Ortho Stem Cell Treatments: The Importance of Delivery

Stem cell therapy is a alternative to traditional orthopedic knee surgery.  Mesenchymal stem cells (MSC) can differentiate into cartilage, bone, tendon, ligament and disc.  Studies have demonstrated that the use of cultured expanded mesenchymal stem cells are both safe and effective in the treatment of knee osteoarthritis.

Does it matter how the stem cells are delivered to a targeted area?

In the case of soft tissue this is not a concern since the surrounding tissue will confine the spread of the stem cells to the targeted area.

In the case of a joint such as the knee the delivery of cells  is of critical significance. The key is that stem cell function through local attachment to the damaged site.  Animal studies have demonstrated that cells injected into a large joint often times have difficulty finding their way to the damaged area.

The key is delivering  stem cells directly into the damaged site.  Koga demonstrated this by comparing the results of blindly injecting stem cells into a joint vs dripping the cells directly into the damaged area.  The illustration below tells the story.  A defect in the cartilage was created and different methods of delivery were examined.  On the left there was minimal cartilage growth after the injection of saline.  In the middle there was minimal cartilage growth after blindly injecting stem cells into the joint. On the right where cells were injected directly into the area of damaged there was robust cartilage growth.  The new cartilage is purple in color.

Bottom Line:  The exact placement of stem cells within a joint is of critical importance.

At the Centeno-Schultz Clinic we utitlize x-ray and MSK ultrasound to guide bone marrow and platetlet derived stem cells into the  area of damaged tissue to maximize clinical outcomes.

Knee Replacement Complications

Stem cell therapy is an alternative to knee replacement.  Studies have documented the success and safety of using bone marrow derived cells in the treatment of knee osteoarthritis in patients who were candidates for knee replacement.  Many of the patients at the Centeno-Schultz Clinic are concerned about the risks of knee replacement.

Listed below are some of the risks which have been discussed in  previous blogs.

1)  44% of patient s/p knee replacement continue to have knee pain.

2)   1 in 10 patients who have a knee replacement suffer a serious complication.

3)    Blood clots and potential pulmonary embolism.

4)     Premature failure as noted in hip replacements.

5)      Alteration in gait, creation of new pain and degeneration when incorrect prosthesis size is utilized.

6)      1 in 10 continue to have knee cap (patella) pain.

7)      Post operative pain in patients s/p knee replacement may have pain originating from structures other than the knee

8)      Patients who smoke are at increased risk for complications and death.

9)      Association with wear particles.  Wear particles are microscopic pieces of metal, ceramic, or plastic that break off of from the knee replacement or hip prosthesis and irritate the local tissues and/or enter the bloodstream.

10)   Increase in serum metal ion levels.

11)   Increase risk of death after age 70  The odds of dying from the surgery are 4 times higher in patients aged 70-79 years old.

13)  Patella resurfacing does not improve outcome

Narcotic Risk: FDA issues public health advisory

The Centeno-Schultz Clinic acknowledges the dangers of utilizing narcotics in managing chronic spine pain.  These include addiction, tolerance requiring escalating doses. cognitive and behaviour changes and death.  The Centeno-Schultz Clinic offers comprehensive spine care including facet and epidural injectionsunder x-ray,  SI joint injections, prolotherapy and radiofrequency.  Stem cell therapy is an alternative to traditional spinal surgery.  Regenexx PL utilities platelet derived growth factors to enhance blood flow and reduce inflammation. Previous blogs have discussed the successful use of stem cells for spine pain.

Medication mix ups or mislabeled has potentially serious consequences.

Today the FDA has issued a warning that pills, tablets, or caplets of Percocet and eight other opioid products packaged by Novartis for Endo Pharmaceuticals may have been mixed up, with one drug being packaged as another.

Patients beware!

Quadriceps Tendon Pain

The Centeno-Schultz Clinic offers PRP, prolotherapy and bone marrow and platelet derived stem cell therapies.  An understanding to function and stability is essential and is covered in Ortho 2.0.  Direct visualization using MSK ultrasound or x-ray is our standard to ensure accurate placement and to avoid the complications associated with blind knee injections.

Muscle and tendon function is critical to the knee joint health. A brief review of the anterior compartment is helpful.

