Joint Preservation Blog

February 12, 2009

Bone Marrow Nucleated Cell Concentrate (BMAC): Is it Concentrated Enough?

 

bmac machine

bmac machine

 

In 2005-2006 we mixed up BMAC in our cell biology lab.  It was easy to create from a marrow aspirate.  We performed some basic MRI studies with pre and post 3.0T high field studies and ran outcome questionnaires for knee and hip arthritis patients.  We were unimpressed by the results and because of this experience moved on to culture expanded mesenchymal stem cells.  

 

BMAC has become popular of late. In this procedure, a physician takes a bone marrow aspirate, places it in a specially designed centrifuge and pulls out a concentrate of bone marrow nucleated cells. This has been billed as a stem cell concentrate, but the stem cells that are concentrated in reasonable numbers tend to be CD34+ heme progenitors (stem cells that make new blood) and not MSC’s (Mesenchymal Stem Cells). Since MSC’s are the MVP of the adult stem cell mix available in a bone marrow concentrate, their concentration is very important to the success of such a treatment. A recent study on bedside bone marrow concentrate machines for MSC’s (BMAC) determined what concentrations were possible from a commercially available centrifuge unit. Using this study to calculate MSC numbers, a 60 ml bone marrow draw would produce 70,000-90,000 MSC’s. The Regenexx procedure yields after culture expansion are in the 5M-100M range. Based on this data, the Regenexx procedure produces approximately 100-1,000 times more cells than you can obtain with BMAC bedside systems. Based on this and other data, our best estimate is that the average micro fracture procedure would release 5-10 ml of un-concentrated marrow, so about 500-1,000 MSC’s into the defect site. Our own dosing data and the copious animal research would suggest that for appropriate cartilage, tendon, ligament, muscle repair the necessary MSC dose is in the millions range. Obtaining that amount of MSC’s from a BMAC system would require unacceptably high volumes of whole marrow from the patient. The conclusion, while very convienent, BMAC doesn’t have the right stuff.

For more information on different stem cell types, I’ve posted a video below:

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January 13, 2009

Steroid Shots

Steroid shots have become a mainstay of modern orthopedic medicine.  Relief from a cortisone shotis due to powerful anti-inflammatory effects of the corticosteroid medication.  You body uses this same chemical daily to modulate inflammation and help control tissue repair (generally to put the brakes on an inflammatory injury response).  In very low doses (about 1,000,000 times less than is used by most doctors) these natural steroids help to reduce swelling and help the joint produce growth factors like TGF-beta which can help heal local tissues.  However, in the high doses commonly used in orthopedics (milligrams or bout 1,000,000 times more than the nano-grams used naturally), steroids can be a big sledge hammer to the system, stamping out bad inflammation and good tissue repair with equal force.  A steroid shot for sciatica is common these days, as doctors often use these to decrease swelling around swollen nerve roots that lead to back and leg pain.  however, the same issues as above apply, the dose if often too high.  Our own experience with out own patients shows that relief from a cortison shot can be obtained with a low nono-gram dose approximately 1,000,000 times less than the commonly used milligram dose.  This also prevents many of the body wide side effects that can seen from high dose milligram cortisone shots, such as weight gain, changes in blood sugar, and moodiness.  Cortisone shots before surgery (the higher milligram dose) will generally reduce the effectivness of healing, as they tend to supress the healing immune system response including knocking down critical repair responses and adult stem cells.  Concerned about high milligram dose cortisone shots?  Alternatives treatments include prolotherapy and using your own stem cells to help heal a joint rather than just reducing the inflammation short term.

Cortisone Shot Flare

 

