Archive for the ‘AVN/Osteonecrosis’ Category

Stem Cells for Hip Osteonecrosis-Mexican Style: Ole?

Thursday, March 8th, 2012

hip avn stem cells

Why are we so finicky about candidacy grading? As you may know, we insist on giving every patient an honest assessment of their candidacy grading-Good, Fair, or Poor. Being a good candidate doesn’t guarantee the procedure will work just like being a poor candidate doesn’t guarantee it will fail. However, given all the patients we’ve treated through the years, the patient has a rough assessment of where they stand. They also know the possible headwinds they may experience. Recently my partner John Schultz performed an evaluation on a patient with ARCO grade 3-4 hip AVN with collapse of the bone. She was a poor candidate for hip stem cell treatment of any type because she had a “square peg in a round hole”. This is based not only on our clinical experience going back 6 years and treating more than a hundred severe hip patients, but also based on the published works by Gangji and Hernigou. Dr. Schultz told her she was a poor candidate for our treatment. Believing stem cells were magic (they are not), she called a Mexican outfit with little experience treating hip AVN and was told that their stem cells would likely work. She went to Mexico and had a very painful bone marrow aspiration from her tibia (not a great place to take a marrow aspirate because the bone is very thick and it’s painful). The cells were spun down in the same way that she could have gotten at many clinics in the United States using a bedside centrifuge. They then re-injected the cells into the hip joint without any guidance (blind), so we have no idea where they went. In addition, for AVN, since the main issue is in the bone, injecting cells into the hip joint after the bone has collapsed will do little good-like trying to fix the roof on a house where the structure of the roof has collapsed. However, this was done this way because the technical expertise needed to place cells into the bone is very high. She had intense pain, so the next day they carried her back from her resort hotel to the clinic for a second injection. After paying $8,500, she’s now signed up for a hip replacement after Dr. Schultz again refused to treat her with stem cells because it wouldn’t help her hip. The upshot? Buyer beware. There’s a good reason we’re brutally honest with patients about their prospects, as we’ve usually treated many patients just like them and know what works and what doesn’t. Again, while this doesn’t mean all good candidates get magic results or all poor candidates get no results, it does mean that we try hard to not take money from patients we have little hope of helping. When we do agree to treat poor candidates, we continually emphasize that we are not optimistic about their prospects. In addition, the basis for the treatment needs to make sense, even if it ultimately fails. For example, not placing cells in the bone to treat a bone disease is a bad idea.

Share

Tags:
Posted in AVN/Osteonecrosis, Hip, Latest News | Comments Off

Dr. Centeno Teaching Orthopedic Surgeons in China this Week

Friday, January 13th, 2012

Dr. Centeno was in China this week teaching orthopedic surgeons how to use autologous stem cells for hip osteonecrosis/AVN as well as for knee arthritis. Above is a picture montage from his trip. The images clockwise from top left: arriving at the lobby of one orthopedic hospital (the Chinese sure know how to make you welcome!), Dr. Centeno in the operating room teaching surgeons how to place stem cells using a minimally invasive technique rather than a surgical CORE decompression, what’s for dinner (boiled peanuts and chicken feet!), a sign in the hospital with a poor English translation (instead of “No Smoking”). Our physician’s commitment to spreading the “gospel” of “Interventional Orthopedics” is one of the things that sets us and our Regenexx network apart!

