Adult Stem cells in Orthopaedics

Adult Stem cells in Orthopaedics
present and future perspectives
Dr. S. Alevrogiannis, M.D., MS (Ortho.), Ph.D.,
Senior Consultant Orthopaedic Surgeon, IASO GENERAL
HOSPITAL/ E’ Orthopaedic Dept. Medical Director

Regenerative
Medicine/Orthopaedics
• Process of creating living, functional tissues to repair or replace
tissue or organ function lost due to age, disease, damage, or
congenital defects
• It helps to produce extended healthy longevity
• Regenerative Orthopaedics :
a sub-division of Regenerative Medicine, dealing with biologic
treatment of most common orthopaedic injuries and chronic
diseases, using Advanced cellular Therapies (adult stem cells).
Future trend to regenerate musculoskeletal organs

MESENCHYMAL STEM CELLS (MSC’s)
• “Natural body’s drugstores”
or
• Medicinal Signaling Cells
or
• Caplan’s cells….
….Msc’s are going to change the way
for future medicine practice…..
Dr Arnold Caplan, Prof. in Biology,
Oncology & General Medicine/
Univ. Cleveland
(“father of MSC’s”)

Uses of Adult Stem Cells in Orthopaedics
(BMAC or ADMSC’s)
• Treated and induced osteogenesisClavicle Non-unions
• Promotes healing in the same way as a core decompression but makes
more intuitive sense to use BMAC compared to dead graftAVN of Femoral Head & Neck
• Has been shown to promote healing equal to iliac crest bone graft with
much less morbidity
Spine Fusions (best
documented uses of BMAC)
• Offers nonsurgical solutions to chronic problems that are recalcitrant to
treatment (lateral epicondylitis study)
Chronic Tendonitis & Partial
Tears
• Shown to reduce time to MRI homogeneity of the ACL graft by more
than 48% (179 days to 369 days)ACL Reconstruction
• Significant case reports of angiogenesis and increasing collateral
circulationCompartment Syndrome
• Promotes tenogenesis and healing
Rotator Cuff Injuries In Elderly
and Immunocompromised

Bone Marrow Concentrate
A Novel Strategy for Bone Defect Treatment
The local application of BMC / bone aspirate in the treatment of bone
deficiencies may be a promising alternative to autogenous bone grafting and
help reduce donor site morbidity.
Current Stem Cell Research & Therapy, 2009,4, 34-43 © 2009 Bentham Science Publishers Ltd.Bone Marrow Concentrate: A
Novel Strategy for Bone Defect Treatment Marcus Jager*, Eva M. Jelinekl, Kai M. Wessl, Axel Scharfstadtl, May Jacobson,
Sherwin V. Kevy and Rodiger Krauspel
Number of cells
A graft needed to contain at least > 1000 MSCs per cm3 to achieve
union.
Hernigou P, Poignard A, Beaujean F, Rouard H. Percutaneous autologous bone marrow grafting for nonunions:
influence of the number and concentration of progenitor cells. J Bone Joint Surg [Am] 2005;87-A:1430-7.

Lateral Epicondylitis
• Most commonly diagnosed condition of the elbow:
1 to 3% of the population
• Can be severe enough to remove people from the work force or
affect ADLs
• Current treatments include stretches, steroid injections, surgery
• Two year follow up study showing results using PRP continued to
improve and were better than steroid injections
Gosens, Peerbooms, Oudsten, et al AOSM Vol 39, No 6
• Steroids are detrimental to tendons
Fubini, et al Ortho Res 2001
• Even in patients with the need for surgical intervention, we have
seen dramatic changes in post operative rehab and symptoms
R. Wade McKenna, D.O.

Non-Unions, Delayed Unions, Fusions
Osteogenesis and angiogenesis are the goal
 Scaffold for osteoconductivity; signal proteins; stem cells to become
osteogenic
 Using BMAC to help change results of synthetic grafts and allografts
to equal autograft and with significantly lower morbidity
Shah, et al; J Spinal Disorders Vol 23, No 1, Feb 2010
 BMAC used with synthetic graft resulted in similar fusion rates as
rib autograft
Shah, et al; J Spinal Disorders Vol 23, No 1, Feb 2010
 Reduced time to heal distal tibia fractures by 50%
Liebergall, et al; Mol Ther 2013 Aug; 21(8); 1631-8
 BMAC with synthetic graft resulted in healing equal to autograft
Kitchel; The Spine J 6(2006) 405-412
Uses of Adult Stem Cells in
Orthopaedics

Achilles Tendon Injuries
• Goal of use of BMAC is to repopulate the collagen scaffold of the
torn tendon
• Reduces time to healing and promotes stronger tissue ingrowth
Adams, et al; Foot Ankle Int. 2014 Jan 8
• Arthroscopy and Laparoscopy
 Use of PRP lowered incidence of draining portal and synovial
tracting
 Using BMAC has helped promote chondrogenesis in published
studies on sheep, rabbits, equine and humans
Uses of Adult Stem Cells in
Orthopaedics

ACL Reconstructions
• Average time to heal - over one year to achieve complete healing
without the use of biologics
• 50-patient study showed using PRP reduced time of healing by
almost 50% (179 days compared to 369 days)
Radice, Yanez, et al; Journal of Arthros and Related Surgery Vol 26, 1, Jan 2010; 50-57
• ACL study currently going through IRB with myself, Dr. James
Andrews, Dr. Michael Heckman, Dr. Adam Anz comparing autograft
with allograft and proximal tibia draws to iliac crest draws
 Autograft has a much higher morbidity than allograft
 If we can show allograft heals just as fast and with lower
complications, we can dramatically change time lost in sports
and at work
 Also looking at proximal tibia draws versus iliac crest draws as
far as influence in healing of the graft

