissues using imaging guidance such as ultrasound or fluoroscopy (“real time” x-ray).The entire process is performed on the same day and is well tolerated with minimal need for pain medications.
What Conditions Can Be Treated with BMAC?
Bone marrow aspiration concentrate therapy is used for a variety of orthopedic conditions.It has been shown to decrease inflammation and aid in healing.
BMAC therapy may:
Treat osteoarthritis by decreasing inflammation in the joint and delaying disease progression
Protect and repair cartilage
Stimulate bone growth to heal fractures
Improve tendon and ligament healing caused by tears, sprains or overuse
Slow or reverse degenerative disc disease
Patients considering BMAC stem cell therapy should seek qualified providers to provide their treatment.Stem cell therapies using a patient’s own bone marrow are compliant with current FDA regulatory guidelines.
However, other stem cell based products that contain umbilical cord blood, amniotic tissue or exosomes are not FDA compliant and should be avoided.
Dr. Christopher J. Rogers and Dr. Mary A. Ambach are board certified in Physical Medicine and Rehabilitation and have specialized training in Regenerative Medicine. They are experts in the use of Bone Marrow Aspiration Concentrate (BMAC) and other Orthobiologics for orthopedic conditions.
Tom Pernice, Jr., an American professional golfer who plays on the PGA Champions Tour, had injured his shoulder.In fact, he had a full thickness tear of his rotator cuff tendon, an injury that often requires surgery.The pain continued for months despite physical therapy and other medical treatments.
Pernice’s colleague, Dr. Greg Rose, co-founder of the Titleist Performance Institute (TPI), recommended that he consult with Dr. Chris Rogers at the San Diego Orthobiologics Medical Group.Dr. Rogers evaluated the large, retracted tendon tear with high-resolution ultrasound imaging.Conservative care had not been effective and the current standard of care would include an arthroscopic surgical repair.Given that Pernice was preparing to start the tour season, he preferred to avoid surgery and a potentially long recovery.At that time, Dr. Rogers shared his experiences using a patient’s own cells to stimulate tendon healing.
For more than 12 years, Dr. Rogers has used platelet rich plasma (PRP) to heal small tendon tears with good results.PRP uses cells from a patient’s own blood to stimulate healing.For larger tendon tears, regenerative cells obtained from a patient’s own adipose (fat) tissue via a mini liposuction procedure would often give good results.Dr. Rogers shared that he had treated several patients with similar injuries, but Pernice’s injury was severe and the tendon had retracted away from its insertion on the bone.After careful consideration of his options, Pernice elected to give cell based therapy a try.
In May 2019, only a few weeks after his treatment, Pernice had already noticed decreased shoulder pain and improved range of motion.After eight more weeks of physical therapy, he was able to compete and won the Legends of Golf at Big Cedar Lodge.“Surgery would have prevented me from playing altogether.This was a very special win,” stated Pernice.
Now, one year after treatment, Pernice notes, “I have no pain in my right shoulder, movement, range of motion… everything’s as good as it could be, or better than it was.”Dr. Rogers was pleased and surprised when his recent repeat ultrasound exam showed that the tendon was nearly completely healed.“This is a very remarkable outcome, a testimony to Tom’s hard work and this treatment’s ability to heal a very bad injury.”
Great bakers know that when it comes to delivering the best treats and sweets, you have to carefully measure your ingredients.
The same applies to Platelet Rich Plasma (PRP) therapy. The measured amount, the dosage, of concentrated platelets and other cells in the plasma, must be customized to each patient’s specific condition to achieve the best outcomes.
Platelet rich plasma uses highly concentrated platelets to speed up the healing process, decrease inflammation and stimulate tissue regeneration.See our blog on PRP. As we go in-depth in the study of PRP, we now know that determining the best PRPtreatment is not just about how much platelets are in the injection.