Share

Posted in AVN/Osteonecrosis, Latest News | Comments Off

Treating Hip AVN/Osteonecrosis with Stem Cells

Thursday, January 5th, 2012

hip avn stem cells

Hip AVN stem cell treatment has been science fiction for many patients but we here at the Centeno-Schultz clinic have been pioneering this advanced procedure for years. RA is a patient that has benefited from an injection of his own stem cells which helped him to dodge the hip replacement bullet. He is now 58 years old seen and was first seen by us in April of 2009. In 2003 he had a fall on his hip while playing volleyball and was eventually diagnosed with avascular necrosis of the hip. By the time he was seen in our clinic he was an ARCO grade III with a large area of osteonecrosis in the head of the femur and flattening of the femoral head. He was only a fair candidate for being able to avoid a hip replacement with a stem cell injection due to this advanced grade of osteonecrosis (grade III means that the femoral head had begun to collapse). The patient had tried various treatments before being evaluated by our clinic and these had included chiropractic adjustments, acupuncture, and arthritis medication. Being an otherwise active man in his late fifties, he wasn’t thrilled about the prospect of undergoing a hip replacement. As a result we agreed to place his own cultured stem cells (Regenexx-C procedure) into the femoral bone lesion under x-ray guidance. Note that rather than an injection of the cells in his joint (an easier injection) that our advanced AVN procedure involved placing a needle into the bone lesion to deliver the stem cells. Now 2 1/2 years out from his procedure, he reports that he’s 70% improved and has yet to pull the trigger on a hip replacement. Even just delaying hip replacement by just a few years in these AVN patients (possibly longer term) may mean the difference between needing just one hip replacement versus needing to replace the worn-out prosthesis at a later and much more invasive second surgery. In addition, research has already shown that less advanced stem cell injection procedures can delay the need for a hip replacement as much as ten years. While we generally have more success with ARCO grade I and II osteonecrosis patients, we’re happy to hear this success story from a more severe grade III patient!

 

Share

Tags:
Posted in AVN/Osteonecrosis, Hip, Latest News, Regenexx-C, Uncategorized | Comments Off

Blood Pressure Drugs and Stem cells: Our Advanced Lab Data

Wednesday, November 16th, 2011

stem cells drug effects

Having an advanced culture facility for stem cells, we can look at things like whether certain medications adversely impact stem cells. We’ve seen many medications that seem to have a negative impact, but one that stood out was a certain class of blood pressure medications known as ACE inhibitors. A very commonly prescribed generic drug of this class is Lisinopril and several years ago it seemed to be everywhere (the drug went generic). About the same time we noted a suspicious rash of a few patients having difficulty culturing cells. When we tracked it down, it seemed these few patients had one thing in common, they all were on this new generic blood pressure drug. When we took the patients off the blood pressure drug and recultured their cells, their stem cells grew fine in culture. On an experimental basis when we exposed their serum (with the blood pressure drug) to normal healthy stem cells, the cells also had a hard time growing. Conversely, when we took the patient’s cells and grew them in serum without the drug the cells would grow well. So it wasn’t a big surprise this week when I came across this study showing an association between these blood pressure drugs and bone loss. Believe it or not, your bones need mesenchymal stem cells to stay healthy. Think of these cells as the maintenance men of the bones-fixing small amounts of damage to keep your bones repaired and strong. What happens when you take a drug that harms the stem cells in your bone? Your bones get weaker from less repairmen fixing the small damage that happens everyday. A good example of this is the recent research showing that patients taking steroids (which harm the stem cells in cartilage and bone) have more of a specific bone disease known as osteonecrosis. The upshot? Certain drugs will harm your stem cells. Since this is a new therapy, only those with advanced lab facilities can provide a list of medications you should avoid.

Share

Posted in AVN/Osteonecrosis, Latest News | Comments Off

Frightening Increase in Osteonecrosis in Patients taking Oral Steroids

Thursday, November 10th, 2011

osteonecrosis steroids

A study just published shows shocking amounts of increase in osteonecrosis in patients treated with oral steroids. Osteonecrosis or avascular necrosis (AVN) literally means “bone death”. This disease usually involves the hip and can mean a rapid collapse of the structure of the femur bone which causes severe arthritis. We’ve known for awhile that the single biggest easily preventable cause of osteonecrosis is the casual use of extremely powerful steroid medications by physicians. These medications are frequently used in patients who have flare-ups of severe arthritis, asthma, or sciatica.This new study now shows that just taking oral steroid medications for up to thirty days (commonly a week to 10 days) increased the likelihood of getting this dreaded disease on average 380%! For those unlucky enough to find themselves on these drugs for more than a year, the likelihood of being diagnosed with osteonecrosis went up 21,200%! As an interventional pain clinic, what’s very concerning to us is that we still see primary medicine physicians placing sciatica patients on these powerful and high risk steroid drugs. We hope this new data will educate physicians to exercise caution before prescribing these drugs, as we’ve seen many patients for stem cell treatment of their osteonecrosis who got the disease because of this preventable cause.