ACL grafts with BMAC average time out 12 weeks
Uses of Bone Marrow Concentrate

ACL reconstructed grafts 6 months out without biologics
Uses of Bone Marrow Concentrate

Adult Human Mesenchymal Stem Cells Delivered via Intra-Articular Injection
to the Knee Following Partial Medial Meniscectomy. A Randomized, Double-
Blind, Controlled Study C. Thomas Vangsness Jr., MD, Jack Farr II, MD, Joel Boyd, MD, David
T. Dellaero, MD, C. Randal Mills, PhD,and Michelle LeRoux-Williams, PhD
Investigation performed at the University of Southern California Orthopaedic Surgery Associates,
Keck School of Medicine, Los Angeles,California, Unlimited Research, San Antonio, Texas, Triangle
Orthopaedic Associates, Durham, North Carolina, Orthopaedic Center of Vero Beach, Vero Beach,
Florida, OrthoIndy, Indianapolis, Indiana, TRIA Orthopaedic Center, Bloomington
Background: There are limited treatment options for tissue restoration and the prevention of degenerative changes
in the knee. Stem cells have been a focus of intense preclinical research into tissue regeneration but limited clinical
investigation. In a randomized, double-blind, controlled study, the safety of the intra-articular injection of human
mesenchymalstem cells into the knee, the ability of mesenchymal stem cells to promote meniscus regeneration following
partial meniscectomy, and the effects of mesenchymal stem cells on osteoarthritic changes in the knee were investigated.
Methods: A total of fifty-five patients at seven institutions underwent a partial medial meniscectomy. A single superolateral
knee injection was given within seven to ten days after the meniscectomy. Patients were randomized to one of three
treatment groups: Group A, in which patients received an injection of 50 · 106 allogeneic mesenchymal stem cells;
Group B, 150 · 106 allogeneic mesenchymal stem cells; and the control group, a sodium hyaluronate (hyaluronic acid/
hyaluronan) vehicle control. Patients were followed to evaluate safety, meniscus regeneration, the overall condition of
the knee joint, and clinical outcomes at intervals through two years. Evaluations included sequential magnetic resonance
imaging (MRI).
Results: No ectopic tissue formation or clinically important safety issues were identified. There was significantly increased
meniscal volume (defined a priori as a 15% threshold) determined by quantitative MRI in 24%of patients in Group A and 6% in
Group B at twelve months post meniscectomy (p = 0.022). No patients in the control group met the 15% threshold for
increased meniscal volume. Patients with osteoarthritic changes who received mesenchymal stem cells experienced a
significant reduction in pain compared with those who received the control, on the basis of visual analog scale assessments.
Conclusions: There was evidence of meniscus regeneration and improvement in knee pain following treatment with
allogeneic human mesenchymal stem cells. These results support the study of human mesenchymal stem cells for the
apparent knee-tissue regeneration and protective effects.

Low Back Pain is costly & prevalent
• 19% to 56% of adults experience low back pain
every year-2nd leading cause for doctors visit
• Leading cause for disability/ worker’s
compensation claims
• € 50 billion per year in health cost
• 1.5 million patients with chronic pain

Indications for stem cell
applications in spine
• Disc herniation:
Goal:
1. Fill discectomy defect
2. prevent recurrent herniation ( 5-20%),
3. Prevent disc collapse and
4. future degeneration/pain
• Discogenic Pain :
Goal:
1. Eliminate pain
2. prevent degeneration

0 4>
<I
£
70
Ο
RN
«
Τ
Percutaneous drilling for the treatment of
secondary osteonecrosis of the knee
G. Μ aru land a,
Τ. M. SEVIER,
Ν. H. SHEIKH,
M. A. MONT
From the Sinai
Hospital of
Baltimore,
Baltimore, USA
Osteonecrosis of the knee comprises two separate disorders, primary spontaneous osteonecrosis
which is often a self-limiting condition and secondary osteonecrosis which is associated with risk
factors and a poor prognosis. In a series of 61 knees (38 patients) we analysed secondary
osteonecrosis of the knee treated by a new technique using multiple small percutaneous 3 mm
drillings.
Total knee replacement was avoided in 59 knees (97%) at a mean follow-up of 3 years (2 to 4).
Of the 61 knees, 56 (92%) had a successful clinical outcome, defined as a Knee Society score
greater than 80 points. The procedure was successful in all 24 knees with small lesions compared
with 32 of 37 knees (86%) with large lesions. All the procedures were performed as day cases and
there were no complications. This technique appears to have a low morbidity, relieves symptoms
and delays more invasive surgery.
JBJS B June 2006

1153
Copyright © 2004 by The Journal of Bone and Joint Surgery, Incorporated
Treatment of Osteonecrosis of the
Femoral Head with Implantation of
Autologous
Bone-Marrow Cells
A Pilot Study
By Valerie Gangji, MD, Jean-Philippe Hauzeur, MD, PhD, celso Matos, MD, Viviane De Maertelaer, PhD,
Michel Toungouz, MD, PhD, and Micheline Lambermont, PharmD
Investigation performed at the Department of Rheumatology and Physical Medicine, the Department of Radiology, and the
Cellular and Molecular Therapy Unit, Erasme University Hospital, Brussels, Belgium

