May 7, 2013
Musculoskeletal Care of the Mature Athlete
Cartilage injured by trauma or affected by age has limited capacity to regenerate. Current methods address small chondral defects via arthroscopic debridement, marrow stimulation techniques (micro-fracture) and restorative treatment, including osteochondral grafting and autologous chondrocyte implantation. Larger defects are managed with total joint replacement. It is universally agreed that the future lies in biologic solutions through cartilage regeneration. At Regenexx, the future is now. While regenerated cartilage may be derived from various cell types including chondrocytes, puripotent stem cells and mesenchymal stem cells, it is the borne marrow derived mesenchymal stem cells that have the greatest advantage and the least disadvantage in the process of cartilage tissue engineering. It is the Platelet Rich Plasma that contains the common growth factors used in cartilage regeneration. Platelet derived growth factor not only promotes the formation of cartilage, it suppresses the formation of IL-1B thereby halting cartilage degradation. If we now add to the discussion, the role of synovial stem cells in joint regeneration, the reader will have an understanding concerning the three steps in the SD-Regenexx procedure.
Dr. Sheinkop, what will you achieve with a Bone Marrow Aspirate Concentrate (BMAC)/STEM CELL SD procedure intervention for my arthritic joint? Will the cartilage re-grow? Let me address the question by laying out a foundation of principles:
1) Cartilage Regeneration
2) Elimination of Pain
3) Improved Range of Motion
4) Increased Functional Capacity
5) Delay or Avoidance of a Joint Replacement
6) Reversal of the Arthritic Progression
BMAC/Stem Cells provide the most physiologic basis for addressing the six bullets I listed under goals of care. Said treatment is available, here and now. While accompanied by an out of pocket financial responsibility, the risk of complication is pretty much non-existent. Compare that to the risks, pain and lengthy rehabilitation following a joint replacement. At the same time the worst possible scenario is that the stem cells are only partially successful. We now know that a timely PRP additional booster may significantly increase the percentage of successful outcomes. Compare that information to the risk of a revision surgery following a failed joint replacement or the lack of satisfaction and limitations inherent in a joint replacement
Sep 26, 2012
Doctor,
So I rode about 85 miles with about 8,500 vertical feet of climbing around Lake Tahoe on Friday, and then another 50 or so miles with 4,000 feet on Saturday, and the hip didn’t bother me once. I’m still doing big stretches in the mornings. Even as I type this, I’m shaking my head, since it doesn’t seem possible and I have to pinch myself. Thank you a million times over. I feel so lucky to know you and to be blessed with your help and care.
The above was received last Sunday from a patient who is now 16 weeks post bone marrow aspirated concentrate to his right hip. He had presented to me at age 40 with chondrolysis (as part of the progression of osteoarthritis) more likely than not attributable to developmental hip dysplasia. By the same token, I could not rule out Femoral Acetabular Impingement. The patient was not only an avid bicyclist; he makes his living through the cycling industry. Over the previous year, the symptoms in his right hip had progressed to a point that he couldn’t swing his leg over the center post of his bike. He sought medical help when he could no longer walk a city block without pausing from the pain.
My patient’s story is of particular interest because there is little published evidence concerning the effect of stem cells on the hip. To date, most attention has been directed to stem cells and the knee. Several weeks ago, I wrote a blog focused on the outcome of stem cells for a marathon runner assigned a diagnosis of a torn acetabular labrum.16 weeks following a bone marrow aspirate concentrate procedure to her problematic hip, she returned to marathon running. The cyclist returned to cycling in a similar time. Imagine, 16 weeks ago, he had difficulty walking and now he is riding up mountains for almost unlimited distances. We don’t have statistical data yet pertaining to outcomes of stem cells for the hip; but I believe these patients stories are the start of a new approach to the arthritic hip and possibly preventing the progression to the need for a joint replacement. Only outcomes studies will confirm if we are postponing or preventing a surgical procedure. To that end, I have introduced an outcomes clinical study initiative based on the model I used for joint replacement publications and scientific presentations over 35 years of surgical practice. I am recruiting several Regenerative Medicine based practices to pool data so our number of patients under observation will lead to statistically meaningful clinical science. Since the introduction of stem cell management of the hip, I am continually amazed at the early results.
