Regenerating one's joints and spine is not in the future; it is happening today! Last year in the US, there were almost 2 million total joint replacements and another 25 to 30 million joint surgeries. In increasing numbers, people are seeking nonsurgical alternatives to joint and spine surgery. Cutting out a part of a joint or injecting it with steroids is not the answer. Surgery can always be done but never undone.
In previous columns, I have discussed dextrose prolotherapy and PRP prolotherapy. This column deals with a new paradigm: stem cell prolotherapy.
When one has been told that one has bone-on-bone, severe arthritis; one has a degenerated joint; or that a lot of cartilage has been worn away and that the only thing left is to have the joint replaced, one now has another option. Stem cells have the potential to regenerate into any type of body tissue, and their use in regenerative medicine is growing in popularity in the medical word as an alternative to invasive orthopedic surgeries, including total joint replacement. The remarkable thing about stem cells is the fact that when you inject them into a specific area of the body, they know what kinds of cells the body needs – for example, meniscus cells or cartilage cells. It is a very exciting time in the field of regenerative medicine.
Bone Marrow Stem Cells
Stem cells are contained within bone marrow. This has been shown in studies for many years now. Harvesting them from one's own body eliminates the possibility of cross-reaction or rejection. This autologous (obtained from oneself) bone marrow aspirate contains not only mesenchymal stem cells (cells that are able to develop into the tissues such as bone and cartilage) and progenitor cells, a different type of stemlike cell, but also other cells that produce growth factors and cytokines (cells that affect the behavior of other cells). These cytokines aid in fibroblastic proliferation. Fibroblasts are cells that synthesize the structural framework. Stem cells can form tissues such as bone, cartilage, labrum, meniscus, and ligament. All this allows for repair and remodeling of cartilage, bone, and other soft-tissue structures such as meniscus, labrum, ligament, and tendon.
Adipose Stem Cells
On the other hand, adipose tissue is also a rich source of adult stem cells. These cells, harvested from one's own fat, have an extensive proliferative capacity and can differentiate into multiple cell lines. Stem cells derived from adipose tissue can differentiate ligaments, bone, cartilage, muscle, or other tissue. This type of stem cell is now being used in musculoskeletal medicine to not only regenerate the above tissues but also provide a scaffold to hold the stem cells in place and allow them to grow. Adipose-derived stem cells are similar but not identical to bone marrow cells.
Not all injuries require stem cells to heal. The success rate with traditional prolotherapy (both dextrose and PRP) is in the 90%-plus range for all patients. However, for those cases of advanced arthritis or aggressive injuries, or when one has been told to have one's joint replaced, some may need to use stem cell prolotherapy to regenerate the defective joint.
I use this in combination with PRP prolotherapy (to accelerate the stem cell healing) and with dextrose prolotherapy (to strengthen and stabilize the surrounding support structures).
As more and more research comes out, what is known by a few physicians is being proved. A recent research study was conducted and titled "Transplanted Bone Marrow and Fat Mesenchymal Stem Cells with Platelet-Rich Fibrin Glue Scaffold Stimulates Full-Thickness Cartilage Defects to Heal."
Several human studies have been done using bone marrow and fat stem cells for articular cartilage lesions. Articular cartilage is a type of cartilage that covers joint surfaces and is most susceptible to injury compared with other types of cartilage. Researchers at Cairo University School of Medicine and the University of Pittsburgh School of Medicine reported on the use of bone marrow mesenchymal stem cells and a platelet-rich fibrin scaffold to heal full-thickness cartilage defects in five patients. The researchers studied the treatment results from the bone marrow mesenchymal stem cells with success.
Articular cartilage has limited repair capacity, and marrow-stimulation procedures such as microfracture, osteochondral grafts, and autologous cartilage implantations have had limited success in articular cartilage defects. The researchers from this study chose mesenchymal stem cells from bone marrow because these can differentiate into cartilage cells. In the case of these five patients, the bone marrow was harvested from the iliac crest (hip bone). Platelets were used as a scaffold because they contain various growth factors that stimulate cartilage regeneration. The researchers expected that the biological effect of multiple growth factors on tissue regeneration is greater that of a single growth factor.
Results: The patients showed significant functional improvement. Two of the patients underwent arthroscopy after the transplantation and showed near normal articular cartilage. Three postoperative MRIs revealed complete healing and congruent cartilage tissue, whereas two patient MRIs showed incomplete (it was partial and not 100% complete) congruity in the cartilage tissue.