Share

Tags:
Posted in AVN/Osteonecrosis, Latest News | Comments Off

Further Analysis of Regenexx-C Data

Wednesday, July 20th, 2011

knee hip stem cell treatment

We’ve been re-analyzing Regenexx-C data for a scientific publication and came across some interesting observations. We’ve traditionally reported that hip arthritis patients tended to respond less often than knee arthritis patients to our cultured stem cell injections. However, when we take out patients with the bone disease avascular necrosis (AVN, also called osteonecrosis), a different picture emerges. AVN  is a disease where the bone in the ball of the hip joint is dying off and the arthritis is not caused by usual wear and tear forces, but usually by this bone death. While we’ve had great success in treating ARCO grade 1 and 2 AVN patients, we usually get grade 3′s and 4′s who want to try the procedure, as those patients are usually facing a hip replacement with many more possible complications than the average patient with hip arthritis. These later stage AVN patients were in our initial hip arthritis data we reported because they also have arthritis. When we remove them from that hip data at the one year mark, we see what we have above (see graph). Initially it looks like the hip arthritis patients are reporting a slightly greater amount of relief than the knee arthritis patients. However, the drop-out rate (the number of patients we couldn’t contact to obtain outcome information) is higher in the hip group than the knee group. To us, this likely still means that the patient’s with hip arthritis are not doing as well as the knee group. This is because more seem to have moved onto other treatments and as a result, are no longer answering outcome questionnaire requests. However, this data also shows that hip patients without AVN tend to do better with stem cell injections than those with AVN. We’ve been working on improvements in the procedures used to accurately place stem cells into the hip to provide maximum benefit, so hopefully the next time we look at this data the hips will be doing as well as the knees. The upshot? We spend many hours pouring through our standardized outcome questionnaires making sure what we do is helping patients and making sure that we can reasonably set expectations for any stem cell based procedure.

Share

Tags: , , ,
Posted in AVN/Osteonecrosis, Hip, Knee, Regenexx-C, Research Presentations/Publications | Comments Off

Ankle AVN and Stem Cells: Only Halfway toward the Finish Line

Monday, May 16th, 2011

ankle stem cell

FB is a middle aged business man who injured his ankle in a running related fall about 12 years ago. The ankle talus bone was fractured, so his doctors placed him into a cast. He saw many doctors as he had continued pain and then in 2006, he got the diagnosis of AVN of the ankle (also known as osteonecrosis). He was told he needed an ankle fusion. He was evaluated by our clinic in 2009, as serial MRI’s had shown no improvement in his condition and he wanted to avoid the ankle fusion. We debated at that time whether we should inject stem cells directly into the talus bone AVN lesion and risk fracturing this small bone or simply inject them into the ankle joint between the talus and the tibia. We ultimately chose the more conservative route and he underwent several Regenexx-C treatments where we injected his own stem cells into the tibio-talar ankle joint. I spoke to FB this week to review his MRI’s and decide on next steps, as from an outcome standpoint, he’s not yet to the finish line (some improvements, but not as much as we had hoped). His MRI images are above. On the left, his before sagittal T1 MRI shows a large dark area of AVN in the talus with the white arrow pointing to the front of that lesion. The problem with AVN bone lesions is that they tend to weaken the bone so much that it collapses. First the cartilage above the lesion goes, then the bone underneath caves in. Note that the same area of the white arrow in the 2011 after images (about 2 years after his first treatment) shows no dark area AVN lesion in the front of the ankle. This white arrow area is exactly where we were able to place most of the stem cells injected under x-ray guidance. However, as happy as we were to see that his AVN lesion was stable and getting smaller, we think we could have done better (similar to the results of stem cell injections we’ve seen in this patient’s AVN lesion in the knee), if we had placed the cells directly in the talus bone. The patient has a decision to make regarding additional bone related treatments. As in keeping with our clinic’s philosophy, we think it’s as important to discuss our successes as well those cases that only got halfway there, like FB. After all, understanding why you got only halfway to the finish line can hopefully help you figure out how to get the rest of the way home!