Tags: arthritis, bone marrow, Hip, Hip Replacement, medicine, Osteoarthritis, stem cells
Sep 19, 2012
Most patient educational initiatives centered on Regenerative Medicine are based on positive reports of patient satisfaction. The truth be told, never say “always” in medicine. Outcomes surveillance leads to a better understanding of the who, what, when, where and how of PRP and Stem Cells. There is a particular role and place for all medical alternatives; to assure a best chance of success, the treatment must be tailored to a diagnosis. I am an orthopedic surgeon by training and an extensive surgical experience; Regenerative Medicine has little chance of success for the treatment of musculoskeletal pain unless causation is established. PRP and Stem Cells won’t work when they are not indicated.
A 45-year-old man came to my office for a consultation regarding pain in his lower extremities. Up until two years ago, he had run marathons, completed triathlons and skied in the winter. Because of musculoskeletal pain and progressive loss of his ability to enjoy his recreational endeavors, he sought out multiple Regenerative Medicine practitioners. He had undergone multiple Prolotherapy treatments, PRP spinal interventions, so on and so forth. I began our encounter by listening to him as he summarized his symptom progression. It took one step in the physical examination to establish causation; a disease entity that requires standard anti-inflammatory management. I took a tape measure and recorded his chest circumference during maximum inspiration and then expiration. Normal chest excursion averages two inches, significantly more in an athlete. Less than one inch chest excursion in an adult male points to Ankylosing Spondylitis, an inflammatory spondyloarthropathy. On further examination, he had a “poker” spine; no side-to-side bend or forward flexion. My orthopedic approach was not one of Regenerative Medicine but referral to the rheumatologist who is best equipped to manage this entity
There is a time and place for all things; beware and take care that the approaches with Regenerative Medicine are causally connected.
Mitchell B. Sheinkop, M.D.
1565 North LaSalle Street . Chicago . Illinois . 60610
312-475-1893
Sep 4, 2012
It is our first morning back at the office after the Labor Day Holiday. My assistant started her daily routine per habit by listening to her voice mail. The first message left by a patient was a description of his progress since undergoing a bone marrow aspirate stem cell procedure for Avascular Necrosis of his left hip and secondary osteoarthritis. “Yesterday was the first day in a year that I was able to flex and rotate my hip enough to put on my pants naturally and cut my own toe nails”. These are activities we take for granted but when a 40 year old requires assistance and adaptive measures to complete activities of daily living, the restoration of independence is a big deal. His next goal, return to senior hockey.
Might Bone Marrow derived stem cells eliminate or at least postpone a knee replacement?
We left for Wisconsin to enjoy a four-day holiday cycling and fly fishing. My wife planned to work on her lapidary and silversmith projects while B. and I would ride and test the Southwestern Wisconsin spring creeks. The county highways in The Driftless area below Lacrosse and just east of the Mississippi are pretty much free of traffic and the region has countless spring creeks loaded with trout. It is fairly common to log cumulative elevations of 2,000 feet over a three hour, 35 mile ride. On Thursday, Friday and Sunday, we rode; Saturday was set aside for fishing. When you wade the spring creeks, it is fairly arduous as you have to constantly climb up and down the stream banks or fight the silt build up in a particular stream. The biking was fabulous and the weather most cooperative; I am sorry to report it was fishing and not catching. The heat and draught in effect since late June have taken their tolls on what started out as a great season of trout fishing. What does all this have to do with stem cells and knee replacements? I have been looking after arthritis in B’s knee for many years. While he has “bone on bone” and occasional instability, the initial cortisone injections followed by several viscosupplementation series and then PRP when the latter became available have kept him cycling and skiing. The most recent approach has been a Concentrated-Stem Cell Plasma injection and there are few within 35 years of age who could keep up with us. I have age related, moderately arthritic knees, having undergone bilateral arthroscopic meniscectomy ten years ago but I have no problems as long as I watch my weight and do my fitness training. B. has an advanced osteoarthritis of a knee but I struggle to keep up with him. ( I do throw a better fly). He has no plans for surgery even though his X-ray couldn’t be worse. This fall after the weather curtails cycling, he will undergo a bone marrow aspirate stem cell procedure and we will start training for the ski season.
Mitchell B. Sheinkop, M.D.