AONED/O
£' ^ 'M 7C
Η
■ ASPECTS OF CURRENT MANAGEMENT
The use of percutaneous autologous
bone marrow transplantation in
nonunion and avascular necrosis of
bone
P. HCRNIGOU,
A. POIGNARD,
O. MANICOM,
G. Marlucu,
H. ROUARD
From Hop it jl Henri
Mondor, Creteil,
France
P. HEMI^.U, MD, PROFESSOR
OF ORTHOPAEDIC SURGSRY
A. Poignard, MD,
Orthopaedic Surgeon
0. Manicom, MD,
Orthopaedic Surgeon
G. Mathieu, MD, Orthopaedic
Surgeon
H. ROUARD, MD, BIDOGIST
HOPITAL HENRI MONDOR,
AVENUE DU MARECHAL DE
LATTRE DE TAS-SIGNY, 94010
Creteil, Frarce.
CORRESPONDENCE SHOULD BE
SENT TO PROFESSOR P.
HERNIGOU: E-MAIL: PHIL
IPPA.HER NIGOUTS1
hmn.aphp.fr
•£>2006 British Editorial
Society of Bone and Joint
Surgery
doi: 10.1302Ό301-620Χ87Β7.
162S9 $2.00 J Bone Jo /or
Surg IBr} 2005;«7-B:896-902.
Bone marrow and orthopaedic surgery
During the development of normal bone in the
young child, osteoblasts and then haematopoietic
stem cells progressively colonise the cartilaginous
matrix, resulting in its ossification to bone matrix.1
It is at this time that red hone marrow appears in
the skeleton, starting dis-tally in the foot and hand
at around one year of age. In normal children, the
marrow in all bone cavities and the spongiosa at the
epiphysis is red, because the amount oi medullar)'
space in young children is limited due to an
abundance of cartilage and the thickness of spongy
bone, while the haematopoietic requirements are
high due to the growth-related expansion of the
blood volume. At the end of the growth period, in
late adolescence, the need for hae-matopoietically
active marrow stabilises and adipose involution
occurs in many areas of the medulla and spongiosa.
Haematopoietic cells are replaced by far, giving
rise to yellow, inactive marrow, but red marrow
still persists in certain areas such as the iliac crests.
The adult skeleton possesses two types of bone
marrow, one red and haematopoietically active, the
other yellow due to adipose involution. The
haematopoietic stem cell in bone marrow has been
studied extensively because of its clinical relevance
in therapeutic transplantation of bone marrow.
Haematopoietic stem cells are pluripotent and
capable of producing progeny that can differentiate
into any and all of the cells of circulating blood and
the immune system through a well-defined series of
steps leading to differentiation into mature blood
cells.
In addition to the haematopoietic element, red
marrow also contains a stroma where the
osteogenic precursor cells are found. The
osteogenic capacity of bone marrow was first
demonstrated in rabbits by Goujon2 in 1869. This
capacity has been exploited by several authors to
reinforce the osteogenic properties of allografts,3
xenografts4 and composite grafts5 by mixing bone
marrow removed during the operation with the
bone graft.
Burwell3 showed that primitive osteogenic cells
in bone marrow are responsible for much of the
biological efficacy of cancellous bone grafts.
Friedenstein et aT showed that new bone was
formed by proliferative fibroblast-like marrow cells
which persisted in ritro after haematopoietic cells
had died and that the number of cells able to
proliferate rapidly could be assayed by counting
the number of fibroblastic colony-forming units
(CFU-Fs) in bone marrow. Several studies have
shown that at least some of these cells are
pluripotent and can differentiate into osteoblasts,
chondrocytes, adipocytes, myoblasts and haemato-
poiesis-supporting cells. Many names have been
used to describe the fibroblastic colony-forming
cells that can be grown from bone marrow,
periosteum, bone fragments, or callus digested
from trabecular bone. In this review the term 'tissue
progenitors' is used to describe the connective
proliferative cell population that can be harvested
from bone marrow and which is capable of
differentiating into one or more connective tissue
phenotypes.
Because bone marrow is known to contain
osteogenic progenitors, its implantation was
perceived to have the potential to lead to effective
bone regeneration. Various preclinical
investigations,14,15 and clinical studies,15"19 have
confirmed this. In clinical practice, autologous
marrow is harvested from the iliac crest and
immediately transplanted to the site in need of
skeletal repair. This type of marrow transfer, or
grafting, is a relatively simple procedure which is
inexpensive and can be done on an outpatient basis.
This technique of transplanting autogenous
connective tissue progenitors is the first of the four
major cell-based strategies of tissue-engineering
which will develop in the future. These are:
1) transplantation of culture-expanded or
modified connective tissue progenitors;
2) targeting local connective tissue progenitors
with growth factors where new tissue is required·.
896 THE JOURNAL OF BONE AND JOINT SURGERY

