Interesting study that examined the muscle activation and biomechanics in knee ACL repair surgery patients at about an average of 5 years after the knee surgery. The study authors noted that many of the muscles that help to stabilize the knee are overactive after knee ACL surgery. The patients also placed less weight on the ACL repaired knee and even had abnormal firing of the gluteal muscles and calf muscles. Women had less abnormal muscles contractions than men, but the women also placed less force on the ACL surgery knee. Why doesn’t a knee with a new ACL have normal muscle activation patterns? The issue we see is that it’s very difficult to replace the ACL surgically and have the same biomechanical properties as the original knee ACL. This study fits with others showing that ACL replacement surgery can lead to more arthritis or that knee ACL surgery doesn’t prevent the onset of arthritis. Our recommendation is if the ACL is completely torn and retracted, you may have a very difficult decision on whether to repair the ACL or leave it alone. More importantly, if your ACL is a partial tear or is a full thickness tear that’s still in place (the two ends aren’t retracted and pulled back like a snapped rubber band), then you may consider stem cell placement into the ACL via injection rather than surgery. Also realize that oftentimes radiology reports may not distinguish between a completely torn and retracted ACL versus one that may be a “complete tear” but is still is in place and otherwise intact (non-retracted).
You know the saying, “there is no free lunch”? Well, several recent studies have rained on the parade of the embryonic stem cells and IPS crowd. A recent piece in the LA times quoting a paper published this week was more percipitation. The problem is that these cell lines have inherent genetic problems. This means that the cells don’t have normal genes, which raises the specter of unintended consequences when these cells are used for therapy (the biggest being cancer). The reason should be clear by now. Embryonic stem cells (or likely even adult stem cells) that are “immortalized” (artificially tricked into growing forever so that they can be mass produced like an antibiotic) pick up these genetic abnormalities because these cells were never designed by nature to have the DNA repair mechanisms that would allow them to be grown for these great lengths of time. For example, everyday, dividing cells in your body pick up back pieces of DNA or errors. We have enzymes that help repair the damage and a secondary line of defense (called the immune system) to yank the malfunctioning cells out of circulation. However, embryonic (or even adult stem cells) were never designed with the mechanisms to be grown for thousands of generations. An embryo is conceived, it grows bigger, and eventually a baby with adult stem cells is born. Nowhere in there was the embryo designed to grow embryonic stem cells for years for the purposes of satisfying a human need for mass produced biologic tissue. How about IPS cells? For those of you who are unaware, IPS means induced pluripotency, which is a fancy way of saying that a normal adult cell is turned into a cell that resembles an embryonic stem cell. Now since this doesn’t even happen in nature, the process of tricking a cell to revert back to the properties of a stem cell is bound to have issues (which many IPS researchers have been very honest about from the start). Again, since normal adult cells aren’t built to divide forever like IPS cells, the same discussion above applies. If you’re seeing a trend here, you’re not the only one. In both instances, it’s our need to create cells that can be mass manufactured to satisfy a business model that creates the problem. How about adult stem cells like those used in the Regenexx procedure family? Adult stem cells are built to do what we’re asking them to do. They help repair tissue and then either differentiate into the bricks and mortar of the repair or they orchestrate the construction job and then disappear from the scene. Growing adult stem cells for short periods (like in the Regenexx-C procedure), still keeps the cells within the parameters of what happens in the body. Studies have shown no significant genetic abnormalities when adult stem cells are grown for short periods and more interestingly, when they are grown very long periods (months and months) and do pick up genetic abnormalities, they don’t form cancers, they just don’t work anymore. Our complications tracking data has also shown that using these short-term cultured stem cells in people poses less risks than the surgical procedures they help many patients avoid. This is consistent with the findings of others showing robust safety for cultured adult stem cells from bone marrow.
In summary, you can’t teach an old dog new tricks (I think that’s my third really bad turn of phrase). Trying to mass produce cells isn’t a good idea with our current state of knowledge. A better idea is using the patient’s own adult stem cells, which is the “customized” medicine long sought by physicians. While the business model may not be as good, it’s sure a heck of a lot safer for the patient.
