Arthritis relief without surgery

Understanding Arthritis
Edward G. Loniewski, DO ,
FACOS , FAOAO
Brighton, MI

Background – Way Back,
Background
• Michigan State University- BA Business
• Hotel, Restaurant & Institutional
Mgt – 1983
• University of London, Bedford
College – Hospitality Marketing,
Beverage Evaluation
• Morton’s – Chicago, Ill
• Michigan State University , College of Osteopathic Medicine – 1990
Edward Loniewski, DO , 810-299-8550

Background
• Founder- SOMA Foundation Research and Development Program .
• Internship- Botsford General Hospital – Farmington, MI – Head
Intern 1991
• Residency – Orthopedics , Michigan State University – 1995
• Burroughs-Welcome – AOA Research fellowship – 1994-1995

Background
• Chairperson, American Osteopathic Academy of Orthopedics
(AOAO), Adult Reconstruction Section, 2004-2005.
• Founder, Acting Director, Saint Joseph Mercy Hospital Livingston,
Bone and Joint Program. Howell, Michigan, 1997-2011
• Founder, Co-owner and President, JointHealing.com, 1999.

Background- Teaching
• Michigan State University, College of
Osteopathic Medicine, Associate Clinical
Professor 1997- Present.
• Saint Joseph Mercy Health Systems- Clinical
Instructor, Family Practice Residency, 2008-
2014.
• University of Michigan, Department of
Orthopedics, Alumni Instructor- 1997-2004.
• Research Reviewer, Michigan State University
College of Osteopathic Medicine Consortium
of Graduate Medical Education, 2005-Present.

Background – Research
Experience
• Alvin Yarrows Research Awards-
1993,94,95
• Fellowship- University of
Chicago- Adult Reconstruction,
Henry Finn, MD – 1995-96
• Andrew Taylor Still Research
Award – 1995
• American College of Osteopathic
Surgeons – Best of Show
Research 1995
• Fellow, American College of
Osteopathic Surgeons (ACOS),
2005.
• Fellow, American Osteopathic
Academy of Orthopedics (AOAO),
2005

Overview
of Talk
What is Arthritis?
What are the causes of
Arthritis?
• Common Theories
How Can You Treat Arthritis at
Home ?
• Exercise
• Diet
• Nutrition
• Shoe Wear
• Bracing

Overview
of Talk
Injections for Arthritis
• Steroids (Cortisone)
• Hyaluronic Acid ( Chicken Fat)
• Platelet Rich Plasma (PRP)
• Bone Marrow Derived Stem Cells
How Do Stem Cells Work?
• Reduce, Restore, Regenerate
Are Stem Cells Safe and Effective?
• Compared to Steroid and HA injections
• Compared to arthroscopy alone
• Compared to total knee replacement
Who is a candidate.
How is the procedure done.
Questions and Answers.

Three O’s of Aging
#1- Osteoarthritis
#2- Osteoporosis
#3- Oop’s I peed my pants!

What is
Arthritis ?
• Arthron has it’s origin
in Greek and latter
translated to Latin
meaning “joint” the
second part of the word
is “itis” meaning
inflammation.
• Thus Arthritis is an
inflamed joint and was
first used in the 16th
century to describe all
painful joints.

What are the signs
of Arthritis?
• Pain
• Swelling
• Stiffness
• Locking
• Catching
• Giving away

What are the risk
factors?
• Age
• Obesity
• Previous Injuries or infections
• Genetics
• Nutritional Deficiencies
• Physical inactivity

Interesting Facts on
Age and Arthritis
• Males are more likely to have arthritis
before the age of 45
• After the Age of 55, females are more
likely
• After the age of 70, almost 70% of
adults will have signs of arthritis on x-ray.
• All races are affected equally

Arthritis Trivia
• There are over 150 types of arthritic
conditions
• Arthritis affects 1in 2 Americans over the
age of 65
• Arthritis costs Americans over 15.5
billion $ each year.
• By 2030, 67 million Americans will have
arthritis.

Summary of
Arthritis
• Arthritis is a disease of
your joint
• Arthritis causes pain,
swelling and stiffness
• As you age, your risk
increases
• More and more Americans
will be affected by this
disease

Pathophysiology of Arthritis
• Radin Theory
• Impact Injuries
• Multiple
traumas to
the area
exceeds the
normal repair
threshold

Causes of Degenerative Arthritis
• When your ability to
repair the multiple daily
injuries to your
cartilage is more than
your body’s ability to
repair the injury

Pump Theory
of Arthritis
• No blood supply to
articular cartilage
• Synovial fluid motion is
analogous to blood
flowing to the heart.
• Cartilage metabolizes
normally when the
pump is working well.

