Stem Cell injections for knee meniscus tears and post-meniscectomy

Stem cells for knee meniscus tears

Ross Hauser, MD

This article will explore new research from March 2018 that paints a fascinating picture of natural meniscus healing, surgical and non-surgical meniscus repair, and when Stem Cell Therapy may or may not work for your meniscus tear. We will also discuss the role of comprehensive Stem Cell Prolotherapy in not only treating the meniscus but the articular knee cartilage as well. If you are considering meniscus surgery, or already had meniscus surgery, this article will provide some good information in understanding your injury and what to expect from surgery and what to expect from stem cell Prolotherapy.

The surgical realities of meniscus tear repairs – what the United States Military says:

Army physicians from the William Beaumont Army Medical Center and doctors from Rush University Medical Center, have published a new March 2018 study in the Journal of Knee Surgery. It reports on how  military surgeons dealt with meniscal injury. The report reveals findings on nearly 30,000 meniscus surgeries.

What are we to make of this? In 4 out of 5 patients, meniscus tissue had to be removed. In 1 out of 5 patients the injury was fixable because of location and size. Meniscus transplant has lost much of its appeal.

The problem is the 4 out of 5 patients not having an option other than tissue removal.

Here is another new 2018 study. This time in the American Journal of Sports Medicine. In this research doctors compared various treatment methods for Meniscus Root Tears.

This was a detailed 10 year study that looked at the long-term effect of surgical repair and non-surgical repair of meniscal injuries.

The 10 year findings revealed:

For many the meniscus can heal itself if you do not remove tissue

One of the often overlooked components of meniscus surgery is that it removes healing elements from the knee. Simply, meniscus surgery removes tissue, weakens the structure of the knee, leads to degeneration through instability and knee breakdown. To complete this assault on the knee, surgery removes healing elements within the meniscus tissue that may help the knee naturally rebuild itself. The same can be said for NSAIDs and painkillers which have been shown to inhibit natural healing.

In this study, the researchers found that the meniscus has its own brigade of chondrogenic progenitor cells (Chondrogenic = cartilage, progenitor = creator or originating cells) specifically in the blood rich red zone of the meniscus. Further, the cells in the blood rich zone could be called upon to migrate across the meniscus and appear at the site of a white zone (no blood supply portion of the meniscus) injury. (See our discussion red-zone and white-zone meniscal tears).

In the research above we talked about the 20% of meniscus injuries that are good candidates for surgical repair because that portion of the meniscus had healing elements. In this research, those healing elements were able to cover the whole meniscus.

Research like this reaffirm two things.

The Meniscus does have the capability to repair and regenerate but the articular cartilage of the knee cannot hold the knee together long enough to let this happen

This is a remarkably fascinating study. Japanese researchers wanted to examine the meniscus healing process after an injury or surgical removal of meniscus tissue. In an animal study the researchers removed a large portion of the meniscus in mice.(4)

What the doctors observed was the meniscus repair and regeneration process after the meniscectomy. After six weeks the doctors observed regenerated tissues resembled those of an intact meniscus forming. The bad news was the articular cartilage of the knee where the removed meniscus use to be, significantly degenerated between two and four weeks after the surgical procedure, and subtle progression in cartilage degeneration was observed between 4 and 6 weeks.

This study requires a deeper look because it also gives us an understanding of what happens in the knee after meniscectomy.

The researchers in this study performed a meniscectomy in the mice

In this study’s summation, the immune system’s rapid response to repair the knee, not only tries to regenerate meniscus tissue damaged by the surgery, but also tried to reinforce and prevent damage to the articular cartilage of the knee as if the immune system knew that the meniscectomy would cause articular cartilage.

The Japanese researchers concluded that the remaining meniscus and the articular cartilage of the meniscectomized knee tried, in vain, to work together to regenerate the meniscus and protect the cartilage.

Harvard researchers publishing in the medical journal Connective Tissue Research, (May 2017)  found similar findings. They isolated and studied the native meniscal tissue in mice and also found an abundance of healing mechanisms.(5)

Stem Cell Prolotherapy – research and validity of treatment

Stem cell Prolotherapy is a non-surgical regenerative treatment that stimulates natural healing repair in the knee. The goal of the treatment is to rebuild tissue and provide stability to the knee. Stem cell Prolotherapy is the combined use of your own harvested stem cells and dextrose Prolotherapy to treat the entire knee environment.