Marrow aspiration
parallel aspiration divergating technique

Pre op Immediate post op 6 weeks po

Articular Cartilage Regeneration With Autologous Peripheral Blood
Stem Cells Versus Hyaluronic Acid: A Randomized
Controlled Trial
Khay-Yong Saw, M.Ch.Orth., F.R.C.S.(Edin), Adam Anz, M.D., Caroline Siew-Yoke Jee, Ph.D.(Lond),
Shahrin Merican, M.B.B.Ch., F.R.C.R., Reza Ching-Soong Ng, M.D., Roohi S. Ahmad, M.S.Orth.,
F.R.C.S.(Edin), and Kunaseegaran Ragavanaidu, M.B.B.S., M.Path.
Purpose: The purpose of this study was to compare histologic and magnetic resonance imaging (MRI) evaluation of articular cartilage regeneration in patients
with chondral lesions treated by arthroscopic subchondral drilling followed by postoperative intra-articular injections of hyaluronic acid (HA) with and without
peripheral blood stem cells (PBSC). Methods: Fifty patients aged 18 to 50 years with International Cartilage Repair Society (ICRS) grade 3 and 4 lesions of the
knee joint underwent arthroscopic subchondral drilling; 25 patients each were randomized to the control (HA) and the intervention (PBSC + HA) GROUPS. BOTH
GROUPS RECEIVED 5 weekly injections commencing 1 week after surgery. Three additional injections of either HA or PBSC + HA WERE GIVEN AT WEEKLY
INTERVALS 6 months after surgery. Subjective IKDC scores and MRI scans were obtained preoperatively and postoperatively at serial visits. We performed
second-look arthroscopy and biopsy at 18 months on 16 patients in each group. We graded biopsy specimens using 14 components of the International Cartilage
Repair Society Visual Assessment Scale Π (ICRS II) and a total score was obtained. MRI scans at 18 months were assessed with a morphologic scoring system.
Results: The total ICRS II histologic scores for the control group averaged 957 and they averaged 1,066 for the intervention group (Ρ = .022). On evaluation of
the MRI morphologic scores, the control group averaged 8.5 and the intervention group averaged 9.9 (Ρ — .013). The mean 24-month IKDC scores for the
control and intervention groups were 71.1 and 74.8, respectively (P = .844). One patient was lost to follow-up. There were no notable adverse events.
Conclusions: After arthroscopic subdiondral drilling into grade 3 and 4 chondral lesions, postoperative intra-articular injections of autologous PBSC in
combination with HA resulted in an improvement of the quality of articular cartilage repair over the same treatment without PBSC, as shown by histologic and
MRI evaluation. Level of Evidence: Level II, randomized controlled trial (RCT).
As clinicians have sought to improve methods for articular cartilage
repair, investigation has recently focused on cell therapy. Limitations
regarding
From Kuala Lumpur Sports Medicine Centre (K-YS.. CS-Y.J., S.M., R.C-
S.N), Kuala Lumpur; Department of Orthopedics (R.SA), Universiti Putra
Malaysia, Serdang, Malaysia; GenomeD (K.R.), Klang, Malaysia; and
Andrews Research and Education Institute (A.A ), Gulf Breeze, Florida,
U.S. A
The authors report that they have no conflicts of interest in the authorship
and publication of this article. Received August 27, 2012; accepted
December 11, 2012. Address correspondence to Khay-Yong Saw,
M.Ch.Orth., F.R.C.S., Kuala Lumpur Sports Medicine Centre, 7th Floor,
Wisma Perintis, 47 Jalan Dungun. Damansara Heights, 50490 Kuala
Lumpur. Malaysia. E-mail: sportsdinic@hctmail.com
© 201 i by die Arthroscopy Association of North
America 0749-8063/12 561/$ 36.00
http://dx.doi.org/10.1016!JARTHRO20L2.12.008
marrow stimulation alone and mature chondrocyte cell therapy have led to
the investigation of stem cells.1-4 Disadvantages of marrow stimulation
include the formation of fibrocartilage and decreasing clinical scores after 24
months in some series.5'6 Chondrocyte therapy also has produced
fibrocartilage in some studies and requires seeding of a matrix/scaffold,
expensive cell culture, and a protracted recovery because of open surgery.7"9
Recent application of stem cell therapy in the setting of cartilage regeneration
has animal and clinical studies to support its safety and efficacy.9"17
We began our investigations of cell therapy for cartilage regeneration in a
goat model using subchondral drilling in 3 groups: one with no postoperative
injections, one with postoperative injections of hyaluronic acid (HA) alone,
and one with postoperative injections of bone marrow aspirate (BMA) and
HA. Histologic grading with the Gill score illustrated best
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol ■. No m (Month), 2013: pp 1-12 1

Role of mesenchymal stem cells in regenerative
medicine: application to bone and cartilage
repair.
MSC can migrate to injured tissues and some of their reparative
properties are mediated by paracrine mechanisms including their
immunomodulatory actions.
MSC possess a critical potential for the treatment of skeletal
diseases, such as osteoarthritis or fracture healing failure, where
treatments are partially effective or palliative.
Granero-Molto F, Weis JA, Longobardi L, Spagnoli A.
Expert Opin Biol Ther. 2008 Mar;8(3):255-68.

MSCs in cartilage repair
Autologous MSCs were expanded ex vitro, embedded in
a collagen gel and re-implanted into areas of articular
cartilage defect in osteoarthritis patients.
Wakitani S, Imoto K, Yamamoto T, Saito M, Murata N, Yoneda M. Human autologous culture expanded bone marrow
mesenchymal cell transplantation for repair of cartilage defects in osteoarthritic knees. Osteoarthritis Cartilage
2002;10:199-206.

Osteochondral Lesions of the Knee
Mesenchymal stem cells represent 2% to 3% of the total
mononuclear cells in bone marrow and have the ability to
differentiate into various lineages, including osteoblasts and
chondroblasts. The rationale of the ''one-step technique'' is
based on the idea of transplanting the entire bone-marrow
cellular pool instead of isolated and expanded mesenchymal
stem Cells.
Osteochondral Lesions of the Knee: A New One-Step Repair Technique with Bone-Marrow-Derived Cells. By
Roberto Buda, MD, Francesca Vannini, MD, PhD, Marco Cavallo, MD, Brunella Grigolo, PhD, Annarita Cenacchi,
MD, and Sandro Giannini, MD
J Bone Joint Surg Am. 2010;92 Suppl 2:2-11 d doi:10.2106/JBJSJ.00813

Arthritis in the United States
3

Economically Detrimental
Direct + Indirect Costs
>$100 billion

Arthritis will continue to climb..