Pump Theory of the Knee
• Interruption of synovial fluid movement by:
• immobilization,
• meniscal or ligament injury,
• changes in synovial fluid viscosity
• Malalignment
• Cause destruction of the cartilage.

Goals of
Treatment
of
Arthritis
Get the Pump MovingGet
Reduce DestructionReduce
Improve alignment of the pumpImprove
Stimulate RepairStimulate
Educate patients and families to take charge and
participate in their health care.Educate

Getting the Pump Moving
• Fact #1:Joints that don’t move get worse.
• Fact #2:Controlled, safe motion helps joints heal.
• Fact #3:Exercise reduces feelings of depression.

Exercise
The Good; The Bad
& The Ugly
• Good- Low impact aerobic exercise
• 80 pts randomized, controlled study-12
wks of aquatics & ROM - showed
improved 50 ft walk, less depression &
anxiety<.05) for up to 9 months ( Minor:
Arthritis & Rheum, 1989)
• The Bad- Repetitive high impact exercise
• Strenuous exercise causes decrease in
proteoglycan synthesis as compared to
moderate exercise programs (p<.05) up
to 16 weeks after program stopped (
Little: Osteoarthritis Cartilage; 1997)
• The Ugly- Stop & Go sports/activities
• Maximum isometric exercise and
standing exercises produced highest hip
pressures on in vivo pressure monitoring
( Tackson; Arthritis Care Res. 1997)

Good Exercises
• Joints love gentle, repetitive motion
which can help heal joints
• Swimming, walking, cycling are great
examples
• Set a simple goal of 10-15 minutes per
day of this activity

Bow legged
Correction
• A mis-aligned joint leads to
excessive, unequal pressure
• Excess pressure causes more
cartilage breakdown

Correcting the
Pump Alignment
• Controlled, retrospective
study of 85 pts, 121
knees
• 1/4” lateral heel
wedge for varus OA
• At 12 months- 88%
reported excellent
or good pain relief
on HSS ( Keating et
al:Ortho Review,
1993)
• Simple ACE Wrap
improves Proprioception
& feeling of stability (
McNair PJ et al: Arch Phys
Med Rehab, 1996)

Correcting the
Pump
• Unloader Bracing
• Recommendation reported by the
Osteoarthritis Research Society
International in the ability of off-loader
knee braces to reduce pain, improve
stability, and diminish the risk of falling
was 76% (95% confidence interval, 69%–
83%)

Shoes make a
difference
Every step we take
causes a force to be
directed back up into the
joint.
We can reduce the
velocity of this force
with proper shoes

Joint Protection
Anatomy of Shoe Wear
• Shock Absorbing Soles-
PUSH
• Stabilizing Heel Cup-
SQUEEZE
• Strong Shank – TWIST
Good Box, Bad Box

Weight Reduction (
Reducing Destruction)
• Every extra pound of weight produces
over 4 million pounds per leg per year.
• The risk for knee OA increased by 36% for
every 2 units of BMI (5 kg) of weight gain.
(March et al; Med J Aust. 2004; 180)
• Obesity resulted in a hip replacement 10
yrs earlier and knee replacement 13 yrs
earlier than non-obese patients. (
Changulani M; JBJS Br. 2008; 90 (3):360-3)
• Reducing only 5% of total body weight at
0.24% per week significantly reduced pain
and disability scores (Christensen R; Ann
Rheum Dis. 2007;66(4):433-9)

Combining Weight
Reduction and Exercise
• Will the age old recommendation of
diet and exercise reduce arthritic
symptoms better than one alone?
• ADAPT (Arthritis Diet & Activity
Promotion Trial) – 18 months of
calorie restriction and exercise
resulted in 24 % improvement in
physical function and 30.3%
reduction in knee pain compared to
diet or exercise alone.

