Lowering the Standard of Care for Knee Stem Cell Procedures
POSTED ON 4/5/2017 IN Regenerative Medicine Education BY Christopher Centeno
I just examined a patient who has knee arthritis and had a bone marrow stem cell procedure at another local clinic. While it didn't work and I can't guarantee him that our more sophisticated procedure will work, I thought reviewing what he received would help explain why his prior procedure was below the standard of care for knee stem cell procedures. Let me explain.
What This Patient Had Done
The patient had a bone marrow concentrate procedure, where bone marrow was taken from the back of the hip and the stem cells were concentrated and reinjected in his knee. The goal was to help his knee arthritis pain and function. This works well in most patients, but in his case, he got no results.
How Was His Treatment Below the Standard of Care for Knee Stem Cell Procedures?
Drawing the Stem Cells
To get the stem cells, a bone marrow aspiration (BMA) is performed. That means that after numbing, a special type of needle is used to draw bone marrow aspirate from the pelvis. Most physicians these days that perform a BMA take shortcuts. The problem is that how the BMA is performed determines how many stem cells the doctor starts with, which determines how many stem cells the doctor can inject.
One of the shortcuts taken by physicians is to only take cells from one site of the bone marrow. This is far easier for the doctor, but it tends to shortchange the patient. Why? Going to more bone marrow sites and drawing smaller volumes helps increase the stem cell number. In this patient's case, the doctor took a shortcut and only went to one site and drew a higher volume, likely dramatically reducing the number of stem cells that were taken from the area. So this patient began his procedure with a handicap. For more on the published data that supports drawing lower volumes from multiple sites, see my video below:
Looking at the Whole Patient
This patient has right-sided knee pain, but his history and exam screams that there are other issues. For instance, he can't walk around a store without leaning over a shopping cart. When his chiropractor manipulates his back, his knee pain gets better. He also had a fall many years ago that likely injured his right SI joint ligaments. Finally, his nerve exam shows problems. So this patient needs his back treated as much as his knee. Was that done? Nope.
In medicine, dosing is everything. On the low end, you need to give a patient the right minimum dose or the treatment is worthless. In this case, there was no attempt at providing that right dose because the doctor had no way to measure it and didn't know what that dose should be per knee. That's very different from the procedure this patient will get here, where we will measure the dose of his cells and make a decision on whether we have only enough to treat one knee or have enough to treat both.
Once it comes time to reinject the cells, you need to make sure they get to the right spot. At the other clinic, this patient got a blind injection, meaning the doctor didn't use imaging guidance to make sure he was actually injecting these cells in the knee joint. Here at our clinic, we will use both X-ray and ultrasound to ensure the cells get placed in the right spot. The upshot? While I can't guarantee that we can help this guy, we can plug the holes in his previous treatment. So hopefully that makes all the difference!
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