The quadriceps is a group of large muscles in the front of the thigh.  It consists of four major muscles:

Rectus femoris: A large muscle that covers most of the other, deeper quadriceps muscles.

Vastus lateralis

Vastus intermedius

Vastus medius

A tendon is a fibrous band of connective tissue that connects the muscle to the bone.  The quadriceps tendon attaches the quadriceps muscles to the patella.

Quadriceps control knee extension and stabilize the kneecap (patella).

Pain can arise from the quadriceps tendon due to inflammation, chronic degeneration or tear.  A tear can be either partial or complete and is usually the result of trauma.  Tendon weakness predisposes to tears.  Conditions that can lead to tendon weakness include  quadriceps tendonitis, chronic diseases, steroid use, immobilization and the use of a class of antibiotics called fluoroquinolones.

Orthopedic Stem Cells: Cell Sources

Stem cells have been successful in the treatment of common orthopedic injuries which include knee osteoarthritis, meniscus tears, quadriceps and patella tendonosis and ACL laxity.  Ortho 2.0 discusses  our comprehensive approach at the Centeno-Schultz Clinic.

Stem cells have also been successful in treatment of some neurologic and cardiac disorders.  The world witnessed the successful creation of a trachea utilizing stem cell technology.

Stem cells are available for many sources which include blood, fat (adipose), muscle, synovial fluid and bone marrow.

For orthopedic applications does it matter where the cells come from?

Yes!

Stem cells derived from the bone marrow are best for orthopedic applications as discussed in recent chapter authored by Dr. Centeno.

Regenexx is a bone marrow derived stem cell treatment for common orthopedic conditions.  The procedure involves harvesting bone marrow from the iliac crest(waist bone) and processing it in a state of the art lab.  Clinical differences are accomplished when processing of cells is performed by a stem cell biologist vs a bedside centrifuge.  This is part of the Regenexx difference.  The laboratory is accredited through the International Cellular Medicine Society and tracks patients in a non-profit registry.

Distal Quadricep Tendinitis: A complication from blind knee Injection

The risks and possible complications associated with blind injections include failure, increased pain and injury and have been previously discussed.

At the Centeno-Schultz Clinic knee injections are performed under x-ray or MSK ultrasound guidance to ensure accurate placement of the PRP, Regenexx SCP or other platelet derived or bone marrow derived therapies.

Unfortunately when guidance is not used complications can occur.  SG is a case in point.

SG is an athletic 45y/o patient who sustained a meniscus injury and declined traditional surgery where a portion of the tear would be cut out.  Removal of a injured meniscus places increased force on the remaining knee structure and is associated with acceleration of the degeneration process.(blog).

SG acknowledged stem cell therapy as an alternative to knee surgery and opted to proceed with Regenexx SD.    He had undergone multiple therapies which included physical therapy, chiropractic adjustments and injection of  Synvisc, a medically approved DW40.  MSK ultrasound was not used.  SG reported that not only was the injection painful since the provider stuck him three times but after the injection the top portion of his knee cap was red, painful to the touch and movement of the knee was difficult.  It remained painful for weeks thereafter.

Diagnostic knee ultrasound at the Centeno-Schultz Clinic demonstrated inflammation and partial tear of the distal quadriceps tendon.  The previous knee injection most likely injured the tendon.  Complications such as these can be avoided with the use of MSK ultrasound guidance.

Low Back Pain: Cluneal Nerve Entrapment

At the Centeno-Schultz Clinic we acknowledge that low back pain can arise from the lumbar facets, intervertebral disc and the sacroiliac joint.

An overlooked cause of low back pain is entrapment of the superior cluneal nerve.

The cluneal nerve is compromised of the posterior rami of L1, L2 and L3 and provides sensation to the upper buttocks.

Three distributions of the cutaneous branches of the nerve exist.   Lu et al described the anatomical relationship of the superior cluneal nerve to the posterior iliac crest.  The medial branch of the superior cluneal nerve is confined within a tunnel consisting of fascia and the superior rim of the iliac crest.    The location is 7-8 cm lateral to the spinous process on the iliac crest.  It is lateral and superior to the posterior superior iliac spine.

The nerve can be entrapped between the fascia and the iliac crest causing pain and restriction in motion.  This is similar to carpal tunnel syndrome where the fascia constricts the median nerve.