1565 N. LaSalle Street
Chicago, Illinois 60610
312-475-1893
Tags: arthritis, Bone Marrow Concentrate, Hip Replacement, Knee, Orthopedic Surgeon, Osteoarthritis, stem cells
Aug 14, 2012
With the increasing data supporting biological repair of certain forms of ACL injury and with the increasing evidence supporting cartilage repair in an injured joint, is there a case for expanding the scope of Bone Marrow Aspirated Concentrate to these increasingly common injuries in the adolescent? For one, the healthiest resource for active and large numbers of mesenchymal derived stem cells is the marrow of an adolescent. There are all kinds of operative approaches for the adolescent presenting with Osteochondritis Dissecans from debridement to whole segment cartilage grafting through open procedures. The net result though of OD in a weight bearing zone is early onset osteoarthritis. There is ever increasing scientific evidence that the adverse long term outcome of joint trauma may be reversed by early application of mesenchymal stem cells. If you add to the treatment algorithm, the cartilage restoration potential of stem cells in the joints of patient’s under age 40, the fact about stem cell repair in adolescents speaks for itself
Turning our discussion to the adolescent Anterior Cruciate Ligament injury, there is no question that said surgical repair has limited survivorship and is only the beginning of a series of revisions over a lifetime. With the recent evidence reported by Regenexx at its annual network meeting, there is a roll for stem cell management of ACL injury in selected cases. Presented were several successfully repaired ACL ruptures in adolescent girls who had sustained recent injury on the athletic field. While we are early in the development of Regenerative Medicine and stem cell treatment for orthopedic injury is still investigational, there are no bridges burned; and just maybe, a lifetime of repeat surgical procedures avoided.
I had occasion on Monday to discuss the stem cell debate with a writer for an orthopedic weekly newsletter. I pointed out that we have been using stem cells in orthopedics for over 70 years whenever we harvest tissue from elsewhere for repairing a defect be it traumatic or degenerative. Bone graft is a means of delivering stem cells to foster bone healing from any cause. Tendon graft is a means of facilitating healing of a traumatic instability, another application of stem cells to effect healing. It just maybe that the legal and payer bottlenecks are the result of lack of clinical understanding of what orthopedics is all about. Would a repackaging of terminology change the stem cell debate in the USA? Stay tuned!
Mitchell B. Sheinkop, M.D.
1565 N. LaSalle St . Chicago . Illinois . 60610
312-475-1893
Tags: ACL Injury, Osteochondritis Dissecans
Jul 31, 2012
Last week, I received a letter from one of the large orthopedic prosthetic manufacturers announcing yet another product recall. This time it had to do with modular designed femoral components generating excessive metal debris at the junctional “welds”. Is the recent flood of product recall the result of faulty manufacturing, more scrutiny by the FDA or consistent with the observation that new isn’t necessarily better? A recent scientific orthopedic publication from the Mayo Clinic confirmed my observation that the length of the surgical incision makes no difference in the immediate recovery but rather it’s the perioperative pain management. Actually, the suggestion was that a minimally invasive incision by reducing the surgeon’s field of vision and maximizing muscle trauma might actually delay or adversely affect a long-term outcome.
When I started my adult orthopedic reconstructive practice sub specializing in joint replacement, the primary concern of the orthopedic surgeon was the length of survivorship of the prosthetic hip and knee. To affect that survivorship, recommendations were advanced to avoid heavy physical labor and sports with impact. My research at Rush documented average survivorship of hips and knees implanted in the mid 1980s of 17 to 20 years. More recently though, the precautions and limitations applied to the patient with the new joint have been thrown to the wind. The Boomers are led to believe they may run, jump and abuse the new implant without limitation and there will be no adverse consequence. To support the theory of the indestructible joint, the orthopedic manufacturing companies introduced hard bearings; that is ceramic and metal on metal. Then came the failure of the ceramic bearing and the concerns about metal ion generation and foreign body granulomas in the metal on metal bearing. Focusing on the latter for a moment, we have learned that there are special risks inherent in metal-on-metal bearings including higher loosening rates and adverse local tissue reactions. The safe upper limit metal ion limit established by researchers include 4.6 mg/L for chromium and 4.0mg/L for cobalt on unilateral metal on metal hips and 7.4 mg/L for chromium and 5.0mg/L for chromium on bilateral procedures.
Recently, I had breakfast with a well known Chicago orthopedic surgeon who happens to be close to me in age, share many of my daily athletic and fitness activities and focuses his practice on the mature athlete. I asked him as to when he thought a joint replacement was indicated, his response “ a total joint is a salvage procedure”. Arthroscopy with stem cell adjunct is the future.
Mitchell B. Sheinkop, M.D.
312-475-1893 or 312-475-1893
1565 N. LaSalle Street . Chicago . Illinois . 60610