cortisone shot flare

cortisone shot flare

As a pain management doctor who performs procedures all day, I have seen Cortisone shot flares in the office.  Cortisone is a corticosteroid, which is a fancy way of saying that it’s a very strong anti-inflammatory which can bring down swelling.  Cortisone is actually an older brand name, newer brand names more commonly used today include Depomedrol and Celestone.  One of the biggest problems that we see in our office is that the commonly dose used of Cortisone is in the milligram range (thousandth of a gram).  While this may not sound like much, for orthopedic applications like sciatica, back pain, knee pain, shoulder pain, elbow pain, and other peripheral joints, this dose is about 100,000 to 1,000,000 times more than your body naturally uses to control swelling.  As an example, if the 50 nano-gram dose that your joint would use on it’s own to control inflammation is the height of a book of matches, the height of the usual dose used by most physicians to control swelling is the height of the Empire State Building.  Why? Unknown, as the science would support that the nano-gram (billionth of a gram) dose is good for the joint, while the milligram dose causes all natural repair function to cease.  This is why too many of these very high dose Cortisone shots can cause a joint to degrade.  Think of it as you can put in a finish nail with a sledgehammer (the milligram dose), but it isn’t pretty.   Steroid shots for sciatica are common, and we only use the giant milligram dose in certain circumstances where we need a huge effect to help the patient, otherwise we have moved to the lower doses.  So what’s the biggest cause of a Cortisone shot flare? While the high dose may be an issue, it’s usually the needle.  To inject joints, most syringes come loaded with a 20 gauge needle.  While this makes drawing up meds very fast and is great for pulling fluid out of a joint (aspirate), its way to large for putting cortisone into a joint.  A 27 gauge needle is a better choice and less likely to cause a cortisone shot flare.  So to avoid a Cortisone shot flare, make sure your doctor uses a smaller needle (25 or 27 gauge).  In addition, we find that cold spray on the skin can help patients tolerate the shot better.  In addition, having the doctor wiggle or put allot of pressure on the area to be injected can help reduce the sensation of the needle stick.  What if don’t want Cortisone?  Alternatives include prolotherapy and using your own stem cells to help heal a joint rather than just reducing the swelling short term.

January 11, 2009

Plantar Fasciitis Foot Brace

 

plantar fascia support brace

plantar fascia support brace

 

As a doctor, I have seen many patients have a difficult time understanding plantar fasciitis. Think of the plantar fascia as a piece of duct tape that travels along the bottom of your foot from your heel to the bottom of your toes.  It’s job is to support the normal arch in your foot, especially when you put weight on the foot.   As this piece of duct tape (plantar fascia) gets too much stress (due to extra weight on the person or too much force from changes in the way the foot moves), the heel area where it attaches can get easily overloaded and become painful.  A plantar fasciitis foot brace is therefore simple, it’s something that helps reduce the extra stress on the duct tape.  However, rather than bracing the plantar fascia, we often find that it’s much more effective to fix the problem.  How?  We strengthen the duct tape!  That can be as simple as taking the patients own adult stem cells and injecting them into the heel area under x-ray guidance (we numb the area first so it’s not uncomfortable).  This allows that heel anchor point to become much stronger and the pain to go away.  Click on the link about to learn more about this type of procedure.

Sprained Ankle Discharge Instructions

torn ankle ligament

torn ankle ligament

As a doctor who has treated sprained ankles and had a severe sprained ankle myself, here are my sprained ankle discharge instructions for my patients:

1.  Stay away from anti-inflammatories if you can help it!  These medications, otherwise known as NSAID’s block inflammation which can make things feel better, but inflammation is the basis of all healing, so blocking it is ill advised.  Use Tylenol if need a pain reliever.

2.  To control the swelling you can use ice and elevation.  Elevation means bringing the ankle above your chest/heart.  Icing means that you keep an ice bag on the ankle until the skin goes numb and then you remove it.  Again, the swelling is there is bring healing cells, growth factors, and new blood supply, so control it when it gets uncomfortable, but realize that it is serving a purpose.

3.  Immobilization as tolerated.   This means stay off of it when it hurts, but animal studies of ligament and joint healing usually show that staying completely off the area for extended periods will reduce the quality of the repair your body is able to muster.

4.  A sprained ankle takes only 4-12 weeks to completely heal.  if you still have pain, swelling, popping, clicking or other signs of an injury that is too big for your body to heal, consider getting an MRI or other type of imaging.  If the ligaments are completely torn in half, you will likely need surgery.  If they are stretched or partially torn, consider an injection based procedure to enhance healing.  In my clinical experience, prolotherapy can usually help.  Other options include surgery (I wouldn’t recommend this for a partial tear), or having the doctor inject your own stem cells into the ankle ligaments to heal the tear.  Below are videos on the newer stem cell procedures:

January 10, 2009

Replacing the Achilles Tendon with a Cadaver Tendon?

