Rotator cuff tears can be difficult to heal and shoulder surgery can have high complication rates. In addition,rotator cuff repair surgeries are often associated with long recovery and rehab times (think blue pillow immobilizer). Here we present a case of a patient (EZ) who had a 2-3 year history of shoulder pain and after an MRI was told he needed surgery to repair the rotator cuff tear. The patient was a physical therapist, so he knew about shoulder rotator cuff tear non-surgical options and wanted to try and avoid more invasive surgery. Shoulder rotator cuff tear injected under active ultrasound guidance shown here. The patient underwent the Regenexx-PL and Regenexx-SCP injection procedures. These two are different and this will be a good discussion of the differences. Regenexx-PLis platelet lysate-our doctors crack open the platelets to get all of the important growth factors out to be immediately available to the stem cells. This is different than PRP (platelet rich plasma) which has intact platelets and acts as a timed release of growth factors. While PRP (platelet rich plasma) can be very helpful at times, when getting stem cells to grow, our lab experiments have shown that PRP under performs platelet lysate. The Regenexx-SCP procedure uses a lab processed platelet preparation where the smaller blood circulating stem cells are preserved. The result? The images above are from an ultrasound of the shoulder (sagittal cuts with a Sonosite M-Turbo in MSK mode). The pre-treatment pictures are on the left (same pictures stacked on the left-one annotated for problems in the bone and one annotated for problems in the muscle). On the right, again the same image stacked, from two months after the first image. Note the break in the bone and the rotator cuff tear in the pre-treatment images and then the repair of the bone and much less prominent rotator cuff tear in the post-treatment images. The patient now reports no pain in the front of the shoulder with movement overhead. Throwing a softball and playing volleyball is now not painful. Overall improvement is noted at 90%.
Posts Tagged ‘tear’
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.
Interesting study presented at the Orthopedic Research Society on how shoulder range of motion and stability aren’t restored fully by rotator cuff surgery.Shoulder rotator cuff surgical repair has become the standard for patients with rotator cuff tears seen on MRI and who still have pain and lost function. Most patients believe this surgery is allot like taking your car into the mechanic to replace a worn-out part in that after surgery, the shoulder will perform like new. We’ve seen patients for years who often complain of less function after surgery than they had before surgery, so this study is helpful to see why this happens. The researchers looked at the patient’s shoulder that was operated with rotator cuff surgery vs. the opposite shoulder without the surgery. They used sophisticated high speed x-ray to check on how much the shoulder joint moved. The shoulder movement was analyzed at 3, 12, and 24 months after surgery. They concluded that shoulder strength and joint stability as well as range of motion wasn’t restored. What long-term implications might this have? Shoulder stability is crucial to protect the shoulder joint long-term. Lost range of motion also means that other joints will be have to be used more to compensate. The reason? Shoulder rotator cuff repair is a big surgery that can reconnect severed rotator cuff tendons, but often these tendons can’t be repaired to their pre-tear integrity. In addition, recovery times from shoulder rotator cuff surgery can be long, often in a large pillow immobilizer, which can weaken tissues. Also, fatty atrophy of the rotator cuff may set in (the muscles may get smaller and weaker and get replaced by fat tissue) and this atrophy isn’t helped by shoulder rotator cuff repair. Finally, since any surgery will generally have more secondary side effects effects of tissue damage compared to any injection, we recommend to our patients that if they have a partial rotator cuff tear, a full thickness and non-tracted tear (the ends of the tear are still together), or severe tendinosis (the tendon is aggravated and perhaps frayed), that they try stem cell injection therapy before considering surgery.
60% of Patients get Knee Arthritis within a few Years of Removing Parts of the Meniscus with SurgeryFriday, January 7th, 2011
Interesting study that shows that 60% of patients who had pieces of their meniscus removed after surgery showed early signs of knee arthritis within years (3.4-8.8 years). Also interesting was that patients who were able to have their knee meniscus repaired fared much better, with only 20% of these patients showing signs of knee arthritis in that time frame. This fits with our prior posts on what happens when pieces of the knee meniscus are surgically removed. The meniscus is a spacer that helps protect knee cartilage. Cutting out pieces of this meniscus spacer only reduces the protection for the knee joint and leads to a more rapid progression of arthritis. What’s interesting about this study is that the patients who had their meniscus repaired fared better, as I blogged on another study that showed that almost all of these knee meniscus repairs really didn’t heal when you went back into the knee to take another look on arthroscopy. My bet is that what we’re seeing here is simply the fact that leaving torn meniscus tissue in a knee is protective (whether or not the repair actually heals). The upshot? Don’t remove meniscus tissue. We can try to repair it surgically, but often that won’t work. However, just leaving it in place and treating these knees non-surgically, in our opinion is a better option than menisectomy.