Nutritional
Deficiencies
Eat a Mediterranean Diet:
• Healthy fats- Omega 3
• Whole grains
• Legumes
• Fish
• Vegetables and Fruit
• Wine

Correct
Nutritional
Deficiencies
Take at least 2,000 I.U.
of Vitamin D per day
500 mg of Vitamin C.
400 IU of Vitamin E per
day

Glucosamine Yes
or No?
Yes!
Glucosamine Sulfate (must be
the Sulfate form) has evidence
suggesting this will reduce pain
and increase activity in
patients with arthritis
Need to take for at least 2
months.
Do Not use the HCL or NAS
form, only use the Sulfate
form.

Summary
Losing as little as 10 lbs can
help
Avoid pounding type
exercises
Simple walking exercises can
help.
Correction of a bow can
reduce pressure
Proper shoe wear reduces
joint reactive forces.
Correct nutritional
deficiencies by taking
vitamins D, C, E and
Glucosamine Sulfate.

Gel Injections
• Replacing hyaluronic acid
restores the natural viscosity
(thickness) of your joint fluid.
• This is like an oil change to your
joint
• Increased hyaluronic Acid can
reduce pain and increase activity
in 56-63% of patients for up to 1
year.

Gel Injections
• Series of 3-5 injections given
one week apart
• Takes 3 weeks up to 3 months
to take full effect.
• Lasts between 6 mo – 1 year.
• Can be repeated.

Gel Injections
• Ideal Patient:
• Degenerative Arthritis
• No age limit
• Must have minimal to no mechanical symptoms.
• Minimal to moderate swelling

Gel Injections
• Insurance normally covers injections to the knee only.
• Risks of injections include rare chance of infections and
increased joint pain.
• Can have additive effect for other treatments.

Summary of Hyaluronic Acid
Injections
3 to 5 injections
given one week
apart
1
Increases viscosity
of the joint fluid.
2
50-65% of
patients respond
for up to one year.
3
Normally lasts
between 6 -12
months.
4
Only knees are
covered by
Insurance.
5

Steroid
Injections
• Usually one injection given into
the joint
• Works by reducing inflammation
of the joint and surrounding tissue

Steroid
Injection
• Starts to work in 1-6 days
• 80% of patients respond
• May last from 2 weeks to 2
months
• May be repeated about every 3-
4 months.
• May loose effect over time.

Steroid Injections
• temporary side effects of:
• Elevated blood sugar
(1-5 days)
• Nausea, vomiting,
heartburn, headache,
dizziness, trouble
sleeping, appetite
changes, increased
sweating, acne, or
pain/redness/swelling
at the injection site
may occur

Steroid Injections
• Covered by most insurances.
• Effective in 80% of patients
• Duration- Lasts between 2 weeks and 2 months with
average at 6 weeks
• May be repeated about every 3 months
• If used correctly, does not cause joint damage or bone
loss
• Repeat injections to tendons and ligaments may cause
weakening
• Long term treatments can become less effective

Platelet Rich
Plasma (PRP)
• Platelets are
found in your
blood or bone
marrow.
• They help the
body repair after
an injury

Platelet Rich Plasma
Growth Factors
• Platelets excrete important growth
factors after an injury
• Most of our scabs after a cut
contain high concentrations of
platelets.
• Growth factors such as insulin-like
growth factor, transforming growth
factor b-I, platelet derived growth
factor are released from platelets to
heal a damaged area
• They act like fertilizer for your
joints.

Platelet Rich Plasma (PRP)
Efficacy: May be more
effective in younger
patients with milder
arthritis.
*Teitze, DC et al. entitled “The effects of platelet
rich plasma in the treatment of large-joint
osteoarthritis: a systemic review.” (Physiology and
Sports Medicine 2014, May;42(2) 27-37)
Safety- Very good profile
since made from own
blood.
Efficacy- one to three
injections revealed
Improved function and
decreased pain in
arthritic knees.*

Platelet Rich
Plasma
• Duration- 6
months to 2
years with an
average of 12
months
• One office visit
lasting about 30
minutes
• Return to
normal
activities the
next day.

