An open letter to Dr. Oz on Stem Cells for Knee ACL Injuries...
POSTED ON 9/11/2014 IN Regenerative Medicine Education BY Christopher Centeno
Dr. Oz on Knee ACL Stem Cell Treatments...
We like Dr. Oz. He's a master at educating patients, which strikes near and dear to my heart as someone who also believes that educating patients is the key to helping them recover. However, he recently published a newspaper column where a mother asked about the use of stem cells to help her daughter recover from an ACL injury. Instead of the stem cells, he recommended invasive surgery. I can certainly see why it would be easy for him to recommend the procedure that's usually performed. However, we respectfully disagree on a number of fronts, not the least of which is that the recent research data doesn't support that ACL knee surgery is very effective.
First, the ACL is a major front-back stabilizer of the knee that's frequently injured in sports. The patient mentioned above was a female college athlete, so it's it's important to note that many female athletes with weak landing skills are 15 times more likely to injure their ACL than men. When an ACL injury occurs, the ligament can be stretched, torn and stay in place, or tear and retract like a rubber band. The most common treatment for a complete tear is surgery to replace the ligament, with about 100,000 procedures annually in the U.S.
There are two main reasons patients opt for surgery: to improve pain/function to return to sports and to reduce the likelihood of arthritis. So what's the scientific evidence that ACL surgery does either?
Return to Sport: Several studies demonstrate problems with returning to play after ACL surgery. In one recent study, patients who opted for no knee ACL surgery were actually able to get back to recreational sports more quickly. After two years, 30% of both patients with and without ACL surgery had lost strength in the leg and 20% of both groups reported that they never returned to their pre-injury level of sports. The bottom line, there were few meaningful differences between these two groups over the first few years. In yet another study, 2/3rds of athletes hadn't returned to pre-injury sports level by one year out from ACL surgery.
Arthritis after Surgery: Arthritis after ACL surgery is epidemic. 2/3rds of teens who get knee ACL surgery will have arthritis by age 30. Other studies show similar patterns of cartilage breakdown after ACL surgery. This recent study showed 3X the rate of arthritis in ACL operated knees versus the non-operated knee. Finally, this this 2013 study, even the newer double bundle ACL reconstruction technique proved no better in avoiding arthritis.
Side Effects and Unintended Consequences: There are also other issues with ACL surgery. For instance, there's a 29% chance that the new ACL graft will fail in young athletes , and patients that opt for surgery are 4-5 times more likely to re-injure the ACL surgical, or other knee, by returning to cutting edge sports. In addition, when the hamstrings tendon is used to reconstruct the ACL damaged ligament (very common), there's significant muscle atrophy, shortness, weakness, and fatty infiltration of that muscle. In addition, using a cadaver ligament for the ACL surgery (also common) has three times the failure rate of using your own tendon.
A trio of studies have looked at whether athletes can ever truly perform the same after ACL surgery-they can't. Why? The new ligament has no proprioception (position sense) like the original equipment. Finally, other studies have shown similar bio mechanical issues after ACL surgery.
What's the Level of Scientific Evidence that ACL Surgery Works? The largest group looking at quality of evidence in medicine is arguably the Cochrane Database of Systematic Reviews. What did they say about whether you should get ACL surgery in 2005? "There is insufficient evidence from randomised trials to determine whether surgery or conservative management was best for ACL injury in the 1980s, and no evidence to inform current practice. Good quality randomised trials are required to remedy this situation."
Have any randomized trials comparing ACL surgery to no surgery (besides what's above) been published to support opting for ACL surgery since 2005? Not so much. How about newer alternatives like stem cells? This is a new field, but the concept has the following advantages:
1. Quicker return to play-in our experience our patients return to full sports at 3-6 months versus 6-12+ months with surgery.
2. An ACL that is healed in place keeps it's original geometry, while a surgical ACL graft is always placed at a steeper angle than the original ligament which may be one reason we're seeing arthritis.
3. A healed ACL doesn't have proprioceptive issues because those position sensors aren't ripped out when the torn ligament is removed. As discussed above, surgically replaced ACLs lose their proprioception or position sense.
4. A precise injection under guidance has much fewer complications than a more invasive surgery (which can include blood clots in the leg, major infections requiring IV antibiotic therapy, and serious nerve injury).
However, what's the evidence that this new procedure involving highly precise placement of the patient's own stem cells into the ACL actually works? The best evidence is on multiple MRIs that we've obtained from before and after the treatment : ACL MRI 1, ACL MRI 2, ACL MRI 3, ACL MRI 4, ACL MRI 5. We also have a research paper in submission with many more images and a computerized analysis as well as a randomized controlled trial ongoing.
The upshot? We still like Dr. Oz. He's done a fantastic job of educating millions of patients in simple ways about their complex bodies. Having said that, he's wrong on this one. There isn't much evidence that ACL surgery for most young athletes makes sense. Perhaps ACL surgery is appropriate for those NFL bound college athletes who are looking to earn millions, but most of those patients will suffer from arthritis before they're 30 anyway. Do stem cells make sense? We're publishing more and more research and we review before and after MRI images every week, so based on that experience I'd say that stem cells are a viable alternative to relatively ineffective ACL surgery. If you don't opt for regenerative techniques, then skip the surgery and work hard in physical therapy!
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