Patients today have many options to treat a shoulder rotator cuff tear and often explore those options through research on the internet before they decide which treatment (surgical, non-surgical stem cell injection, physical therapy) fits the best. A recent study examined what was the optimal time for surgery of a rotator cuff tear. These patients had a painful tear due to trauma, weakness in the shoulder, and couldn’t fully lift the shoulder to the side and over their head. The study concluded that surgical rotator cuff tear outcome wasn’t compromised (regardless of the rotator cuff tear size) up to four months after injury. Most tears could also wait longer, but patients with massive rotator cuff tears who waited longer than 4 months had the worst outcome. As we advise patients on what type of rotator cuff tears we believe we can treat through injection of their own stem cells under imaging guidance and which types would be better treated via surgical repair (usually the massive rotator cuff tears with retraction of the two ends need surgery), it’s helpful to reassure patients that waiting to make a decision about whether surgery or stem cell injection is right, up top a point, doesn’t seem to impact surgical outcome. While many rotator cuff tears can be treated successfully with the injection of the patient’s own stem cells, if that process doesn’t work, at least in tears that aren’t the massive, retracted type (which we wouldn’t generally treat with stem cells), waiting for surgery to try a non-surgical option, doesn’t seem to negatively impact outcome.
Interesting animal model of tendon healing using stem cell injections to help repair Achilles tendon injuries. The Achilles tendon is the large tendon in the back of the ankle, just above the heel. It’s also known as the “heel cord”. It’s the connection between the strong calf muscles and the heel, allowing forceful push off of the foot while walking and running. An Achilles tendon rupture is the most common injury of a tendon. It occurs more commonly in men and is usually seen in younger athletes or middle aged recreational athletes. In addition, the Quinolone family of antibiotics such as Cipro and Levaquin have recently been shown to be a cause of Achilles tendon ruptures. While this problem is commonly treated with surgery, the most modern randomized trials have showed no benefit to surgery. This is important, as Achilles tendon rupture surgery involves extensive downtime and surgical repairs have a high failure rate. To avoid Achilles tendon surgery, the above study sought to determine if the same type of stem cell mix used in Regenexx-SD might help Achilles tendon tears heal. It compared the injection of a bone marrow stem cell mix to cultured mesenchymal stem cells. What was interesting was that the Regenexx-SD type stem cell injection treatment into the Achilles tendon produced better results than the cultured cells. The authors thought this may have been due to the release of certain healing chemicals from the whole cell mix of the Regenexx-SD type therapy (which contains other stem cell types and other cells involved in tendon healing).
The failure of the cultured stem cells in this animal model may have been due to issues that we’ve observed in other research studies. One thing we’ve noticed is that to get enough cells to create a single treatment, it’s common for researchers to pool the cells of several subjects. In addition, the appearance of the stem cells used in these studies often shows that the cultured cells have been grown for too long a time and are under severe stress (not healthy). This may explain why the cultured cells didn’t work as well as fresh cells from a stem cell concentrate. However, the fact that this study confirms an animal model of tendon healing is consistent with results we’ve observed when we inject the stem cells obtained with the Regenexx-SD and Regenexx-C procedures into tendon tears. In addition, any injection based treatment for tendon tears will be significantly less traumatic and usually have a much shorter recovery time than any open surgical treatment.
A study out this month shows that rotator cuff tears in the shoulder are common in elderly patients with diabetes. This makes sense, as based on our stem cell culture experience with Regenexx-C, diabetic patients were less likely to have stem cells capable of growing to high numbers in culture. This study showed more shoulder joint effusions (swelling) in diabetics as well as swollen tendons (such as biceps). In addition, diabetics had more tears in the supraspinatus (one of the muscles of the shoulder rotator cuff). The authors discussed that in diabetics, routine shoulder imaging with ultrasound may be a good way to prevent major tears from occurring. This also would be a great application for stem cell therapies like Regenexx-SD or Regenexx-SCP, where injections of these cells could be performed using ultrasound guidance to deliver cells to the exact weak areas and minor tears, hopefully to prevent a full thickness rotator cuff tear from developing (one that might only be successfully treated with higher risk surgery). This approach may make financial sense as well, since shoulder rotator cuff surgery is less successful in diabetics when compared to patients without diabetes. If you add this shoulder treatment approach to the success we’ve already seen in helping patients with rotator cuff tears avoid surgery by injecting their own stem cells, this may be a great way to deploy stem cell therapies for shoulder problems in the future.