Platelet Rich Plasma
for soft tissue
issues!
• May be used to treat
tendonitis, bursitis and
ligament sprains or tears
• Used by many pro athletes
to speed recovery .
• Provides multi use for
arthritis and soft tissue
issues in one setting

Platelet Rich
Plasma
• Superior to Hyaluronic and
Steroid Injections
• Cost - $500- $1,000 per
injection
• Not covered by insurance

Summary
of PRP
Platelets release factors which help
heal damaged joints and surrounding
tissues.
One single injection can provide relief
for one year
Superior pain relief and longer pain
relief than Hyaluronic and steroid
injections.
May be more effective in younger and
less severe arthritic patients
Not covered by insurance

Bone Marrow
Concentrate Stem Cells
• Bone Marrow contains regenerative
cells including:
• Hematopoietic Stem Cells
• Mesenchymal Stem Cells
• Endothelial Progenitor Cells
• Platelets
• Plasma Proteins
• Bone Marrow Concentrate provides 3
different but complimentary therapies
• Stem Cells
• Platelet Rich Plasma (PRP)
• Plasma Proteins ( A2M and IRAP)

Is Stem Cell
Therapy A
Miracle ?
• Miracles must be:
• Attributable to a Divine
Power
• Beyond the power of
created nature
• Beyond the order of
created nature
• Extraordinary
• Sensible
• The Miracle of the Sun
in Fatima, Portugal ,
October 13, 1917 was a
true miracle

Stem Cell Therapy
• Is not attributable to a divine power
• Is within the power of created
nature
• Is within the order of created nature
• Is not extraordinary
• Is only sensible after the pain stops.
• NO MIRACLES HERE!

Bone Marrow
• Advancement in techniques allow
easy and almost painless harvest of
bone marrow from your pelvis
• We can now increase cell harvest
by over 300% and also capture over
90% of the cells.
• “Stem Cell Research can
revolutionize medicine more than
anything since antibiotics” - Ronald
Regan.

How does Stem Cell Therapy
Work?
• Special Cells in Bone Marrow Work Together
• Platelet Growth Factors – “The Fertilizer”
• Plasma Proteins- Reducers and Scavengers
• Stem Cells – ” The Conductors”
• To
• Reduce – Bad Chemicals
• Restore- Cell to Cell Communication
• Regenerate – Cell Balance

REDUCE
IL-1B
REGENERATE
Normal
Homeostasis
RESTORE
CELL TO CELL
COMMUNICATION

How do Cell Based Therapies
work?
• Platelets – “The
Fertilizer”
• Platelets clump or clot just
like your scab and release
many growth factors such
as:
• PDGF
• TGF-B
• IGF
• VEGF
• Tighter the clumping=
longer duration of release
of growth factors

Plasma
Proteins
The fluid between your
platelets and bone
marrow is Plasma
Plasma contains
proteins which help in
the healing process
Traditionally, these
proteins were discarded
Proteins

Plasma Proteins
• Proteins found in this
plasma help with
reducing destruction
to joints and
inhibiting chemicals
which destroy the
joint.
• Concentrating plasma
proteins such as A2M
or IRAP have been
shown to help reduce
pain and restore
function in arthritic
joints *
*Frizziero A, Autolgous conditioned serum for the treatment of
osteoarthritis and other possible applications in musculoskeletal d
Br Med Bull. 2013: 105: 169-84.

Plasma Protein IRAP
• IRAP stands for intrluleukin-1 Receptor
Antagonist Protein which binds to a
receptor secreting Interluekin-1 Beta.
• This receptor helps block the harmful
production of Interlukein-1 Beta ( IL-1 B)
• Reducing IL-1 B will help reduce
destruction to your joint. *
• IRAP is used by many race horses to
improve performances.
• Attur M, Plasma levels of interleukin-1 receptor
antagonist (IL1Ra) predict radiographic progression of
symptomatic knee osteoarthritis. Osteoarthritis
Cartilage. 2015 Nov;23(11):1915-24

Stem Cells
• Conductors of joint
biochemical function
• Reduce harmful
inflammation
• Restore normal cell-cell
communication
• Regenerate/normalize
bone and cartilage
balance and repair.