Reality
for 10 million
Americans
Desire
Golden Years?

Mesenchymal Stem Cell Injections Improve Symptoms of
Knee Osteoarthritis
Yong-Gon Koh, M.D., Seung-Bae Jo, M.D., Oh-Ryong Kwon, M.D., Dong-Suk Suh, M.D., Seung-Woo
Lee, M.D., Sung-Ho Park, M.D., and Yun-Jin Choi, M.D.
Purpose: The purpose of this study was to evaluate the clinical and imaging results of patients who received intraarticular injections of
autologous mesenchymal stem cells for the treatment of knee osteoarthritis. Methods: The study group comprised 18 patients (6 men and 12
women), among whom the mean age was 54.6 years (range, 41 to 69 years). In each patient the adipose synovium was harvested from the
inner side of the infrapatellar fat pad by skin incision extension at the arthroscopic lateral portal site after the patient underwent arthroscopic
debridement. After stem cells were isolated, a mean of 1.18 Χ 106 stem cells (range, 0.3 χ 106 to 2.7 χ 106 stem cells) were prepared with
approximately 3.0 mL of platelet-rich plasma (with a mean of 1.28 χ 106 platelets per microliter) and injected into the selected knees of
patients. Clinical outcome was evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index, the Lysholm score, and the
visual analog scale (VAS) for grading knee pain. We also compared magnetic resonance imaging (MRI) data collected both preoperatively and
at the final follow-up. Results: Western Ontario and McMaster Universities Osteoarthritis Index scores decreased significantly (Ρ < .001) from
49.9 points preoperatively to 30.3 points at the final follow-up (mean follow-up, 24.3 months; range, 24 to 26 months). Lysholm scores also
improved significantly (P < .001) by the last follow-up visit, increasing from a mean preoperative value of 40.1 points to 73.4 points by the end
of the study. Likewise, changes in VAS scores throughout the follow-up period were also significant (P = .005); the mean VAS score
decreased from 4.8 preoperatively to 2.0 at the last follow-up visit. Radiography showed that, at the final follow-up point, the whole-organ
MRI score had significantly improved from 60.0 points to 48.3 points (P < .001). Particularly notable was the change in cartilage whole-organ
MRI score, which improved from 28.3 points to 21.7 points (P < .001). Further analysis showed that improvements in dinical and MRI results
were positively related to the number of stem cells injected. Conclusions: The results of our study are encouraging and show that intra-articular
injection of infrapatellar fat pad—derived mesenchymal stem cells is effective for reducing pain and improving knee function in patients being
treated for knee osteoarthritis. Level of Evidence: Level IV, therapeutic case series.
Recently, mesenchymal stem cells (MSCs) have been suggested
for use in the cell-based treatment of cartilage lesions. These cells
show great potential as therapeutic agents in regenerative medicine
because of their multilineage potential, immunosuppressive
activities, limited immunogenicity, and relative ease of growth in
culture.1 Although ethical and political issues
From the Center for Stem Cell & Arthritis Research, Department of Orthopedic
Surgery (Y-G.K., S-B.J., O-R.K, D-S.S., Y-J.C), and Department of Radiology (S-W.L.,
S-H.P.), Yonsei Sarong Hospital, Seoul, South Korea. Y-G.K and S-BJ. contributed
equally to this work. The authors report that they have no conflicts of interest in the
authorship and publication of this article.
Received July 14, 2012; accepted November 13, 2012. Address correspondence
to Yun-Jin Choi, M.D., Center for Stem Cell & Arthritis Research. Department of
Orthopaedic Surgery, Yonsei Sarang Hospital 478-3, Bangbae-dong, Seocho-gu,
Seoul, South Korea. E-mail: yunjinchd78@gmail.com
© 2013 by the Arthroscopy Association of North America
0749-8063/12466/$ 36.00
http://dxMoij>rg/10.1016/J ARTHRO3012.IL.017
surround the use of embryonic stem cells, the use of MSCs is
generally well accepted by society. Furthermore, MSCs are an
autologous source of cells, eliminating concerns regarding rejection
and disease transmission, and they are less tumorigenic than their
embryonic counterparts.2
The transplantation of MSCs into full-thickness articular cartilage
defects has been attempted under various conditions in vivo. For
example. Murphy et al.1 used direct intra-articular injection to
deliver adult stem cells isolated from caprine bone marrow into
injured knees. They reported that degeneration of the articular
cartilage and subchondral sclerosis were reduced in cell-treated
joints compared with joints treated with vehicle alone without cells.
Furthermore, there have been several studies on human patients
reporting good outcomes within 6 months of intra-articular injection
of autologous MSCs.4'5 In 2008 Centeno et al.5 described a
technique for using autologous culture-expanded bone marrow—
derived stem cells for regeneration of
748 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 29, No 4 (April), 2013: pp 748-755

Autologous Bone Marrow Aspirate
OrthopaedicstodayEUROPE I APRIL2013 I Healio.com/Orthopaedics
"THE AIM OF RESEARCHERS IN REGENERATIVE MEDICINE IS TO
REPAIR OR REGENERATE ORgans or tissues that are damaged by aging,
disease or trauma, such that function is restoreci or improved" Gobbi
said. "The use of bone marrow derived multipotent MSCs represents
a valuable treatment option, especially for the treatment of the
degenerative diseases of cartilage," he said.
Gobbi and colleagues started using bone marrow aspirate
con¬centrate (BMAC) for cartilage repair in 2006. They found that
combining BMAC with a scaffold to treat full-thickness cartilage
defects achieved good results.
"THEREFORE, WE STARTED TREATING BIG DEFECTS IN PATIENTS
WHO WERE referred to total knee replacement (TKR)," Gobbi said.
"We started talking about biological arthroplasty."

