The CMC (Carpal Metacarpal) joint is at the base of the thumb. It’s the most common site of thumb arthritis.  Patients with this problem have difficulty lifting or grasping things and will often get knife like pain at this location where the thumb meets the wrist.  Options for these patients at this point are pretty limited and include steroid shots, joint replacement (not quite there yet), and removal of a wrist bone with replacement of the joint by a coiled up tendon.  While many of the joints we’ve treated with the patient’s own cultured stem cells are large joints, we have always liked treating smaller joints in the hand, foot, or spine, since they require relatively few cells to treat.  I had our research assistant yesterday pull our data on the patients we have treated over the past 2 years with CMC thumb arthritis to get a sense of how we’re doing with this type of hand arthritis.  The results?  We have treated 6 patients who are on average just under a year out (11.3 months) from treatment (this is far fewer than the several hundred large joints we have treated).  83.4% of thumb patients are reporting greater than 50% improvement after a simple injection of their own stem cells, 66.7% of thumb patients are reporting greater than 75% improvement and the average change is 70% improved.  We have had no significant complications in this group.  A case report of a patient in this group of patients with thumb arthritis can be found here. This fits with my recollection of these patients.  Even if the effect only lasts 1-2 years (given our knee data I’d bet it lasts more than 2 years), this is such a small joint that most patients can grow enough cells for many, many treatments which can be saved “on ice” in cryo-preservation indefinitely.

CM is a 50 year old woman who was treated 2 years ago for moderate hip arthritis with an injection of her own cultured stem cells.  The patient at that point had bone cysts, but good cartilage remaining.  Two years later she reports good relief for the past 24 months with the hip feeling much more fluid.  At this point, her hip is just beginning to feel less fluid with more stiffness, so she would like an updated injection.  She was very good at growing stem cells in culture (some patients aren’t as prolific a cell grower as CM), so she has cells in cryo preservation (“on ice”) which can be used for this next injection (without having to draw more cells and re-culture).  CM brings up an important point in our hip data.  First, hip patients tend to have less relief on average than knee arthritis patients.  This will be part of an upcoming publication, but we belive this may be caused by technical issues with getting stem cells to attach to the right areas of the hip when cells are placed through injection.  CM had great range of motion when she was injected (often not the case with hip arthritis patients) and as a result, we got excellent placement of cells.  The second observation in our data is that hip patients have less duration of effect than knee patients.  This is likely due to the reasons above.  Finally, since we only have 3-4 year follow-up data on a reasonable number of patients, any or all of our patients may need re-injections at some point in the future as a stem cell “booster shot”.

Laser is arguably (like stem cells) a cool word.  Who could forget Dr. Evil’s infamous “Laser” talk with hand parentheses!  We often get asked by patients about “Laser” (hand parentheses included) low back surgery.  We tell them that when you have a disc bulge pressing on a nerve, removing disc tissue is removing disc tissue, it doesn’t matter how it’s removed: with a scalpel, a surgical device, a needle based coblation tool, or a “Laser”.  The removal of the back wall of the annulus fibrosis (the thick outer covering of the disc) weakens the back part of the disc and thus makes the disc more likely to fail.  Discs don’t heal well, so unlike some areas of the body where removing a small amount of tissue might cause more to grow back, this generally doesn’t happen in the spine.  In addition, disrupting important blood supply for this part of the outer disc can also have long-term adverse consequences on the long-term health of the disc.  So using a laser to vaporize this disc tissue is no different than using anything else to remove it, the tissue is still removed and the disc is weakened.  Our approach (and we believe the approach of all future biologic applications for the disc) is to rebuild the back of the disc by trying to get it to heal.  We have seen evidence on MRI of healing of low back discs and reduction in the size of disc bulges. In summary, “Laser” low back surgery is all the rage, but still involves weakening the structure of the disc.

