Stem Cell injections for knee meniscus tears and post-meniscectomy
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.
- If you have questions about meniscus tear stem cell treatment, get help and information from our Caring Medical staff
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.
- In 81.3% of patients, a partial meniscectomy was performed in 81.3% of cases.
- In 20.3% a meniscal repair was performed. This is typically limited to the red-zone of the meniscus where ample blood supply allows for sutchuring and healing.
- Very rarely a meniscus allograft transplantation (cadaver donor) in 0.7% of patients was performed.
- Older patients were more likely to get a meniscectomy and less likely to get a repair.(1)
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:
- Meniscus repair led to osteoarthritis in 53% of patients and to knee replacement in 33.5% of patients
- Meniscectomy lead to osteoarthritis in 99.3% of patients and to knee replacement in 51.5% in patients
- Non-operative treatments (Traditional treatments include physical therapy, NSAIDs, and pain medication) led to osteoarthritis in 95.1% of patients and to knee replacement in 45.5% in patients.(2)
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 September 2017, in the Journal of orthopaedic research, (3) doctors at the University of Iowa, working with researchers from the Harvard Medical School and the National Institutes of Health, looked for the healing elements in the meniscus and identified what they do.
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.
- In essence the injury is calling for help and the chondrogenic progenitor cells respond to begin the rebuilding process. The meniscus has its own damage control mechanism, it sits in the blood rich portion of the meniscus. When red zone meniscus is removed, the meniscus ability to heal itself is removed with it.
Research like this reaffirm two things.
- The Meniscus does have the capability to repair and regenerate.
- When we surgically remove meniscus tissue we remove the cells that can naturally repair meniscal damage.
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.
- The suggestion is that the meniscus was trying to heal while the knee environment was collapsing towards degenerative disease. We have new meniscus tissue at 6 weeks being crushed by progressive degenerative changes.
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
- The left anterior halves of the medial menisci in mice were removed. Then the mice were observed to see how their knee dealt with this injury.
- At day three: Extensive macrophagic infiltration into the synovial membrane around the meniscectomized area was observed.
- Explanation: macrophages are immune cells that clean up and remove debris left behind by injury. The body is removing hindrances to healing. In other words the knee is getting ready to heal.
- At day three: Extensive macrophagic infiltration into the synovial membrane around the meniscectomized area was observed.
- Synovial hyperplasia was detected 2 weeks after the operation.
- Explanation: Synovial hyperplasia is inflammation. Healing inflammation. The synovial tissue of the knee was filled with many fibroblastic cells (collagen producers to rebuild cartilage).
- The articular cartilage at the interface of the resected meniscus significantly degenerated between 2 and 4 weeks after the surgical procedure, subtle progression in cartilage degeneration was observed between 4 and 6 weeks. The degeneration slowed but continued.
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)
- The mouse meniscal stem cells had clonogenicity (the ability to survive in hostile inflammatory environment and reproduce) and multi-potentiality (the ability to change and signal multiple types of healing mechanisms).
- They had the ability to create important extracellular matrix components of adult meniscus. Please see my article on extracellular matrix and joint healing for fascinating new research.
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.
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)
- “Regenerative medicine (stem cells, Prolotherapy and blood platelet solutions) seeks to harness the potential of cell biology for tissue replacement therapies, which will restore lost tissue functionality. Controlling and enhancing tissue healing is not just a matter of cells, but also of molecules and mechanical forces.”
- My note: Stem cell treatments are much more than simply injecting stem cells into the knee – while there are no guarantees that any treatment will work 100% – we, as doctors, have to make sure we are doing the most we can to guarantee success. This includes understanding that an athlete may have had a long history of painkiller and cortisone use – this is explained in my article How stem cells heal degenerative joint disease after years of cortisone and painkillers
- This is also covered in my article Why didn’t stem cell therapy work for my knee pain? Where I describe stem cell therapy failure because a single injection does not treat the whole knee. Meniscus damage is a whole knee disease as outlined in the research above.
- Continuing the research cited above from the journal Sports Medicine: The researchers acknowledge the following problems in consistency in treatment. First they “describe the main biological technologies to boost musculoskeletal healing, including bone marrow and subcutaneous fat-derived regenerative products, as well as platelet-rich plasma and conditioned media (meniscus scaffolds).”
- Then they examined a total of 54 studies investigated the effects of mesenchymal stem-cell products for joint conditions including anterior cruciate ligament, meniscus, and chondral lesions as well as osteoarthritis. In 22 studies, cellular products were injected intra-articularly, whereas in 32 studies mesenchymal stem-cell products were implanted during surgical/arthroscopic procedures. The heterogeneity of clinical conditions, cellular products, and approaches for delivery/implantation make comparability difficult.
- Mesenchymal stem-cell products products appear safe in the short- and mid-term, but studies with a long follow-up are scarce. Although the current number of randomized clinical studies is low, stem-cell products may have therapeutic potential. However, these regenerative technologies still need to be optimized.”
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
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