Mesenchymal stem cells in arthritic diseases
MSCs possess potent immunosuppression and anti-inflammation
effects through secretion of various soluble factors,
MSCs can influence the local tissue environment and exert protective
effects with an end result of effectively stimulating regeneration in
situ.
Can be used for therapeutic application in degenerative joint diseases
such as RA and OA.
Faye H Chen and Rocky S Tuan
Arthritis Research & Therapy 2008,10:223 (doi:10.1186/ar2514)

ADS/ MSC in osteoarthritis
• Desando and co-workers report in Arthritis Research &
Therapy that intra-articular delivery of adipose-
derived stem cells attenuates progression of synovial
activation and joint destruction in Osteoarthritis.
• Mesenchymal stem cell therapy in osteoarthritis:
advanced tissue repair or intervention with
smouldering synovial activation
Peter LEM van Lent* and Wim B van den Arthritis Research & Therapy 2013, 15:112
http://arthritis-research. com/conten t/15/2/112

Gradual Regeneration of Articular Surface
P08t-0p
Figure 8. A 34-year-old woman (Fig 3) with
recurrent dislocation of her patella as an
adolescent. Immediate postoperative
radiographs showed evidence of
subchondral drilling, whereas radiographs
at 6 months and 2 years showed a
progressive reappearance of the lateral
patello-femoral articulation.
Saw et al.: Arthroscopy 2011

MATERIAL & METHOD
( Sept. 2012 - OCT. 2014).
• Autologous ADMSC’s through a punch biopsy
• Proliferation of the stem cells in a GMP certified laboratory in an average
of 23d- (18-31)
• A full patient consent form for proliferation and application was signed by
all pts
• A full metabolomic profile was performed and necessary probiotics and
food supplements were given to each patient
• Antioccidents were given to each patient
• Radiographic staging according to Kollgren scale was performed pre-op.
• 37 pts with hip and 72 with knee arthritis, had underwent an MRI scan
before visiting a doctor of our team
• Questionnaires (SF-36 & Harris Hip Score ) were also given to the pts
• All pts underwent a prescheduled FU clinical observation by one senior
consultant at 1,3,6,12,24 m post application

TREATMENT PROTOCOL
• An average of 15.5× 106 (12.1-16.7× 106 ) MSC’s through an ultrasound guided
injection for the knees and through fluoroscopy for the hips were given
• All of the pts were treated in a hospital as an O.D.C manner
• Weight bearing was restricted for a couple of hours post the application and a
partial weight bearing protocol was encouraged to be followed for a week
• NSAID’s and/or corticosteroids intake was forbidden from at least 15d before and
20d post the intra-articular application
• 2 iv administration of an average of 15.5× 106 (11.3-17.2× 106 ) each, using a
transfusion kit were given the day 2 & 3,
• All pts (68- 22M/46F) with clinical & x -ray sign of knee varus or valgus deformity of
more than 50 had to wear an orthotic knee brace for at least 6w.
• 12 out of 42 pts with hip arthritis underwent a subsequent hip arthroscopy at the
time of stem cell application
• No repetition of the stem cell or PRP application in the affected joint was
performed to any of the pts for the FU period of time

HIP
ΜΑΤERIAL
Ν 42
MALE 16
FEMALE 26
AGE 63.1 (42-92)
HEIGHT 171 (162-191)
cm
BMI 36 (22-47)
Patient Demographics
Improvement 50% is significant high,
regardless age and BMI. In all patients
autologous adipose derived stem cells (ADSC's)
from a punch biopsy were used, instead of
bone marrow stem cells (BMSC's), because of
the older age of the pts. In 12 out of 42 pts
(8M-4F) a subsequent hip arthroscopy due to
FAI was performed, but the clinical result was
not superior to the other group that was
treated by mesenchymal stem cells only.
We believe that the results could be better if
the patients could get a second stem cell
application, as a single injection shot, 6 months
post the first procedure.
Our results are slightly better than others that
use " a same day procedure" using BMSC's.
This data analysis of 2014, shows a significant percentage of
50% improvement >50% in a group of patients suffering by
hip arthritis, with the clinical result lasting for more than 2
years long. It is interesting to note is that the severity of
disease affects the clinical outcome with Grade IV
(according to Kollgren-Laurence scale) arthritis, having the
worst results. In this registry, unfortunately 33 out of 42
patients (78.5%) were at a final stage of osteoarthritis.
A modified Mulligan physiotherapy protocol was used in all
patients in order to improve degree of motion in the hip
joint.
All patients underwent a specific clinical approved
treatment protocol
• metabolomic profile
• 3-day stem cell application ( 1st day- hip injection, 2nd
day iv infusion and 3rd day secretomics hip injection )
• antioxidants (im injections)
• Food supplementation and regiment according to ortho-
molecular analysis
This is not a
controlled
trial but only
a registry
data.
All patients
had their own
stem cells
back, after
cultivation
and
proliferation
of the cells, in
a GMP
laboratory,
using their
own serum.
68
54
73 71 71 70
0
20
40
60
80
100
1m 3m 6m 12m 18m 24m
Percentage of patients
reporting > 50%
improvement
8,2
2,8
3,5
2,9 2,7 2,6 2,3
0
1
2
3
4
5
6
7
8
9
0 1m 3m 6m 12m 18m 24m
Time Interval VS Pain Score
0
20
40
60
80
100
Harris Hip Score
(functionality improvement)
CUMMULATINESUCCESSRATE%CUMMULATINESUCCESSSCORE%