A recent publication by the Agency for Research and Quality that looked at conservative care vs. surgical repair for shoulder rotator cuff tears concluded that surgery provided no measurable benefit. This comes on the heels of other studies showing that orthopedic surgery for meniscus tears may have no benefit over physical therapy, 60% of knee surgery for ACL partial tears likely wasn’t needed, and knee surgery didn’t prevent the development of arthritis. Why all of these studies showing lack of efficacy for these surgeries on knees and shoulders?  Even arthroscopic surgery does a certain amount of damage to get the injured area into a state where it will heal.  In addition, removing parts of a joint (in a shoulder surgery often the end of the collar bone and the ligaments that help stabilize the front of the shoulder joint) can lead to more degeneration of the joint with time.  It’s a bit like repairing a car and having left over parts after the repair and then concluding that you didn’t need those extra parts in the first place.  All the parts are needed and we must be very careful about removing any of them (cutting ligaments, debriding cartilage out of the joint, removing pieces of labrum in a shoulder or meniscus in a knee).  The conclusion?  Orthopedic surgery is a God send for many trauma patients who need to be put back together and can help patients in select circumstances for common sports injuries, but the idea that routine surgery is needed for many problems like meniscus tears, joint arthritis, or torn ligaments, tendons, or muscles, doesn’t appear to be supported by the developing science.  We would advocate using injections in these circumstances (where appropriate and after physical therapy fails to solve the problem) to try to prompt the body to help heal itself.

Interesting story out this week on Medtronic’s Bone Morphogenic Protien (BMP) device used to promote spinal fusion-Amplify.  Spinal fusion is when a surgeon does something to cause one vertebra to fuse to the other (grow together).  Lumbar fusions are big surgeries with big risks.  BMP-2 is used by surgeons to stimulate two bones that normally wouldn’t grow together to fuse. We have published with CSU on the use of BMP-2, so we have some knowledge of it’s properties. One of the concerns we’ve seen clinically is that when used in fusions, it seems to really irritate spinal nerves and lead to significant radiculopathy.  Now this article raises concerns about it possibly leading to a higher rate of cancer. This may make some sense and this is one of the reasons we have always avoided using recombinant growth factors with our stem cell procedure. The concern is that these growth factors can be given at doses many, many times their normal physiologic ranges to “whip” cells into doing certain things.  This extra stimulus may promote tumors, as cells are cycling much faster than their design specifications.  As an alternative, we have always used the patient’s own growth factors from blood platelets to grow cells, as the levels of growth factors are more physiologic.  The jury is still out on the cancer risks of this device, so only time will tell.

MF is a young active man from South America who has a L4-L5 disc bulge that causes leg symptoms and back pain.  He wanted to avoid surgery for the disc bulge, so he sought out the Regenexx Disc treatment, where we cultured his own stem cells to get greater numbers and then used imaging guidance to inject these into specific parts of his lumbar disc.  It’s important for any clinic offering investigational care to discuss it’s successes and it’s cases that didn’t quite get there (at least on the first try).  For MF, 4 months out form the procedure he’s only had a small improvement in symptoms and this is consistent with his pre and post MRI’s of the low back.  The images above are side views (sagittals) of his low back, showing some decrease in size of the disc bulge, but only by 20% or so.  The axial images below (top down view) again show a small decrease in size of the disc.  The reason he may not have gotten more relief may be because this L4-L5 disc is bulging both in the middle and out to the side, partially obstructing the foramen (the hole where the nerve exits).  We have recommended a second procedure for MF, as we believe that we have demonstrated some effect based on objective MRI imaging and believe that it may be possible to decrease the size of the bulge in this other sideways direction (into the foramen).

The knee ACL is one of the main ligaments in the knee that helps to stabilize it in a front back direction.  When this ligament gets injured, many patients opt to have it replaced.  The logic goes that without a strong ligament, especially when they’re active, the knee may be prone to more damage.  In addition, the wisdom has been that even a partial tear was unlikely to heal.  However a new research study out this week questions that concept.  In this study, athletes with knee ACL tears were randomly assigned to either surgery to replace the ligament or follow a strict physical therapy program.  60% of the athletes that didn’t get the knee surgery never needed to have the ACL replaced.  This brings up an important point.  We have seen more patients getting ACL surgery to replace the ligament, even with partial tears.  We would advocate that these patients wait to see if the ligament heals and if it doesn’t heal, many non-surgical options exist that we believe should be tried before surgical replacement of the ACL.  These include prolotherapy (study by Reeves showing effitiveness) or PRP injections (platelet rich plasma taken from a vein, spun down, and injected into the knee).  We belive these injections should be guided by imaging (x-ray or ultrasound).  We have also helped select patients with full thickness (non-retracted) or partial ACL tears by injecting their own stem cells into the tears.  If all of the less invasive injection options fail, then replacing the ligament may be needed.  However, Frobell’s study shows that for many athletes with ACL tears, just letting it heal over time may be enough.