Share

Tags: , ,
Posted in Ankle, AVN/Osteonecrosis, Latest News, Regenexx-C | Comments Off

Hip AVN and Stem Cells: Difficult Choices for a JRA Patient

Wednesday, March 23rd, 2011

hip avn avoid surgery

JM is a 33 year old with a long history of juvenile rheumatoid arthritis (JRA) who was seen in January of 2009 for AVN of the hip. At that time he had been in remission from the JRA for about 10 years and had been diagnosed at the age of 18 months. He already had his right hip replaced due to joint damage from the JRA and didn’t want another hip replacement. He initially came to us for a stem cell treatment of left sided hip arthritis, but on initial exam his MRI showed stage 1-2 AVN in the bone, so we redirected treatment at the bone rather than the cartilage, as treating cartilage didn’t make much sense if the bone would eventually collapse underneath the cartilage. Stopping the advancement of the AVN or osteonecrosis was therefore our main focus. As a result, he underwent a percutaneous core decompression of the hip with a Regenexx-C bone procedure on 1/29/09 (needle placed under x-ray guidance into the AVN bone lesion). He is now 2+ years out from the procedure and just sent us an e-mail this week (some of the info was personal or about complex health choices, so this is redacted):

“…the pain in my left hip is 50-60% better with that one treatment…”

JM now has a bigger quandry. Because of his long history of active JRA, many of his joints are failing. We didn’t treat the cartilage so it’s difficult to know if we could have helped that problem with Regenexx-C. Because of his severe JRA, he’s left with alignment issues in the hip and is trying to decide the best way to proceed. JM’s result brings up a key point that we always discuss with AVN patients. Our primary goal is to treat the bone collapse with a secondary goal of treating cartilage. If we catch the disease early, our clinical experience tells us we may help both. However, for JM, his cartilage loss began in many joints (including this hip) due to the JRA. The upshot? For our approach to AVN to be a total success, we need to see these cases when they are at stage 1-2 and before serious cartilage loss occurs in the joint. Our experience has been that patients with early AVN, but severe cartilage damage for other reasons, may only have be partial improvement in their pain. We’re trying to help JM decide on his best options going forward.

Share

Tags: , , , ,
Posted in AVN/Osteonecrosis, Hip, Regenexx-C, Rheumatoid Arthritis | Comments Off

Oral Steroids and the Tragedy of Osteonecrosis/Avascular Necrosis

Friday, March 18th, 2011

Hip ostenonecrosis avn steroids

One of the tragic medical conditions we’ve seen this past 6 years while being involved in orthopedic stem cell work is young healthy patients that develop osteonecrosis (ON also known as avascular necrosis) of the hip after taking oral steroids. As an example, we just reviewed stem cell procedure candidacy for a young man who was given high dose oral steroids for an upper respiratory infection and as a result developed osteonecrosis. Luckily this was one of the few patients who contacted us early, while he was firmly in stage 1-where the success rate of a stem cell reimplant to treat osteonecrosis is still very high. As a result of yesterday’s reminder of this very dire societal problem, I decided to focus the blog this morning on high dose oral steroids and ON. Osteonecrosis is a disease where the bone (usually in one area, sometimes in many) begins to die off and will often rapidly collapse. This problem occurs most often in the hip. In many patients frequent causes are alcoholism and malnutrition, but the most common easily preventable cause of osteonecrosis is high dose oral steroids. Oral steroids like Prednisone are powerful anti-inflammatories that can reduce swelling in serious medical conditions like asthma, however they are also given to patients for much less serious conditions such as a simple upper respiratory infection or a flare up of sciatica. Your body uses steroid anti-inflammatory hormones everyday, so your body is used to seeing a certain amount of these compounds. The problem is that while oral steroids can reduce swelling, they are given in such high doses that they can cause some of the cells that help to maintain bone to die off or become stunned. Not everyone or even most people that take these powerful drugs will get osteonecrosis. How much does taking oral steroids raise your osteonecrosis risk? One recent study in Japan calculated that your risk of getting osteonecrosis was 20 times higher by taking oral steroids (OR=20.3). Since the overall risk of spontaneously being diagnosed with ON is small, 20 times a small number is still a relatively small number. However, to put this risk in perspective, the anti-inflammatory Vioxx was taken off the market by the FDA because it roughly doubled the risk of sudden death due to a heart attack. Your odds of getting a heart attack with Vioxx are 10 times less than your risk of having your hip turn to mush with oral steroids. What’s interesting is that we have known for awhile (1987) that oral steroid dose is directly related to the amount of ostenecrosis that is caused by the drug-the higher the dose, the more ON you see as a side effect. This same effect has been seen by others. As a result, some authors have argued for lower pulsed doses of steroids (meaning giving the patient a lower dose with “drug holidays” in-between doses).