Many times in the United States, high grade ankle ligament tears (grade 3) are surgically repaired. This is despite their being a paucity of evidence that this is the best course of action for high grade ankle ligament sprains. A recent study of randomly assigned grade 3 ankle ligament sprain patients looked at this issue. In the study, there was a surgically treated group and one that used an ankle brace. Both groups of grade 3 ankle sprain patients got back to activity about the same. The advantage of the surgical group was less recurrance of re-injury of the ankle ligaments. The big disadvantage for the surgically treated ankles, more ankle arthritis. Why would surgery of the ankle ligaments cause more arthritis down the road? The answer may be in another study showing that lateral ankle ligament surgery and repair actually lead to abnormal motion of the foot and ankle. When a joint moves abnormally, we frequently see more arthritis, as parts of the joint can become worn out more quickly. For the ankle, this may be caused by the fact that restoring normal ankle ligament tension and position may be very difficult to nearly impossible. In our clinic, we often see patients after ankle ligament surgeries that are left with ligaments that are too tight. These artificially tightened ligaments can cause abnormal motion in the ankle. As a result, we frequently council our patients to avoid ankle ligament reconstruction surgery. Non-surgical methods of repair (like injecting the patient’s own stem cells into the ankle ligament tear), in our experience, are often more effective and should be attempted before considering an ankle ligament surgery. In essence, based on the published research, ankle ligament surgery should be a last ditch effort to make the ankle more functional and not a first line treatment for ankle ligament injury or severe sprain.
A recent study looked at whether surgically repairing the outside ankle ligaments (lateral) actually restored the normal way the foot and ankle should move. The outside ankle ligaments are important for stabilizing the ankle (keeping everything properly aligned) as we walk and run. As a result, the study tested the whole reason for performing surgery, restoring normal movements. However, if the surgery failed to restore those normal motions, then the surgery may actually cause problems down the road with certain parts of the ankle wearing out faster due to the abnormal motions. The verdict? No type of lateral ankle ligament repair restored normal motion to the foot and ankle. This is a huge problem for patients considering ankle ligament surgery and repair, because the whole concept behind the invasive surgery and extended recovery time is that the surgery will restore normal motion to the unstable ankle and allow the patent’s ankle to be used like it was before the injury. As a result of these and other research findings, we frequently council patients to consider non-surgical options for an ankle ligament tear. This is especially true when the ankle has intact ligament fibers (a partial tear or a full thickness tear without retraction). Non-surgical treatment can often be performed through a needle without the need for surgery. We feel this approach is better, as any approach that involves artificially suturing or replacing parts of the ankle ligaments (as the above study reveals), doesn’t restore the normal motion. We’ve seen patients report success when the patent’s own stem cells are injected into the ankle ligament tear using either x-ray or ultrasound guidance to ensure the stem cells get to the right spot in the ankle ligament tear. In summary, the vast majority of patients we speak to believe that the research supports that surgery is the best option for the ankle ligament injury, however, we believe the research support for this invasive approach is still lacking.
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 believe 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.
Many patients get orthopedic knee surgery to repair a meniscus tear or torn ligament because they believe that doing so will stave off the development of knee arthritis. Not so, says a Dutch study out last week that demonstrated that 326 patients followed for 10 years who had orthopedic surgery to prevent the development of arthritis, got arthritis anyway. This surgery group was compared to a group with no surgery and found to have about the same amount of arthritis as the group who didn’t have surgery. This study brings up an important societal issue. Why spend billions operating on knees if we’re not preventing more serious problems from happening down the road? Where does society as a whole benefit from this spending? It’s our belief that biologic solutions for orthopedic knee problems (such as stem cells, growth factors, biologic replacement parts created in labs) will eventually solve this issue and prevent this development of severe arthritis, but only time will tell if that’s a correct assumption…
GS is a 57 year old white male who works on his feet. When we first examined him several months ago, things were bad. He injured his left ankle in a car accident in 1973. He had tried and failed physical therapy, chiropractic, massage therapy and steroid injections into the ankle. He was miserable, being forced to get off of his feet for several hours a day and spiraling out of control on pain meds and alcohol. At times he would drink a case a beer a day to manage the pain and continue working. He was told he needed an ankle fusion, something he had heard might help or might make things worse. On exam, we noted that not only did he have MRI evidence of severe ankle arthritis and a partially torn deltoid ligament (the ligament that helps to stabilize the inside of the ankle), but he also had other issues such as swollen tendons. We initiated injections for the inside ankle ligaments and ankle arthritis using his own stem cells. The result, after the second injection and at the third injection today is that he reports that he’s off the booze and pain killers and that his ankle is 90% better. He no longer has to get off of his feet and his wife’s happy that he’s not spiraling out of control on prescription drugs and alcohol. GS’s case is another example of how exact placement of cells based on history, exam, and imaging is needed to preserve a severely degenerated joint. Did GS get a new ankle due to stem cells? No. We have simply breathed some new life into his ankle by improving the stability and hopefully helping the joint last a bit longer.
(Please note, this patient was treated with the Regenexx-C cultured stem cell procedure and not Regenexx-SD. While Regenexx-SD does rely on the same stem cell type that was used to treat these patients and other clinics have reported good results using similar procedures that don’t rely on stem cell culturing, Regenexx-SD clinical effectiveness has not yet been established.)