KNEE
Patient Demographics
Improvement 50% is significant high, regardless
age and BMI. In all patients autologous adipose
derived stem cells (ADSC's) from a punch biopsy
were used, instead of bone marrow stem cells
(BMSC's), because of the older age of the pts. Axial
deformity of the knee is a significant factor
predisposing for non-improvement and all patients
in our registry, with either varus or valgus
deformity, more than 50 had to wear a knee brace
for at least 6 weeks.
Of note is that the severity of disease, affects the
clinical outcome result, with Grade IV (according to
Kollgren-Laurence scale) arthritis, having the worst
results.
The percentage of patient reporting 75%
improvement is high, proving that the procedure
could be performed, as an alternative to a total
knee replacement.
Our results are slightly better than others that use "
a same day procedure" using BMSC's.
This data analysis of 2014, includes our patients that were
tracked in our advanced registry. We report any
improvement from baseline (0-100%) and in the first chart
we can see patients reporting 50% clinical improvement
in 24 months. In the 2nd chart there are patients reporting
75% clinical improvement.
All patients underwent a specific clinical approved
treatment protocol
• metabolomic profile
• 3-day stem cell application ( 1st day- hip injection, 2nd
day iv infusion and 3rd day secretomics hip injection )
• antioxidants (im injections)
• Food supplementation and regiment according to
ortho-molecular analysis
This is not a
controlled trial
but only a
registry data.
All patients had
their own stem
cells back, after
cultivation and
proliferation of
the cells, in a
GMP laboratory,
using their own
serum.
ΜΑΤERIAL
Ν 92
MALE 34
FEMALE 58
AGE 62.8 (43-89)
HEIGHT 169 (152-189) cm
BMI 32 (21-45)
82
74
83 88 90 92
0
20
40
60
80
100
1m 3m 6m 12m 18m 24m
PERCENTAGE OF PATIENTS
REPORTING > 50%
IMPROVEMENT
71
65
72 74 78 78
0
20
40
60
80
100
1m 3m 6m 12m 18m 24m
PERCENTAGE OF PATIENTS
REPORTING > 75%
IMPROVEMENT
CUMMULATINESUCCESSRATE%
7,8
2,8
4,1
2,1 2,3 2,2 2,1
0
2
4
6
8
10
0 1m 3m 6m 12m 18m 24m
VAS SCORE
CUMMULATINESUCCESSRATE%

SAFETY
In the diagram below we report data from our Advanced
Cellular Therapies registry of a total of 152 knee , hip,
shoulder , Hand/Wrist and Foot/Ankle patients until June
2014. Patients were asked to complete specific
questionnaires at the beginning of the treatment and at 1,
3, 6, 12 and 24 month following the treatment. Each
complaint was adjudicated using HHS criteria with adverse
effects forms being filled out by the treating physician. The
number of patients that are included in this registry is not
big enough but is statistically significant and the results are
comparable to other similar data in the literature. More
patients need to be included in the registry in order to
support our results.
Our data supports that our Advanced
Cellular Therapies procedures are as safe
as other common injection procedures.
A.C.T
PROCEDURES
N 152
MEAN
F.U
18.2 (1-51)M
AGE 64.3 (41-91)
BMI 27.8 (22-38)
PATIENT
DEMOGRAPHICS
Pain / Swelling
Skin
Neurologic
Immune /
Allergic
Bleeding /
Hematoma
M…
CATEGORIES OF AE
No Adverse Events Adverse Events
10.5%
89.5%
52,1%
8,7%
8,7%
8,7%
4,4%
17,4%

Pain/swelling was the most commonly reported side-effect (52.1% of all complaints) in between 3-6 months following
the treatment. It was supposed to be originated from the inflammatory process and was subsided to 12 of them at
the end of 6 months. For the rest of them (4 patients) pain was thought to be related to continued degenerative
disease or treatment failure. The miscellaneous category included only 2 patients (8.7% of all complaints), one with a
calf muscle cramping and another one with clicking/catching in the knee joint due to preexisting degenerative
meniscal tear. The skin category included self limited itching/rash (8,7%), skin discoloration (4,3%) and a skin wound
breakdown in the site of punch biopsy, which was treated conservatively uneventfully. Both patients who reported in
the bleeding/hematoma category had self-limited hematomas at the punch biopsy area. One patient reported a self-
limited nerve sensation after an injection procedure at the knee that was resolved a couple of weeks later. One
patient in the immune/allergic category reported fever (38.5-390 C) with rigor a few hours after an iv injection, and
this was thought to be caused of an extent amount of stem cells that were released to the blood circulation. After
that incidence we changed our iv administration protocol and a transfusion filter is always used in order to avoid any
thrombophlevitis or pulmonary embolism. The other one was presented with a face skin flush/irritation due to
allergic reaction. Both of them went away a couple of days later without any other special treatment.
NOTES
Side effects were reported in only 16 patients (10,5%) of a total of 152
patients in our registry

Impressive Clinical Improvement

M 56.MODERATE (L) HIP ARTHRITIS
BEFORE 6M.P.O

EMBRYONIC OR ADULT STEM CELLS?
EMBRYONIC
• (+) easy to produce
• (-) many complications
• (-) ethical considerations
• (-) DNA mix- what in next generation?
• (-) foreign materials for the body-immune response?
• (-) transmission of genes and inheriting diseases
With present technology, embryonic stem cells ARE NOT
the answer to orthopaedic problems

WHAT KIND OF ADULT STEM CELL
ARE THE BEST ?