Conclusion: The researchers concluded that the transplantation of autologous culture-expanded bone-marrow mesenchymal stem cells in platelet-rich fibrin glue shows great promise in the treatment of full-thickness articular cartilage defects, particularly large-sized defects (>4 cm). The positive 1-year clinical outcomes support further randomized controlled clinical trials of this treatment modality with larger numbers of patients and longer follow-up periods.
In my practice, I use all four types of prolotherapy in a nonsurgical procedure to regenerate joints: bone marrow stem cell prolotherapy, adipose (fat) stem cell prolotherapy, PRP prolotherapy, and dextrose prolotherapy. All of these are considered forms of prolotherapy, since they cause the tissue to proliferate or regenerate. When new tissue, whether it be cartilage, bone, ligament, tendon, meniscus, labrum, or other, is regenerated, it becomes more vibrant and stronger and the joint can function well again. The goal is the same: to stimulate the repair of injured tissues.
The techniques that I use for stem cell prolotherapy involve direct bone marrow aspiration as well as adipose aspiration to obtain stem cells. Both solutions are then centrifuged and concentrated to get a solution with the most concentration of stem cells. In our experience, we have discovered that these stem cells act as great proliferant solutions for regeneration. We inject both of these sources of stem cells and then use PRP prolotherapy to accelerate their healing. In addition, we use dextrose prolotherapy to the outside of the joint to help stabilize the ligaments and tendons that hold the joint in place. Using two sources of stem cells (bone and fat) as well as PRP prolotherapy and dextrose prolotherapy is considered the gold standard for stem cell regeneration. Many other clinics only use one or two of the above procedures but not all four.
Again, this procedure is usually used for cases wherein one has been told to have one's joint replaced or has bone-on-bone, advanced arthritis; severe meniscus or labral tear; or other aggressive injuries. This is only recommended after a very through history and physical exam. It is important to have an X-ray to confirm what is known by the above exams. Not everyone is a candidate for this procedure, but many are.
I had a patient who at age 40 was told to have his hip replaced. He told me that they calculated that he would need total hip replacement at least three, and as many as five, more times in his lifetime. After a consultation that included a thorough history and exam, plus review of his X-rays, he was deemed a candidate for stem cell prolotherapy.
Another patient was told at age 66 that he needed his knee replaced. He then chose to have the surgery. Due to complications at the time of surgery, which included taking him back to the operating room, he needed to stay in the hospital for a total of 14 days. That delay in getting him up and about and in getting to physical therapy left him with a knee that cannot fully flex. Now, four years later, they are telling him that he needs his other knee replaced. Since one knee was already dysfunctional due to a surgery, he sought out a nonsurgical opinion. He too was a candidate for stem cell prolotherapy.
There are many more patient stories that I could tell, but the big picture is that if the surgery does not work out as planned, you can never go back. And it can leave one with a lifetime of additional or even worse pain. It is always best to get a nonsurgical opinion before one decides to have surgery.
The good news following the stem cell procedure is that one can exercise and start getting back into shape. Except for a few days of no exercise, movement with daily living and work is encouraged. With stem cell prolotherapy, there is no down time, no wound infection, no antibiotics, no multiple doses of prescription narcotics, and no physical therapy for rehab. Plus it allows one's body to heal itself. There are none of the problems that can be associated with total joint replacement: wound not healing, device failure, bleeding into the wound, and others. And lastly, many joint replacements only last anywhere from 8 to 12 years, meaning that the procedure will have to be done several more times in the patient's lifetime. Stem cell prolotherapy, in over 90 % of the cases, only has to be done once if done properly. Stem cell prolotherapy is gaining recognition and rightfully so. I am not against surgery; what I am against is the excessive orthopedic surgeries being done that sometimes have little or no effect and, worse, may have disastrous effects. The rush to "cut first and ask questions later" approach is finding that there are alternatives which people are demanding. And stem cell prolotherapy is one of them.
Remember that once surgery is done, it cannot be undone!
Peter A. Fields, MD, DC, is well known in the field of stem cell therapy and lectures on and teaches other physicians these techniques.
1919 Santa Monica Blvd, Suite 220
Santa Monica, California 90404
310-453-1234; fax: 310-453-1212