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Biologic/Regenerative Therapy

Biologic/Regenerative Therapy

Biologic & Regenerative medicine therapies can be used alone and in combination with surgery for the treatment of musculoskeletal problems. Biologic therapies include blood products, cells, growth factors, and human donor tissue. These therapeutic techniques help overcome the body’s limited healing capacity by decreasing inflammation, supporting the healing process, and replacing injured structures.

Dr. Williams offers the following biologics therapies:

Platelet Rich Plasma (PRP)
Stem Cell Therapy: Bone Marrow Aspiration
Stem Cell Therapy: Fat – Adipose Aspiration
Amniotic Fluid Therapy
Cartilage Repair & Reconstruction

What conditions are best treated with biologic therapies?

  • Mild to moderate Osteoarthritis (OA)
  • Joint Inflammation – Synovitis
  • Tendon injuries (Tennis elbow, Golfer’s elbow, Jumper’s knee, Achilles Tendon, Rotator cuff tears)
  • Ligament injuries & sprains
  • Muscle injuries & strains
  • Articular cartilage damage

Platelet Rich Plasma (PRP)

Platelet rich plasma is derived from peripheral blood; whole blood is processed to increase the concentration of platelets in a small volume of plasma. This preparation is typically used for therapeutic injection. Platelets are the body’s natural clotting factor; platelets are also rich is growth factors (transforming growth factor-b, platelet-derived growth factor, fibroblast growth factor, etc.). These factors are known to promote the growth and repair of musculoskeletal tissues.

PRP therapy is typically performed in the office setting. Patients undergo a simple peripheral blood draw; the blood is spun to concentrate the platelets for injection into the affected area. In cases of joint inflammation, synovitis, arthritis, and cartilage injury, it is recommended that patients undergo three PRP injections. These injections are typically spaced approximately 2 weeks apart. This regimen can be indicated as a stand-alone treatment, or as an associated treatment coordinated with a surgical procedure. In cases of muscle, tendon, and ligament injuries, Dr. Williams will make a specific recommendation on the frequency of PRP treatment based on the specific injury in question.

Best Candidates for PRP: Patients with knee or shoulder joint inflammation, early arthritis, synovitis, cartilage injuries, muscle injuries, ligament sprains and tendon injuries can benefit from PRP treatment.

Stem Cells: Bone Marrow Aspirate Concentrate (BMAC)

Stem cells are immature precursor cells that are very helpful in promoting tissue healing and regeneration. Stem cells, also known as Mesenchymal Stem Cells or Medicinal Signaling Cells (MSCs), are most abundant in bone marrow and adipose tissue (fat). These cells have the ability to differentiate into many types of tissue (cartilage, muscle, tendon, etc.). Additionally, stem cells can act as helper cells that actively drive the body’s natural healing process. Placing high concentrations of these stem cells in an anatomic area of injury is the therapeutic goal of this treatment strategy.

Stem cells derived from bone marrow are obtained by inserting a large-bore needle into the intramedullary space of the iliac crest (hip bone). This procedure is typically done under anesthesia and is a simple needle puncture. The aspirated blood is then centrifuged to concentrate the growth factors and healing agents. This preparation, called bone marrow aspirate concentrate (BMAC), can be used effectively in a myriad of clinical circumstances.

Best candidates: BMAC can be used in the treatment of tendinopathy (tennis elbow, golfer’s elbow, patellar tendinopathy, jumper’s knee), and ligament injuries. BMAC can also be used an adjunct to cartilage repair procedures (osteochondral allograft, osteochondral autograft, chondroplasty). BMAC is also sometimes used as a supplement therapy for patients with osteoarthritis.

Stem Cells: Fat (Adipose) Derived Mesenchymal Stem Cells

Adipose or fat tissue has the highest concentration of stem cells in the body. Adipose tissue on average has 100-500 times as many stem cells as bone marrow blood. The target cell in fat tissue is called the pericyte; this cell exists on the small blood vessels in adipose tissue.  Approved adipose tissue stem cell harvesting systems in the U.S. are designed to concentrate these pericytes for therapeutic use. Unlike bone marrow, adipose-based stem cells do not degrade with age, and represent the best stem cell source in older patients. Typically, adipose tissue harvest is performed in the operating room or in a procedure room setting. The harvest is done using a long aspiration needle placed percutaneously around the belly button or the flanks of the abdomen. This procedure is typically not painful. Approximately 150-200 cc of whole fatty tissue is harvested by lipo-aspiration. This volume usually results in 15-20 cc of usable adipose stromal fraction for therapeutic use. These cells have a strong anti-inflammatory effect on soft tissues, and are effective in the treatment of joint synovitis, joint inflammation and early osteoarthritis. Other therapeutic indications for fat based MSCs include:  cartilage repair procedures, meniscus repair, patellar tendinopathy, elbow tendinopathy (tennis elbow, golfer’s elbow), and rotator cuff repairs. Adipose-based stem cells can be used as an adjunct to most soft tissue-based repairs performed in orthopedic surgery.

Best candidates: Those patients suffering from mild to moderate knee and shoulder arthritis symptoms typically benefit greatly from Adipose stem cell treatment. Patients undergoing surgery for rotator cuff repair, meniscus repair, jumpers knee surgery, tennis elbow surgery, golfer elbow surgery, and cartilage repair surgery can also benefit from adipose stem cell therapy.