Not All PRP are the same
There are other factors that need to be considered to obtain the best PRP treatment. There are other other cells in the PRP, specifically the red blood cells and white blood cells that need to be adjusted depending on the patient’s condition. Platelets release growth factors that facilitate the healing process. The timing and pattern of growth factor release and the individual’s cellular response to growth factors may vary. This can affect outcome and should be thought out in determining PRP treatment. There is a wide variety of methods used to harvest, process and deliver PRP therapy.The resulting platelet count, cell composition and PRP quality are highly variable and can affect clinical outcome.
Only physicians truly experienced in using PRP know how to adjust the dosing appropriately. Joints, tendons, ligament and nerves require their own specific PRP formulation. Imagine if a doctor writes the incorrect kind and amount of antibiotic to treat your specific infection.Patients should make sure that they do their homework in seeking skilled and experienced physicians providing their PRP treatment. These physicians should not only know how to provide the best customized PRP for your need, they should also be adept in the delivery of PRP therapy. These physicians should have advanced training in diagnostic ultrasound or fluoroscopic (xray) guided procedures to make the procedure safe, comfortable and effective.
Not all PRP dosing is the same. Patients should choose physicians who have the knowledge and expertise to ensure they get the right kind of PRP for their orthopedic condition.
Dr. Christopher J. Rogers and Dr Mary A. Ambach are experts and key leaders in the field of regenerative medicine.They are board certified doctors with over 20 years of combined research and clinical experience in platelet rich plasma and other cell based therapies.
In the last two decades, advancements in stem cell research and technology have soared.These revolutionary advances hold a great deal of promise for patients who may suffer from a variety of medical conditions.
What are Stem Cells?
Stem cells have the unique ability to turn into many different types of cells, such as a muscle cell, a tendon cell or a cartilage cell.This process is called “differentiation”.Stem cells also function as part of a repair system that maintains and replenishes cells throughout your entire life.They achieve this by decreasing inflammation, protecting injured cells and stimulating other cells to regenerate.There are many different kinds of stem cells, each with their own specific abilities.
Embryonic stem cells are derived from embryos and have been used for research purposes in the past.They can differentiate into any one of the more than 200 cells in the body.They are only available for the treatment of patients in clinical studies.
Adult stem cells are undifferentiated cells that have a more specific ability to differentiate.There are several different types of these cells and they can replenish certain cells depending upon the specific tissue in which they live.In 1991, a unique population of adult stem cells called the Mesenchymal Stem Cell (MSC) was discovered.The MSC was noted to have an active role in connective tissue repair and the capacity to differentiate into bone, cartilage, and tendon cells.
Since then, significant progress has been made to offer safe and effective treatments using MSCs to heal injured or inflamed tissues.The most studied sources of the MSCs include a patient’s own bone marrow or adipose tissue which contain a heterogenous mixture of reparative cells.
How Can They Be Used?
Stem cell research and technology has evolved to offer many potential medical uses due to their self-renewing qualities and the ability to stimulate tissue healing.Researchers have found stem cells useful for:
●The Study of Disease Processes:Stem cells help scientists understand how diseases occur. Watching and studying stem cells as they mature into their differentiated state helps doctors understand certain diseases and how disease conditions develop.
●Drug Development:Stem cells are used to test drugs for safety and quality. Studying the effectiveness of medications on human stem cells determines their efficacy and toxicity.Stem cells can be “turned into” specific types of cells and then drugs can be tested to see how they work on those specific cells.
●Regenerative Medicine:The body’s natural ability to heal itself is harnessed by stimulating the repair of damaged, diseased or injured tissue using stem cells.Stem cells, directed to differentiate into specific cell types, offer the possibility of a renewable source of replacement cells to treat many common diseases.
Which Orthopedic Conditions have been treated with Stem Cell Therapy?
Several orthopedic conditions have been treated with stem cell therapy.High quality clinical trials have been published regarding the treatment of:
osteoarthritis in the knee, hip or shoulder
rotator cuff tendon tears
achilles tendinopathy
partial anterior cruciate ligament (ACL) tears
non-healing bone injuries
lumbar disc degeneration and low back pain
For more information, published scientific studies can be found at:
