Stem Cell Therapy for Osteoarthritis
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
Click here: Second Opinion Arthritis Treatment Kit
Harnessing the Healing Potential…
The body’s response to injury is a very specific series of steps collectively referred to as the “Healing Cascade”.
This natural healing process requires a combination of stem cells, growth factors, and matrix to optimize tissue repair and regeneration. The use of these bioactive cells to augment and accelerate the natural healing process is considered by many to be a “new frontier” of clinical treatment.
Osteoarthritis is the most common form of arthritis. It is the type of arthritis that people think about when they talk about arthritis and aging.
More than 90 percent of people over the age of 50 will eventually develop some type of arthritis and that type is usually osteoarthritis (OA). OA preferentially attacks the weight bearing areas of the skeleton including the neck, low back, hips, knees, base of the big toe, and base of the thumb.
OA develops because of the loss of cartilage, the gristle that caps the ends of long bones within a joint. Cartilage consists of a matrix consisting of glycosaminoglycans. Within this matrix are cells called chondrocytes that help make new cartilage.
OA develops when there is an imbalance between the normal synthesis and the normal breakdown of cartilage. Certain components within the glycosaminoglycan matrix are lost, water accumulates, and enzymes such as matrix metallo-proteinases begin to “chew away” at cartilage. The end result is cracking and wearing away of cartilage.
The diagnosis of OA is established through a careful history and physical examination. Standard x-rays and sometimes ultrasound or magnetic resonance imaging can better quantify the degree of damage the arthritis has caused.
Treatment of this order involves modalities requiring medication and those that don’t. Non drug therapies consist of patient education, exercise, physical and occupational therapy, assistive devises such as canes, walkers, thermal modalities (heat or ice), and weight loss, if indicated.
Medications used to treat OA include analgesics, nonsteroidal anti-inflammatory drugs, topical analgesics, and joint injections with either glucocorticoid (steroid) or hyaluronan (lubricants).
Some work has been done to try and develop drugs that block the effects of matrix-metalloproteinase inhibitors.
Surgical procedures such as arthroscopic debridement and total joint replacement also have a role in treatment. (Of note, is the controversial success that arthroscopic debridement has in osteoarthritis... it may not be all that effective!)
More recently, devices such as polymer spacers have been used in some joints.
For younger patients, osteotomy – removing a wedge of bone to make the leg line up straighter – is a palliative procedure. It buys time but the patient will still eventually require knee replacement and the procedure takes about six months to recover from.
A current type of treatment for younger osteoarthritis patients is to harvest cartilage cells from nearby healthy cartilage and transplant them into the affected area. This procedure has limitations because only a limited number of cells can be generated. The patient has to undergo two surgical procedures and then go at limited weight bearing for six months.
A more exciting development is the role of stem cells
Scientists at Britain’s Cardiff University have identified a type of stem cell that can be transformed into cartilage cells (chondrocytes).
Immature stem cells have the ability to become any tissue in the body. What’s interesting about the British study is that the cells they have discovered are at a more advanced stage. While they no longer have the ability to differentiate into any cell, they do have the ability to become a chondrocyte when properly cultured in the lab.
In essence, by culturing these cells, scientists will be able to grow a substantial number of cartilage cells that can be transplanted.
The Cardiff team is now conducting tests in animals, with the hope of initiating a clinical trial in the near future.
Closer to home, we are currently using stem cells harvested from the iliac crest (hip bone) of the patient using local anesthetic and a special small biopsy needle. These stem cells- called "mesenchymal stem cells- are "autologous", meaning they are the patient's own stem cells.
In addition, we use a matrix of adipose fat which also contains stem cells and at the same time provides a scaffold for the stem cells to cling to.
Bone marrow is a rich source of autologous adult stem cells, growth factors, and accessory cells. Recent technologic advances now provide the ability to highly concentrate these multi-potent (meaning they can become a cell for any part of the body – a heart cell, a lung cell, a kidney cell, etc.) and, stem cells and growth factors at the point-of-care in less than 15 minutes.
The bone marrow in the hip contains a source of multi-potent stem cells, platelets, growth factors, adhesion molecules, and other proteins responsible for tissue repair and regeneration. Through simple aspiration, a physician can obtain all of these cells from the bone marrow.
Concentrated bone marrow contains enhanced levels of:
Bone Marrow-Mesenchemyl Stem (BM-MS) Cells for bone formation
• BM-MS cells decrease with age
• Concentrating mimics the cell load and healing potential of young patients
• Convert directly to bone and work in areas of hypoxia
Endothelial Stem Cells for supporting vasculature
• Healing is impaired until the vasculature is restored
• Converts directly to vasculature
• Stimulate BM-MS cells
• Stimulated by and work in areas of hypoxia
Hematopoietic Stem Cells for supplying nutrients
• Form blood cells
• Cell-to-cell contact with BM-MS cells stimulate osteogenesis
Platelets to modulate the regeneration process
• Recruit bone marrow progenitor cells to foci of injury
• Provide adhesion sites for stem cells
• Platelet-fibrin clot/network provides migration highway at the site of injury
• Mediate cell-to-cell adhesion
• Maintenance of tissue integration, wound healing, and cellular migration
Here is how it’s done at our center…
A nurse will go over specific precautions that are needed prior to the procedure. Patients taking anti-inflammatory medicines or immunosuppressive medicines need to hold the drugs for at least a week and possibly longer.
To do this procedure, a patient is placed in the prone position (on their tummy) and the skin overlying the posterior iliac crest is anesthetized. A special biopsy needle coated with heparin to prevent clotting is then introduced into the iliac crest using ultrasound guidance. The needle is advanced into the marrow space and a small amount of bone marrow which contains abundant amounts of stem cells is obtained by drawing back on a syringe.
The stem cells are then processed carefully in heparinized saline and then concentrated in a special centrifuge.
We then harvest fat from the buttock or flank using a special tumescent technique. The amount of fat collected depends on the size of the joint to be treated.
For patients with osteoarthritis of the knee or hip, we then will anesthetize the joint. Using ultrasound guidance, we then will “irritate” the cartilage and bone with a special needle.
The next step is an arthroscopy so we can correctly identify the area of bare bone where the cartilage has been worn away and cartilage needs to grow. We induce injury using a special trochar so that the stem cells have an area to home in on. Remember, the first phase of healing is establishing a site of injury.
After this, we will inject the stem cell concentrate followed by the fat, platelet rich plasma, and thrombin to make the mixture a thick gooey gel that adheres to the bone.
In addition to the stem cells, addition of growth factors from platelet rich plasma (PRP) may hasten the growth of cartilage.
Platelets are cells in the blood that have many growth factors. We are able to obtain a significant quantity of platelets by drawing blood from the patient and then spinning them down using a special centrifuge. This platelet rich plasma is what we inject into the joint after the stem cells are injected. The PRP stimulates the stem cells to differentiate into chondrocytes (cartilage cells).
Following the procedure, the patient is advised to limit the amount of weight bearing for approximately three days. We will often have the patient use a special unloader type brace to help with this.
Potential complications as with any invasive procedure include infection, bleeding, damage to blood vessels and nerves, and loss of life and limb. These are all rare.
Your insurance may or may not reimburse you for this procedure. Medicare, does not cover this procedure.
What you get at our center is a unique combination of experience, patient support, and the use of the most advanced technologies to deliver the optimal stem cell treatment for osteoarthritis of the knee or hip.
For more information, call us at (301) 694-5800.
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