We see more and more patients calling us these days who finally have a few local options for bone marrow stem cell therapy for their orthopedic problems. As the original clinic in the U.S. doing this work, we applaud this expansion of options for patients. However, we also continue to hear from patients that physicians are performing these procedures without any type of imaging guidance. Imaging guidance means that the doctor can see where the needle is going. This is doubly important in the procedure used to harvest the stem cells: a bone marrow aspiration. While many physicians who are just starting to use bone marrow stem cells to treat things like knee, shoulder, hip, ankle, and hand/foot problems may believe they can take an accurate bone marrow aspirate without knowing where the needle is located, a simple anatomy review will show why this isn’t the case. Above you can see a slice through the PSIS area of the back of the pelvis (near the dimples of Venus). This is the most common bone marrow aspiration site to obtain stem cells. Note that the red arrow points to a section of the bone that’s paper thin and that the green arrow points to an area where it’s very thick. These areas are very close together, such that a needle that happens to get into the thin area will get no bone marrow (which is located inside the bone), but simply go through and through the bone, leading to a slow draw of blood that contains few of the stem cells sought. However, a needle that is guided to the correct thick area can easily tap into the bone marrow space and collect stem cells. How did we learn this? 5 years ago as we started to culture cells, we learned it the hard way. A sample from the thin area produced no measurable cells in culture, while a needle into the thick area produced good cultured stem cells. The upshot? When taking bone marrow, a “blind” procedure (without fluoroscopic or ultrasound guidance) is likely to sometimes collect no stem cells. In addition, since the bedside centrifuges used by many physicians have no way to measure what’s obtained (unlike a full level 3 lab), the doctor never knows he’s just taken a bad sample that won’t help the patient, as a bad sample looks just like a good sample!
Note: Any case reports or patient results presented on this web-site are not indicative of all patient results. Like any medical procedure, all Regenexx procedures have a success and failure rate.
Have you had this experience? You see your orthopedic surgeon who spends a few minutes performing an exam, looks at your films, and suggests shoulder surgery. But do you really need shoulder surgery? Are there much less invasive options? Is there a shoulder surgery alternative? While we often treat many smaller rotator cuff tears and other shoulder problems with stem cells, we also believe that some shoulders don’t even need that level of care. Many patients will get better by getting rid of myofascial trigger points with an IMS technique. Never heard of this therapy? You’re not alone. I explain trigger points and IMS it in more detail in our medical practice’s book, Orthopedics 2.0. Briefly, muscle trigger points are spots in the muscle that become painful and locked, so that the muscle is painful and weak. These spots can be simply cleared by a well trained provider with an acupuncture needle (however IMS isn’t Chinese acupuncture). Now a new study published by one our colleagues shows that IMS is effective in a randomized controlled trial. The results of the study showed that a three month program of IMS is more effective than no treatment. Based on experience, I would say that many of these patients with simple shoulder muscle trigger points often get unnecessary surgery. Why haven’t you heard of this very valuable treatment that is much less invasive than surgery? The economics of medicine. Trigger point injection therapy (either Travell type with the injection of anesthetic or IMS) don’t pay well, so these therapies have become a lost art. However, apparently a lost art that’s effective and based on the low invasiveness of the technique, in our opinion, far safer than surgery.
Note: Any case reports or patient results presented on this web-site are not indicative of all patient results. Like any medical procedure, all Regenexx procedures have a success and failure rate.
Interesting study last month on the use of a specific type of platelet rich plasma-PRFM (platelet rich fibrin matrix), which is more commonly used in surgery. Instead of a cell suspension, PRFM is more like a dense fibrin clot that has platelets embedded inside. In this study, two groups of shoulder rotator cuff repair patients were studied, one where PRFM was used and the other without-no differences in outcomes between the PMRF and usual group were found in this study. My personal take on the research would be that surgical repair for small and medium sized rotator cuff tears isn’t always recommended (which the study authors commented on by saying PRFM might work for larger tears). Another issue with PRFM is you tend to get an unusually dense fibrin matrix (a very thick and dense clot, different from the soft gel that naturally occurs with a blood clot). This dense matrix is a bit more like fibrin glue. The problem with dense clots (like fibrin glue) is that mesenchymal stem cells have difficulty migrating through the clot, and are more likely to perish. Since MSC’s would be the likely cells stimulated by the platelets to enhance repair, the dense clot of PRFM may have worked against these researchers.