 

As a doctor, replacing the Achilles tendon with a cadaver tendonwould be the absolute last resort for patients with complete and retracted tears of the Achilles tendon.  This means that the two pieces of the tendon aren’t connected.  For patients with partial tears of the Achilles tendon where the tendon is still intact and not completely torn and retracted, this should not be considered.  This is due to the significant complications that can accompany this type of very big surgery.  Newer methods of tissue bioengineering look to replace this Achilles tendon replacement surgery.  This involves injecting the patient’s own mesnechymal stem cells into the Achilles tendon tears.  We have some experience with injecting adult mesenchymal stem cells into torn tendons with very good results.  This procedure is much less invasive and involves much less recovery and downtime for the patient. 

athletic ankle supports

ankle-support

As a doctor with an ankle problem, who is athletic, the best ankle brace I’ve found is the Malleoloc.  However, if you have an ankle problem like I did, why not ditch the ankle supports?  There are now new treatments where they inject your own stem cells into the ankle ligament tears to heal the damage.  This way you avoid athletic ankle supports and surgery!  This procedure should allow you to get rid of the athletic ankle supports for good.  In this minor procedure, your own adult stem cells are grown to larger numbers.  These repair cells are then injected into your torn ankle ligaments.  After this cutting edge procedure, you can wear an athletic ankle support for a few weeks, but continue working out while the ligaments mend.  You get to ditch the athletic ankle supports after just a month.  Why do these injections instead of supports?  An unstable ankle eventually damages the cartilage in the ankle and leads to early arthritis.  So what’s a little ankle pain now, will be an arthritis problem in the future, unless you heal the ankle ligaments.

basketball ankle supports

ankle brace

ankle brace

As a doctor with an ankle problem, who plays basketball, the best ankle brace I’ve found is the Malleoloc.  However, if you have an ankle problem like I did, why not get rid of the brace?  There are now new treatments where the doctor injects your own stem cells into the ankle ligament tear to heal the damage.  This way you avoid braces and surgery!  This procedure should allow you to get rid of the basketball ankle supports for good.  In this procedure, your own adult mesenchymal stem cells are isolated and then grown to larger numbers.  These healing repair cells are then injected into your torn ankle ligaments.  After this cutting edge procedure, you can wear a basketball ankle support for a few weeks, but continue playing and working out while the ligaments heal.  Maximum healing is 6-12 weeks.  You can come out of the basketball ankle supports after just a month.  Why go through all of this?  An unstable ankle eventually damages the cartilage in the ankle and leads to early arthritis.  So what’s a mild pain in the ankle now, will be big arthritis in 20 years, unless you get the ankle ligaments fixed.

Mcdavid elastic ankle braces

 

mcdavid elastic ankle brace

mcdavid elastic ankle brace

 

 

As a doctor with an ankle problem, I like most of the Mcdavid elastic ankle braces that use both a hard shell component to add stability and elastic to allow movement.  However, if you have an ankle problem like mine, why not get rid of the brace?  New non-surgical treatments where the doctor injects your own stem cells into the ankle ligament tear to heal it should allow you to get rid of the Mcdavid elastic ankle brace for good.  In this procedure, your own adult mesenchymal stem cells are isolated and then grown to bigger numbers.  They are then injected under x-ray guidance into your torn ankle ligaments.  After this break-through procedure, you can wear a brace for a few weeks, but continue playing and working out while the ligaments heal.  Maximum healing is 6-12 weeks.  You can come out of the Mcdavid elastic ankle brace after just a month.  Why go through all of this?  An unstable ankle eventually damages the cartilage in the ankle and leads to early arthritis.  So what’s a pain in the ankle now, will be severe arthritis in 20 years, unless you get the ankle ligaments fixed.  Think of these ligaments as duct tape that holds your ankle bones together.  When that duct tape is torn, it needs to be fixed, not braced.

Ankle support in london?

As a physician, you might say that I have an American MD specializing in Regenerative Medicine and a “doctorate of hard knocks” in ankle braces.  When I came across people searching for “Ankle support in london” I had to throw in my two cents.  I don’t live in London, far from it, I’m in beautiful Boulder, Colorado.  If you’re looking for an ankle support brace, I can tell you first hand that I’ve tried them all.  The winner?  The Malleoloc.  However, my quest for the perfect ankle support didn’t end there, I then tried prolotherapy which allowed me to get rid of the ankle support brace.  This technique involves injecting substances into the ankle ligaments to kick off an inflammatory healing response.  This worked pretty well, even allowed me to take a run every once in a blue moon.  What would I do today instead of the ankle support?  I’d try this cutting edge procedure where they inject your won stem cells into the ankle ligaments to heal and repair the damage.  The video below shows a patient where this was done in the U.S.:

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