Case reports  have documented the entrapment of the superior cluneal nerve as a cause of unilateral back and buttock pain.  Patients who have undergone iliac crest bone grafts for lumbar fusions are at risk for entrapment.  Stem cell therapy is an alternative to spinal surgery and fusions.

The Centeno-Schultz Clinic is committed to establishing an accurate diagnosis so effective treatment can be started and you can return to your passions.

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Low Back Pain: Think Lumbar Facet

At the Centeno-Schultz Clinic we are committed to identifying the source of a given patient’s pain.  Back pain can arise from many sources which include dysfunctional muscles, structural instability, facet joint, sacroiliac joint and  disc degeneration.  Ortho 2.0 details the importance of function and stability.

The lumbar facet joint is a small joint in the posterior portion of the spine that is composed of the superior articular process of one vertebrae and the inferior articular process of vertebrae directly below it.  Similar to the knee-joint,  the facet joint is lined with cartilage which allows for  smooth and  painless motion.  It functions to limit the movement of each spinal  motion segment.  Trauma, instability and degeneration can cause damage to the cartilage lined joint resulting in pain.  Conventional radio-graphic studies often times fail to demonstrate facet injury.  Diagnosis is made by injection of local anesthetic into the joint (intra-articular facet injections) or medial branch blocks.

AB is 36 y/o patient with 10year history of low back pain, constant in duration, progressive in nature over the last 11 months, localized in lumbar region right>left with radiations into hips.  Pain was sharp and throbbing.  Aggravating factors included prolonged walking, sitting and running.

Alleviating factors:  percoset, ice and rest.

Treatment to date included PT, chiropractic care, oral narcotics and muscles relaxants.  Patient had undergone two  lumber epidural steroid injections without significant benefit.

MRI of lumbar spine was significant for mild disc degeneration at L4/5, L5/S1 and facet degeneration at L4/5 and L5/S1.

Patient presented to Centeno-Schultz Clinic frustrated with the treatment to date and lack of  improvement.  She underwent x-ray guided injection into the lumbar facet joints which has provided her significant and sustained benefit.

Rather than relying exclusively on the MRI which demonstrated degeneration of the lumbar discs we took history and performed a thorough physical examination which was significant for lumbar facet dysfunction.

Comprehensive care is our commitment at the Centeno-Schultz Clinic.  In order to save a joint not only do you need to know how to help that joint, but you also need to know how it got that way in the first place.

Orthopedic Stem Cells Sources: Autologous vs Donor

At the Centeno-Schultz Clinic we acknowledge the regenerative potential of stem cell therapy for common orthopedic conditions.  Stem cell treatment utilizing Regenexx C and Regenexx SD has been used successfully as an alternative to

shoulder surgery

knee surgery and joint replacement

Peer reviewed studies have demonstrated its safety.

Regenexx utilizes a patient’s own stem cells which are referred to as autologous.

Stem cells can also come from donors and are referred to as allogeneic.

Is there a difference?

Yes as discussed in Dr. Centeno’s recent chapter on Stem Cell Therapy.

Autologous stem cell cells do not have the same communicable disease transmission risk as donor cells since they are the patient’s own cells.

Donor stem cells have the following concerns.

Gene transmission:  Stem cells transplanted from the bone marrow of mice bred to have osteoporosis were able to induce osteoporosis in healthy mice.

Immunosuppressive potential is reduced in mismatched settings.

Orthopedic Stem Cells: How they work

At Centeno-Schultz Clinic we acknowledge the regenerative potential of stems cells in treating common orthopedic injuries.   Dr. Centeno authored a chapter on stem cell use in orthopedic injury.
Regenexx C & Regenexx SD are alternatives to knee surgeries.

How do stem cells work?

Three principal ways:  differentiation, paracrine affect and regulation of inflammation.

Mesenchymal stem cells are multipotent and can differentiate into cartilage, tendon, bone and ligament.

Paracrine means that mesenchymal stem cells release certain growth factors to assist in tissue repair.  Mesenchymal stem cells  can be viewed as construction managers as they recruit other cells to the local area and coordinate the repair of damaged tissue.  The growth factors include TGF-beta, VEGF and FGF.

Finally MSC’s have been demonstrated to regulate inflammation.  Inflammation is not all bad and is the first step in healing.