Advantages of ADSC’s vs other sources
• Obtained in larger volumes with adipose
tissue
• lower risks
• Less invasive
• Less painful
• Easier to extract than bone marrow
• Does not cause cancer or teratomas

Curr Mol Med. 2013 Jul;13(6):1010-22.
Oxidative stress protection by novel telomerase activators in mesenchymal stem cells derived from healthy and
diseased individuals.
Tichon A1, Eitan E, Kurkalli BG, Braiman A, Gazit A, Slavin S, Beith-Yannai E, Priel E.
Author information
Abstract
Human Bone Marrow Mesenchymal Stem cells (hMSC) are a promising candidate for cytotherapy. However, the
therapeutic potential is limited since the therapy requires ex-vivo cell culturing in which deterioration in cellular
viability and aging is observed with time. Telomerase ribonucleoprotein complex re-elongates telomeres and
therefore promotes genomic integrity, proliferation and lifespan. Recently we showed that increasing telomerase
reverse transcriptase (TERT) expression by novel compound confers resistance from apoptosis induced by
oxidative stress. Here we investigated the possibility that a controlled induction of human TERT (hTERT) levels by
chemical compounds (AGS-499 and AGS-500) might improve the functionality of hMSC derived from healthy and
neurodegenerative diseased individuals. We demonstrate that AGS treatments of hMSC increased telomerase
activity and hTERT levels in a time and dose dependent manner. Prolonged treatments with the compounds
increased the average telomeres length, without altering population doublings (PD) or inducing chromosomal
aberrations. AGS treatments of hMSC protected the cells from apoptosis and DNA damages induced by H2O2, and
from the toxicity induced by long term exposure to DMSO. These AGS effects were shown to be mediated by
telomerase since they were not observed when TERT was depleted from hMSC or in mouse embryonic stem cells
derived from TERT knockout mice. Furthermore, AGS compounds did not alter the functionality of hMSC as
examined by their ability to differentiate into various lineages in the presence of the compounds. These results
suggest that pharmaceutical increase of telomerase may confer a beneficial therapeutic advantage in
regenerative medicine when hMSC therapy is applied.

“GROW” STEM CELLS IN A LAB OR NOT?
• Number of studies suggest that manipulating
them outside of the body:
 loose their effectiveness & proliferation capacity
alter the genetic makeup of the cells
alter telomeres significantly
• Larger number of MSC’s do not translate into
greater success (AAOS 2012, Osiris company)
• BMSC’s need proliferation ± telomerase

SVF (Stromal Vascular Fraction)
full of G.F, regenerative cells, 3D-matrix
• ADMSC’s ( high numbers)
• Hematopoietic stem cells
• Adipocytes (fat cells) and attached progenitor
cells
• T-regulatory cells (“self-check”)
• Monocytes
• Perivascular cellular components

Are MSC’s important?
Support
• hematopoietic stem cells (CD34+)
• Homing
• Release of signals
• Immunomodulation
CD34+ and MSCs show additive effects when
combined

ADULT STEM CELLS IN REGENERATIVE
ORTHOPAEDICS
MSCs
BODIES’ SUPERVISORS OF REPAIR
The most important job of MSC’s is that
they dramatically reduce (immuno-
modulate) the inflammation in an
area affected by an orthopaedic
disorder. When inflammation is
reduced, repair can take place
HSCs
TRUE WORKERS OF REPAIR
Contain cells that have short and long
term regeneration capacities
Unlike MSC’s the number of HSC’s does
not diminish greatly with age
• Drivers of tissue regeneration
• They cause angiogenesis
• They up-regulate the release of G.F
• They increase the release of other
stem cells from bone marrow

Other Synovial Fluid Factors:
• Growth Factors:
-IGF-1, FGF, TG-Beta super family
Can we stimulate these to increase GAG synthesis
after cartilage injury
• Catabolic Factors: Cytokines:
- IL-1, TNF, IL-6,7,8
Can we inhibit these to avoid matrix breakdown
after cartilage injury

NEW FRONTIERS IN STEM CELL SCIENCE
• Certain supplements for  telomerase
• SVF (virtual gold mine in Regenerative Medicine)
• Hyperbaric Oxygen
• Nitric Oxide
• Cytokines
• HGH or TGF-1
• Metabolomic supplements
• Light therapy
• Electrical current therapy

Conclusion
 ADMSC’s seems to be a
• Non-operative
• Without hospitalization
• Painless technique for pts suffering from knee & hip OA.
 The severity of arthritis affects the clinical result
 We need more pts, randomized trials and more specific treatment
protocols in order to ascertain our patients that the adult stem cell
world is the best alternative to a total joint replacement, for those
they don’t want to, or can’t undergo such a procedure

References
• ISSCR Guidelines for the Clinical Translation for Stem
Cells
• Patient Handbook on Stem Cell Therapies
provide the requisite information for the clinical use of
stem cells
International Society for Stem Cell Research. Guidelines for Clinical Translation of Stem Cells, 2008 Dec 3; Available
from:
• http://www.isscr.org/clinical_trans/
• 56. International Society for Stem Cell Research. Patient Handbook on Stem Cell Therapies, 2008 Dec 3;
Available from:
• http://www.isscr.org/clinical_trans

Adult Stem cells in Orthopaedics

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Destacado

Destacado (20)

Similar a Adult Stem cells in Orthopaedics

Similar a Adult Stem cells in Orthopaedics (20)

Último

Último (20)

Adult Stem cells in Orthopaedics