GO is 51 year old who fell from a ladder and when we first met him last summer he had a 3 month history of right knee pain.  His MRI showed a radial tear of the medial meniscus measuring 4 mm by 6 mm and he seemed to have pain associated with that tear.  He didn’t want arthroscopic knee surgery because he was concerned about recent research showing that arthroscopic surgery may not be effective for this problem.  The reason may be that chopping out parts of the meniscus may lead to more joint arthritis through extra forces on the joint surfaces (i.e. less meniscus cushion=more pressure on cartilage surfaces).  Rather than a knee surgery, we injected his own cultured stem cells into the tear under imaging guidance.  He’s now about a year out from his injection and this is what he wrote us today:

-100% pain relief from medial meniscus procedure

-Patient quote: “This procedure needs to be expanded across the world. I know of friends that are still having knee surgery because there insurance will not pay for this procedure. I think once insurance companies find out the stem cell procedure is less money and better for the patients they will be happy pay for this.  Like most stuff I’m sure surgery will still be needed in some situations but stem cells will soon be the leading treatment for most joint injuries.   I plan to have my wife get treated with this stem cell procedure. I have recommend this treatment to many friends and anyone else that will listen. ”I now have become addicted to medical information and medical procedures and plan to go back to school to get into the medical field. This stem cell procedure made me feel hole again and this is something I want to help others feel.  I thank God for foresight of Dr. Schultz to setup the Regenexx company and for the work done by the Regenexx company.

Congratulations to Dr. Schultz for his great work on this patient.  It’s always great to hear this kind of feedback.  As always, it’s important to note that we can’t heal all meniscus tears and there are times that the procedure will fail and the patient will need to have the meniscus surgically treated.

Every few months it’s helpful for me to take a “day in the life” snapshot of long-term and short-term follow-up exams or reports of patients treated with their own cultured stem cells for arthritis.  Today’s installment involves several patients treated for thumb/knee arthritis (blackberry thumb), SI joint arthrits/injury, a knee osteochondral defect, and a hip arthritis patient.  BS is 50ish female with chronic right knee arthritis pain who was unable to hike and had severe right thumb pain at the CMC joint (blackberry thumb or texting thumb) that didn’t permit her to pick up samples as an interior designer.  We injected her own cultured stem cells into the knee and into the thumb about two years ago.  Both areas are significantly better still, she now hikes and lifts samples without issue.  The patient returns to get the other side done (left knee and left thumb joint, as over time they are becoming more arthritic).

SM is a twenty something college graduate student who was involved in a car crash, injuring her sacroiliac joint.  We had tried traditional cortisone injections into the SI with only temporay relief.  We tried prolotherapy which didn’t halp long-term.  We then tried injecting her own cultured stem cells into the joint.  Low back pain went from a constant 5/10 to 0/10.  She was unable to run before the injection of her own stem cells and had gained weight.  Now about 6 months after the procedure, she went for a 6.5 mile run yesterday.

SP is a thirty something personal trainer from out of town with a large osteochondral defect in his trochlear groove of the knee (pot hole in the cartilage).  He was offered micro fracture, but literally couldn’t afford (financially) being out of commission on crutches and in a brace for 6-12 weels or laid up in bed on a CPM machine.  We injected his cultured stem cells into his OCD under MRI planned x-ray guidance and he is now about 3-4 months out form the procedure and reports about 70-80% improvement in pain and function.  He was here for a “booster shot” to see if we could get him a little further down the recovery curve.

I try to also include patients who fail the procedure in these updates.  RD is a fifty something year old patient with moderate hip arthritis who was told he was a FAIR candidate (meaning there was a significant chance the procedure may fail).  He is now a few months out from the procedure, which was the injection of his own stem cells into the weight beraring area of the hip under x-ray guidance.  RD hasn’t noted any improvement.  Why?  One reason may be that we were not able to grow as many cells as we would like for RD, which does happen.  The ability to grow stem cells in culture is as variable as one patient’s healing response vs. another patient’s healing response.  For RD, the procedure clearly looks like a failure.

We were recently happy to show the former president of Argentina our Colorado clinic and give he and his wife a presentation on the use of cultured stem cells to treat orthopedic conditions.  The ex-president and his wife were very interested in the technology we use and in bringing this procedure to Argentina as the practice of medicine.  The president was in town with other Latin American luminaries as part of the Biennial of the Americas celebration in Denver.