This weekend, we hosted an IOF level 2–3 upper-extremity and foot/ankle course in our Colorado facility. As I checked out the four rooms they had running, I realized that all of the other courses on stem cells and PRP you can take right now are but a simple survey of this topic. This brought up a concept that also sparked on LinkedIn this weekend. We now have armies of physicians who believe that stem cells are magic pixie dust. Why? Because they took a weekend course, and that’s what they were told. They exist at somewhere between what I call level-0 and level-1 knowledge of how to precisely place stem cells into the musculoskeletal system. While many of them claim to be experts in the area of using stem cells to heal orthopedic injuries, they’re not. In fact, they’re in a place of not knowing what they don’t know. Let me explain.
At Regenexx we invented stem cell injections to treat orthopedic injuries, like knee injuries and arthritis, tendon/ligament tears, and spine conditions. Nobody on earth did these procedures before we invented or adapted them from scratch. One of the things we learned along the way was that precise placement is key to the success of the patient. The idea that you can just throw stem cells somewhere in the vicinity of the problem is not tenable. As an example, early on in 2005 when we treated our first degenerative-disc patients with stem cells, most patients had no results. Why? We chose the wrong patients, and we didn’t understand how to place the stem cells in the right spot. Later when we figured it out, we had a reliable therapy that helped patients. The same thing happened with the ACL in the knee and many other areas.
If it’s true that the success or failure of a stem cell procedure depends on the doctor’s skill in injecting under guidance to get to the right place, then the physician’s training becomes key. Find a doctor with the right training and you’re more likely to get good results. Find a doctor with poor training in this area and you’ll be more likely to waste your hard-earned dollars.
The problem is that this skill of injecting precisely into parts of the orthopedic system using guidance technology for the purpose of tissue regeneration or healing is NOT taught in medical school, residency, or fellowship. Orthopedic surgeons, family doctors, internists, general surgeons, plastic surgeons, and so on don’t get this training. The closest you can find are some PMR physicians and interventional radiologists or interventional spine physicians. However, none of those specialties are trained in accessing the many parts of the musculoskeletal with the aim of tissue healing. Why? Because their whole training has been in injecting high-dose steroids. When the focus shifts to repair, different structures in new ways need to be injected. Hence, many of these doctors take weekend courses to try to catch up.
These past few months, I’ve paid attention to curricula from lots of conferences teaching how to use platelet rich plasma and stem cells to treat musculoskeletal conditions. It doesn’t matter who teaches the course or where it’s located, they are all, at best, what I would call a survey of the subject. As an example, after examining four different popular courses on the topics that IOF taught this weekend (upper extremity and foot/ankle), the total time spent in one of these areas (i.e., foot/ankle) was 60–120 minutes. That’s it. Would you want a physician who only spent a few minutes on how best to inject stem cells into your ankle structures performing that procedure? I know I wouldn’t. Now let’s take the Interventional Orthopedics Foundation (IOF). The complete foot/ankle course alone is 32 hours of didactic, hands-on cadaver work, and written testing! That’s just the foot and ankle. Add in the rest of the body and it’s hundreds of hours.
If you read this blog, you know that I often get my inspiration to write based on what I experience that gets my dander up. This weekend, as I was thinking about the amazing depth and breadth of IOF courses versus the lack of it taught at every other institution out there, a physician on LinkedIn who appeared to be a family doctor specializing in cosmetics got upset because I had taken the position that plastic surgeons and doctors specializing in cosmetics had no business injecting knees, just like I had no business performing Brazilian butt lifts. It was clear that she didn’t know what she didn’t know, so I thought that explaining the layers of knowledge in knee injections might help.
I’ll use as an example the injection of the knee ACL, but this could be any other structure in the knee, hip, shoulder, hand, wrist, foot, ankle, or spine.
Level-0 Knowledge—Injecting into the knee joint blind without guidance. This is something that almost all physicians, regardless of specialty training, have done at one time or another. The likelihood of getting stem cells into the knee ACL is almost zero and only slightly better than chance. With a blind injection, there is a significant chance of not getting into the knee joint at all.
Level-1 Knowledge—Injecting into the knee joint via the suprapatellar pouch under ultrasound or documenting contrast flow in the knee joint via fluoroscopy. This is something that most physicians must be taught, but we still don’t have any stem cells inside the ACL ligament. This is the level of education you can find at most of the survey courses I discuss above.
Level-2 Knowledge—Injecting into the insertion of the ACL using ultrasound or fluoroscopy to demonstrate that cells will go somewhere in the ligament. This is what we mastered six years ago and it was an advancement as prior to this, there was no method to inject into the ligament. The problem is that the ligament has two bundles that attach at two ends each, so getting cells in the entire ligament wasn’t considered in this procedure. This might be taught on a case-by-case basis at a survey course if you pressed an experienced instructor, but it is usually not taught as part of the course.
Level-3 Knowledge—After we had mastered getting into the ACL ligament reliably and documenting that with fluoroscopy, it didn’t take long to realize that there are two bundles of the ACL and that if we were going to give the ligament a maximal chance of healing, we needed to inject both bundles at both ends (their origin and insertion). This took about two years to get right, but we eventually figured out how to selectively target the anterior-medial or posterior-lateral bundle. Injecting at both ends became critical, as we soon noted that just injecting the bottom of the ACL meant that the cells would often dump out a tear in the back and never make it to the origin up higher. This is where the IOF courses live on a routine basis.
Level-4 Knowledge—After a few years of injecting both bundles at both ends, one of our fellows (Dr. Bashir) began to notice what we all had seen, that many times injecting the ACL in a certain spot meant that the cells would end up in the meniscal roots. Basically, Dr. Bashir was able to confirm via anatomy research and cadaver dissections that just like elsewhere in the body, everything is connected. Hence, one of the reasons we often see meniscus and ACL tears go hand in hand is likely these connections. We all began focusing on refining the injection technique further to target both the torn ACL and damaged meniscus.
We can do this with any structure—dive down into the layers of complexity from simplest to the most complex. The same holds true for a knee meniscus, a shoulder biceps tendon, or the ankle ligaments. Hence, the family physician only had level-0 knowledge. She didn’t know what she didn’t know. The same holds true for almost all physicians or surgeons just entering into the world of precise image-guided regenerative orthopedics.
The upshot? First, if you’re a physician, time to graduate from 60 minutes of foot and ankle training to 32 hours. If you think you already know this stuff, there’s about a 99% chance you don’t know what you don’t know. If you’re a patient presented with a bewildering array of physicians (and poorly trained midlevel providers in chiropractic offices) claiming that they know what they’re doing, there is one way you can find out. Ask to see if that provider has completed all of the IOF training (all 32 hours) in the body area where you need treatment! Even better, make sure that provider has completed all of the IOF training in every area (hundreds of hours).
About the Author
Christopher J. Centeno, M.D. is an international expert and specialist in regenerative medicine and the clinical use of mesenchymal stem cells in orthopedics. He is board certified in physical medicine as well as rehabilitation and in pain management through The American Board of Physical Medicine and Rehabilitation.…