Who’s at risk for getting this dreaded disease when taking oral steroid medications? Patients with connective tissue diseases (i.e. lupus), high cholesterol or triglycerides, or prior trauma to the area. What can you do to prevent getting ON if you find yourself needing to take oral steroids? If you had asked me this question last week I would have said nothing, but performing this literature review for the blog this morning, I actually did find a few interesting studies that suggest there may be ways to reduce your risk. One simple way to reduce risk for patients that need to take oral steroids everyday is to use a drug holiday. In one animal study, stopping and starting steroids reduced the number of osteonecrosis cases by more than 80%. In another recent study, a vitamin supplement approach was used. Animals placed on very high dose steroids who were given Vitamin E saw their ON risk lowered from about 70% to 23%.This is a such a simple solution and one with other health benefits, that other patients at higher risk due of osteonecoris due to drug therapy (like those taking bisphosphonates such as Boniva, Fosamax, and Actonel) may want to consider taking Vitamin E. The upshot? Personally, I would recommend to my family and loved ones to stay off all oral steroids if possible. For common and less severe medical problems like upper respiratory tract infections and flare ups of musculoskeletal conditions, we won’t perscribe these drugs due to this osteonecrosis risk-we’ve just seen too many tragic cases. For those who need to be on these drugs for serious medical conditions for which there is no other option, ask your doctor to consider reducing the dose to the least amount that will still produce an effect or to provide a regular drug holiday from the medications. In addition, even for those who have to take these drugs for a short-term problem, make sure you take your Vitamin E!

Share

Tags: , , , , , ,
Posted in AVN/Osteonecrosis, Hip, Latest News | Comments Off

Knee AVN (osteonecrosis) helped with Stem Cell Injection

Thursday, January 20th, 2011

Knee avascular necrosis (AVN- also called osteonecrosis) is a dreaded disease where the bone begins to fall apart. It was once thought that this problem occurred due to bad blood supply to the bone (hence the name).  While this may still be the case in some circumstances, AVN is likely more often caused by bone cells that are unable to keep up with the normal wear and tear that happens to all bones. This means that more bone cells die off due to normal use than can be replaced by new bone cells (mesenchymal stem cells differentiating to osteoblasts who then make new bone cells). So placing more stem cells in the AVN area to make more bone might help. This is the case of a woman in her 70′s who has had multiple knee surgeries and refused to give up and get a knee replacement due to concerns about complications. She was diagnosed with AVN of the knee and had this area watched with serial MRI’s for years. She had tried the latest and greatest technologies for her knees and wanted stem cells when they became available. As a result, she came to see us for the Regenexx-C procedure with injection of her own bone marrow stem cells into her medial femoral condyle of the knee (area of the AVN lesion). Above are the pre and post stem cell treatment MRI’s. (she lives on the east coast, see we were unable to get her imaged on the same machine). The left two MRI slices (1/2 and 2/2) are front views of the knee and the AVN lesion on the top left picture is encircled in the dashed line. It’s the dark color in the otherwise white bone. On the bottom right pre-treatment image, she has a fracture in the bone which is about to flake off. We felt it unlikely we would save this piece, so the treatment was focused on stopping the AVN above, as if left unchecked, the rest of that side of the knee bone would have continued to collapse. The after treatment pictures are on the right. The upper right picture shows normal bone signal in the dotted circle (no AVN lesion) and the lower right picture shows that the piece that was hanging on in the pre-treatment MRI has flaked off and been reabsorbed by the body. The summary is that the lesion has dramatically improved in this end-stage knee, due to an injection of the patients own stem cells under x-ray guidance into this bone AVN lesion. The radiologist’s impression is below. Has her pain changed in that knee? I spoke to her last night and she stated that it used be very swollen and painful all the time, but now the swelling is markedly down and the pain has significantly receded since the injection. The upshot? We’ve had good experience treating AVN lesions with using the patient’s own stem cells to treat certain lesions and stopping the progression of the AVN. There are a number of published reports on this technique, so others have confirmed that using the patient’s own bone marrow stem cells can halt the progression of this horrible disease. It should be noted that we don’t know the long-term outcome of the treatment yet, but in the 9 month time frame, things are going very well.

Share

Tags: , , , , , , , , ,
Posted in AVN/Osteonecrosis, Knee, Latest News, Regenexx-C | Comments Off