In research published by the Journal of Bone and Joint Surgery, doctors have found that a  single stem cell injection following meniscus knee surgery may provide knee pain relief and aid in meniscus regrowth. In this study, patients received a single injection of donated adult stem cells following the surgical removal of all or part of a torn meniscus. These patients reported a significant reduction in pain. Further, some meniscal tissue regrew. Up to 15 percent increase in meniscal volume at one year. There was no additional increase in meniscal volume at year two. (Comment: Maybe they should have given more than one injection.) (6)

That question was seemingly answered in accompanying press release from the American Academy of Orthopaedic Surgeons press department.

“The results of this study suggest that mesenchymal stem cells have the potential to improve the overall condition of the knee joint,” said Dr. Vangsness (a study author). “I am very excited and encouraged” by the results. With the success of a single injection, “It begs the question: What if we give a series of injections?” (7)

Not all meniscus tears and injuries (even that after meniscus surgery) require stem cell therapy to heal. We have documented in numerous studies that simple dextrose Prolotherapy has a 90% success rate in our office. However, for cases of advanced meniscus and related cartilage damage, our team of Prolotherapy practitioners may choose to use stem cell injections in combination with dextrose Prolotherapy to strengthen and stabilize the surrounding support structures of the knee.

We have published extensively on this subject, please see our research at:

Rationale for Using Direct Bone Marrow Aspirate as a Proliferant for Regenerative Injection Therapy (Prolotherapy)

Hauser R, Eteshola E. Rationale for using direct bone marrow aspirate as a proliferant for regenerative injection therapy (prolotherapy). The Open Stem Cell Journal. 2013;4:7-14.

Adult mesenchymal stem cells (MSCs) obtainable from autologous bone marrow aspirates have generated tremendous interest in the medical and scientific communities in the last two decades and are currently being investigated by a of interested physicians for use in point-of-care stem cell therapies due to their great potential to differentiate into multiple cell lineages such as bone, cartilage, muscle, tendon, and nerve. However, as these stem cells are found in very low numbers in adult tissue, centrifugal concentration or expansion through in vitro culturing has been pursued to obtain higher numbers of efficacious regenerative therapeutic applications. More recently, some physicians and scientists have chosen to explore use for direct injection of un-fractionated, native whole bone marrow aspirate as a strategy in regenerative treatment regimes. This review examines the potential merits and disadvantages of using either concentrated and culture expanded MSCs versus native whole bone marrow aspirate as key proliferant in direct regenerative injection therapy (RIT). Results from a number of published investigations have clearly shown high potential of various deleterious effects on manipulating MSCs obtained from native bone marrow aspirate either by centrifugal forces or expansion through in vitro culturing; moreover, currently used centrifugal concentration techniques do not significantly concentrate MSCs from bone marrow aspirate, thus, defeating the purpose of this manipulative step. On the other hand, preliminary results and observations of using un-fractionated whole bone marrow injection for treatment of various musculoskeletal joint diseases (for example, osteoarthritic joints) suggest that the procedure is safe and potentially efficacious, with no known deleterious effects as yet reported. Read entire article

Bone Marrow Prolotherapy for Degenerative Joint Disease

Regenerative Injection Therapy with Whole Bone Marrow Aspirate for Degenerative Joint Disease: A Case Series

Hauser R, Orlofsky A. Regenerative injection therapy with whole bone marrow aspirate for degenerative joint disease: a case series. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2013;6:65-72.

ABSTRACT

Regenerative therapeutic strategies for joint diseases usually employ either enriched concentrates of bone marrow-derived stem cells, chondrogenic preparations such as platelet-rich plasma, or irritant solutions such as Prolotherapy hyperosmotic dextrose. In this case series, we describe our experience with a simple, cost-effective regenerative treatment using direct injection of unfractionated whole bone marrow (WBM) into osteoarthritic joints in combination with hyperosmotic dextrose. Seven patients with hip, knee or ankle osteoarthritis (OA) received two to seven treatments over a period of two to twelve months. Patient-reported assessments were collected in interviews and by questionnaire. All patients reported improvements with respect to pain, as well as gains in functionality and quality of life. Three patients, including two whose progress under other therapy had plateaued or reversed, achieved complete or near-complete symptomatic relief, and two additional patients achieved resumption of vigorous exercise. These preliminary findings suggest that OA treatment with WBM injection merits further investigation…Read full Article

Treating Osteoarthritic Joints Using Dextrose Prolotherapy and Direct Bone Marrow Aspirate Injection Therapy

Ross Hauser, MD, Woldin B. Treating osteoarthritic joints using dextrose prolotherapy and direct bone marrow aspirate injection therapy. The Open Arthritis Journal. 2014;7:1-9.Osteoarthritis is a chronic, progressive disease of the articular joints, and to date, has no cure or effective long-term treatment.

Objective: To determine if bone marrow prolotherapy (BMP), a combined treatment protocol employing separate injections of hypertonic dextrose prolotherapy and bone marrow aspirate, would be effective as a means of reducing joint pain and improving function in osteoarthritic joints.