Note: Any case reports or patient results presented on this web-site are not indicative of all patient results. Like any medical procedure, all Regenexx procedures have a success and failure rate.
You might think that with about 40,000 shoulder rotator cuff tear repair surgeries performed in the United States each year, that there was solid medical evidence supporting that this type of shoulder surgery was effective. However, a recent published review by Agency for Healthcare Research and Quality looked at more than 150 published papers and concluded that there was no solid evidence that rotator cuff surgery benefited patients more than no surgery. Huh? We’re operating on shoulders at a furious pace and we don’t know for sure whether the operations help patients more than not operating? Medicine is like any other field, at some point an idea takes hold and spreads like wildfire. In this case the idea was that sewing the torn shoulder rotator cuff back together was a good idea. It may still be in some patients. However, sewing a shoulder rotator cuff tear means prolonged immobilization as you have to substantially weaken the area through shoulder surgery before you can get it to heal. This type of long-term inactivity for the rotator cuff muscles and tendons can lead to shoulder rotator cuff atrophy and/or a weaker, but healed rotator cuff tendon. Add to that research showing that many patients never regain full range of motion after a shoulder rotator cuff tear surgery, likely due to the same immobilization and prolonged bracing needed to get the shoulder rotator cuff to heal, and it starts to make sense that the research doesn’t support that shoulder surgery is more effective than no shoulder rotator cuff tear surgery. So what to do? Shoulder surgery or no shoulder surgery? We tell our patients that if you have a massive tear and have otherwise good healthy tissue and are an active person who will benefit from working rotator cuff muscles, then surgery may be your best option. However, on the other hand, if you have a partial rotator cuff tear or a full thickness rotator cuff tear without retraction (the two ends pulled apart), then you should consider non-surgical injection based repair rotator cuff strategies rather than shoulder surgery. These injections allow the patient to be more active during recovery and hopefully this increased activity will allow the patient to have a stronger and more functional shoulder rotator cuff repair when compared to a more invasive shoulder surgery.
Note: Any case reports or patient results presented on this web-site are not indicative of all patient results. Like any medical procedure, all Regenexx procedures have a success and failure rate.
Note: Any case reports or patient results presented on this web-site are not indicative of all patient results. Like any medical procedure, all Regenexx procedures have a success and failure rate.
Note: Any case reports or patient results presented on this web-site are not indicative of all patient results. Like any medical procedure, all Regenexx procedures have a success and failure rate.
Treating a rotator cuff tear with stem cell injection rather than surgery can be difficult, especially when you don’t know where the tear is located. Injecting the rotator cuff blind without imaging is a challenge, as it’s a deep muscle and placing a needle into it without the ability to see where the needle is going is like driving your car with mud on the windshield-it’s possible, just not advisable. This video shows us injecting stem cells into the rotator cuff of a physical therapist with a tear in the tendon/muscle. You can see the needle off to the right (diagonal line) and the supraspinatus tendon/muscle right on top of the humerus bone. This is a cross sectional view of the area. In the last part of the clip, you see something spread from the end of the needle. This is a good shot of the stem cells spreading into the damaged tendon. For this patient, a combination of the Regenexx-PL and Regenexx-SCP procedures were used. Again, as I have blogged in the past, part of the Regenexx difference is the ability to place cells where they’re needed with high accuracy. We also have before and after ultrasound images on the same patient that will be posted later this week.
Note: Any case reports or patient results presented on this web-site are not indicative of all patient results. Like any medical procedure, all Regenexx procedures have a success and failure rate.
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