Amniotic Fluid Therapy

Amniotic tissue contains hyaluronic acid (HA); HA is a natural component of normal knee fluid. Hyaluronic acid has natural lubricating and anti-inflammatory properties. This fluid is also known to be rich in beneficial growth factors that can helpful in joints affected by arthritis and inflammation.  Amniotic fluid is typically harvested from healthy donors by a third party.  After harvest, the fluid is carefully screened for sterility before being made available for clinical use. This tissue may be used as a solo injection or in combination with certain surgical procedures.

Best candidates: Patients with joint pain associated with mild to moderate joint arthritis. The ideal patient has joint pain but is not quite ready for a surgical procedure. Patients who have failed treatment with other knee injections (cortisone, gel shots) may find this particular therapy most useful. Patients being treated for the management of chronic OA may also benefit from amniotic fluid as a maintenance therapy.

Cartilage Repair & Reconstruction

Dr. Williams has been an innovator in the area of cartilage repair and reconstruction since the 1990s. Current methods of modern cartilage repair include: osteochondral allograft transplantation, osteochondral autograft transplantation (OATS), particulate juvenile articular cartilage (DeNovo NT), and matrix associated autologous chondrocyte (MACI). Our practice does over 200 such cases annually. All of these methods are designed to restore areas of articular cartilage damage with functional healthy tissue. Eligible patients can expect pain relief and increased function following a period of rehabilitation following these procedures.

 

References

Platelet Rich Plasma (PRP)

Knee cartilage injury, arthritis, joint inflammation

Cerza et al. Am J Sports Med. 2012. 40(12):2822-7.
Riboh et al. Am J Sports Med. 2016. 44(3):792-800.
Patel et al. Am J Sports Med.2013. 41(2):356-64.
Cole et al. Am J Sports Med.2016 45(2):339-346.
Kon et al. Arthroscopy. 2011. 27(11):1490-501.
Kon. Knee Surg Sports Traumatol Arthrosc. 18(4):472-9.
Siclari et al. Knee Surg Sports Traumatol Arthrosc. 22(6):1225-34.
Lee et al. Eur J Orthop Surg Traumatol. 2013. 23(5):581-7.

Tendinopathy
Charousset et al. Am J Sports Med. 2014. 42(4):906-11.
Dragoo et al. Am J Sports Med. 2014. 42(3):610-8.
Vetrano et al. Am J Sports Med. 2013. 41(4):795-803.
Zayni et al. Muscles Ligaments Tendons J. 2015. 3;5(2):92-8.

Bone Marrow Aspiration – Stem Cell Therapy

Knee cartilage injury, arthritis, joint inflammation
Rodriguez-Fontan et al. Phys Med Rehab (PMR) 2018. 10(12):1353-1359.

Tendinopathy
Pascarella et al. Am J Sports Med. 2011 39(9):1975-83. Thornton et al. Am J Sports Med. 2005 33(10):1558-1564.

Rotator Cuff
Meniscus Repair
Kim et al. J Orthop Surg Res. 2018. 3;13(1).
Koch et al. Int J Mol Sci. 2019. 5;20(5).

Fat – Adipose Based Stem Cell Therapy

Knee arthritis, joint inflammation
Jo et al. Am J Sports Med.45(12):2774-2783.
Koh et al. Am J Sports Med.42(7):1628-1637.

Articular cartilage repair
Kim et al. Am J Sports Med. 2014 42(10): pp. 2424-2434.
Oladeji et al. Am J Sports Med. 2017 45(12):2797-2803.
Koh et al. Arthroscopy. 2016. 32(1):97-109.
Pak et al. Int J Mol Sci. 2018. 23;19(7): E2146.

Rotator Cuff
Jo et al. Stem Cells. 2018. 36(9):1441-1450.
Kim et al. Am J Sports Med.2017 45(9): 2010-2018.

Tendinopathy
Lee et al. Stem Cells. 2015. 33(10):2995-3005.
Usuelli et al. Knee Surg Sports Traumatol Arthrosc. 2018. 26(7):2000-2010.

Meniscus Repair
Toratani et al. Arthroscopy. 2017. 33(2):346-354.

Amniotic Fluid Therapy

Knee Joint arthritis
Farr et al. J Knee Surg. 2019. 32(11):1143-1154.
O’Brien et al Arthroscopy. 2019. 35(8):2421-2433.
Vines et al. J Knee Surg. 2016. 29(6):443-50.

Cartilage Repair & Reconstruction

Osteochondral Allograft
Wang et al. American Journal of Sports Medicine. 2019. 47(1):71-81.
Wang et al. Am J Sports Med. 2018. 46(3):581-589.
Krych et al. Am J Sports Med 2012. 40(5): 1053-1059.
Bugbee et al. Orthop J Sports Med. 2016. 4(7 suppl 4).

Osteochondral Autograft (OATS, Mosaicplasty)
Pareek et al. Arthroscopy. 2016. 32(10):2118-2130.
Krych et al. J Bone Joint Surg 2012. 94(11):971-78.
Nho et al. The Am J Sports Med. 2008. 36(6):1101-1109.

Particulate Juvenile Articular Cartilage (DeNovo NT)
Farr et al. Am J Sports Med. 2014. (42)6:1417-1425.
Wang T. Arthroscopy. 2018. 34(5):1498-1505.
Stevens et al. Cartilage. 2014. 5(2):74-7.

Matrix Associated Autologous Chondrocyte Implantation (MACI)
Ebert et al. Orthop J Sports Med. 2019. 19;7(12).
Hoburg et al. Orthop J Sports Med. 2019. 25;7(4).
Brittberg et al. Am J Sports Med. 2018. 46(6):1343-1351.
Kreuz et al. Cartilage. 2019. 10(3):305-313.