Design: Patients with a clinical diagnosis of radiographic osteoarthritis who visited our pain clinic and underwent BMP treatments (N = 24, mean age 64.9) were asked to complete a questionnaire assessing their condition before and after treatment.

Methods: BMP treatments (average 3.6) were conducted at 6 to 8 week intervals and involved autologous harvesting and aspiration of the patient’s tibial bone marrow, after which a hypertonic dextrose solution was injected at sites in and around the index joint (prolotherapy), followed by injections of the bone marrow aspirate directly into and around the joint. At 6 months post-treatment, patients were e-mailed a questionnaire asking them to rate their condition before and after BMP treatment in terms of pain levels at rest, performing activities of daily living, and during exercise (Visual Analog Pain Scale), as well as their degree of stiffness, range of motion, and level of crepitus. Changes in the self-reported scores of these variables for each patient were analyzed to determine the effectiveness of BMP treatment. Data were obtained by comparing the differences between baseline and post-treatment scores and analyzed utilizing a two-tailed paired t test.

Results: Patient-reported improvements in pain relief and joint function were statistically significant (P < .001), as were gains in activities of daily living, exercise ability, and range of motion and losses in stiffness and crepitus. No adverse events occurred.

Conclusion: Our survey of patient-reported outcomes supports the use of BMP as an effective therapy for treating osteoarthritis and suggests that BMP has potential for enhancing the quality of life of individuals with the disease. Download PDF 

Injury to the meniscus is injury to the entire knee joint. This is why many doctors can provide stem cell treatments, not all get the best results

An international team of researchers writing in the journal Sports Medicine (May 2017) offer a summary of their research that should be of great interest to the patient athlete researching stem cells for meniscus repair.(8)

Stem cells, combined with Platelet Rich Plasma Therapy meniscus injections and Prolotherapy meniscus injections are healing solutions. Caring Medical has conducted research showing the effectiveness of PRP Prolotherapy (PRPP), including case reports of MRI-documented meniscus tears successfully treated with Prolotherapy and Platelet Rich Plasma.(9) 

If you have questions about meniscus tear stem cell prolotherapy treatment, get help and information from our Caring Medical staff

1. Pekari TB, Wang KC, Cotter EJ, Kusnezov N, Waterman BR. Contemporary Surgical Trends in the Management of Symptomatic Meniscal Tears among United States Military Service members from 2010 to 2015. The journal of knee surgery. 2018 Mar 7. [Google Scholar]

2. Pekari TB, Wang KC, Cotter EJ, Kusnezov N, Waterman BR. Contemporary Surgical Trends in the Management of Symptomatic Meniscal Tears among United States Military Service members from 2010 to 2015. The journal of knee surgery. 2018 Mar 7. [Google Scholar]

3. Seol D, Zhou C, Brouillette MJ, Song I, Yu Y, Choe HH, Lehman AD, Jang KW, Fredericks DC, Laughlin BJ, Martin JA. Characteristics of meniscus progenitor cells migrated from injured meniscus. Journal of Orthopaedic Research. 2016 Nov 1. [Google Scholar]

4. Hiyama K, Muneta T, Koga H, Sekiya I, Tsuji K. Meniscal regeneration after resection of the anterior half of the medial meniscus in mice. Journal of Orthopaedic Research. 2016 Nov 2. [Google Scholar]

5. Vangsness Jr CT, Jack Farr II, Boyd J, Dellaero DT, Mills CR, LeRoux-Williams M. Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial meniscectomy: a randomized, double-blind, controlled study. JBJS. 2014 Jan 15;96(2):90-8. [Google Scholar]

6. Stem Cell therapy following Meniscal Surgery http://newsroom.aaos.org/media-resources/Press-releases/stem-cell-therapy-following-meniscus-knee-surgery-may-reduce-pain-restore-meniscus.htm

7.Gamer LW, Shi RR, Gendelman A, Mathewson D, Gamer J, Rosen V. Identification and characterization of adult mouse meniscus stem/progenitor cells. Connective tissue research. 2017 Feb 4:1-8. [Google Scholar]

8.Andia I, Maffulli N. Biological therapies in regenerative sports medicine. Sports Medicine. 2017 May 1;47(5):807-28. [Google Scholar]

9. Hauser R, Phillips HJ, Maddela HS. The case for utilizing Prolotherapy as first-line treatment for meniscal pathology: a retrospective study shows Prolotherapy is effective in the treatment of MRI-documented meniscal tears and degeneration. Journal of Prolotherapy. 2010;2(3):416-437. [Google Scholar]

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