The Normal
Joint
• Biochemical balance
• Separate layers of
cartilage and bone
• Biomechanically stable
• Meniscus has normal
height
• No shift of the joint
• Mechanical and
anatomic alignment
maintained
• Normal smooth
range of motion

The Abnormal
Biochemical Joint
• Elevated levels of IL-1B
• Cascade of growth factor changes
• Tunnels form between bone to cartilage
• Cross talk occurs and thus loss of
paracrine signaling.
• Stress fracture and bone marrow lesions
happen in the area under cartilage.
• Physical function starts to suffer-
collapse, bowing, meniscal bulging and
failure

The Abnormal Biomechanical Joint
• Tunneling from IL-1B release-
Stress fracture causes loss of
bone support.
• Bone loss causes shift of joint
• Meniscus bulges and fails
• Chronic stress on ligaments cause
loss of stability and shear begins
• Shear causes subluxation- Further
Shift
• Subluxation causes loss of motion
• Loss of motion causes loss of
function of synovial fluid

Cell Based Therapy only corrects the BioChemical Joint
and Not the BioMechanical Joint

Joint Homeostasis
• Homeostasis- the tendency toward a
relatively stable equilibrium between
interdependent elements, especially
as maintained by physiological
processes.
• Insult > Repair = Destruction & Pain
• Repair > Insult = Regeneration and
Restoration
• BONE MARROW STEM CELL works
by restoring this normal balance.

Interleukin 1B
• The Godfather of
Interleukins ( The Kingpin)
• Many other pathways must
keep IL-1B happy to keep
functioning
• IL-1 family (aka The
Corleone Family) is a group
of 11 cytokines, IL-1 come
from macrophages and thus
make them very potent and
hardy.
• The IL-1 family owns the
judges, police, newspapers
and the casinos. They have
their hands in everything.

Interleukin 1 B wide ranging
effects
• Regulates and initiates
inflammatory responses
• Causes lining of joint to snap,
crackle and pop.
• Causes cartilage breakdown
• Causes cartilage cells to
actually make harmful
chemicals against healthy cells
• Inhibits transforming growth
factor-ß (TGFB) (The
Untouchables)
• Increase VEGF which causes
tunneling between cartilage
and bone .

TGF-B – The Untouchables
To the Rescue!
• TGF superfamily include a number of
important growth factors for cartilage
regeneration and repair
• Stem Cells are Activated by TGF
• TGF-β1 and TGF-β2 are important in
making new cartilage 40
• TGF-β helps establish clear communication
between cartilage cells ( Paracrine
signaling.)
• TGF works with other chemicals to restore
a normal chemical balance in the joint.

Breakdown of Cell to Cell
Communication
• Normal joints have a barrier
between cartilage and bone.
• IL-1B and VEGF elevations cause
”tunneling” between
subchondral bone and cartilage
• Elevated VEGF causes new blood
vessels to grow around nerve
endings in the joint causing
Neoangiogensis
• Elevated IL-1B and
neoangiogensis cause increased
sensitivity of nerves which
reduce the effects of pain
medications used for arthritis.

Breakdown of Cell to Cell
Communication
• Cross-Talk between cartilage
cells and bone cells :
• Chemicals released from bone
cause damage to cartilage
cells.
• Chemicals released from
cartilage cells damage bone
cells.37.
• Cartilage Cells try to act like
bone cells and bone cells try
to act like cartilage cells!

Bone Marrow Stem Cell RESTORES
Cell to Cell Communication
• Bone Marrow reduces IL-1
B causing:
• A shut down of tunneling
effect
• Neoangiogensis ( Pain)
• Stimulates TGF-B
• TGF-B (The Untouchables)
elevation causes:
• Stem Cell Growth Signaling
required for cartilage and
bone homeostasis

Stem Cells Regenerate
Homeostasis
• Stem cells work to help build damaged
tissue by conducting many different
biochemical processes.
• This can not happen until the
destructive biochemical imbalance is
reduced and the cell to cell
communication is restored.

Stem Cells Regenerate
Normal Balance of
Damage and Repair-
Homeostasis
• Stem Cells work on
maintaining hemostasis
or balance by:
• Increasing growth factors
and
• Decreasing inflammation.
• Net Result – increased
cell formation.
• No Relation between
amount of cartilage
formation and pain relief.

Putting it all together
• IL1 B (Don Corleone) is significantly elevated in osteoarthritic joints
• This disrupts normal function of the joint by:
• Reducing TGF-B (The Untouchable)
• Increased channeling between cartilage and bone
• Causing loss of normal communication between bone
cells talking to bone cells and cartilage cells talking to
cartilage cells (paracrine signaling )
• Stimulating Neoangiogenesis causing hypersensitivity
of the nerves.
• Bone Marrow Stem Cell therapy introduces IRAP which:
• Puts the hit on Don Corleone ( IL-1B)
• Allows the Untouchables ( TGF-B) to get to work and:
• Increase Stem Cell production
• Stop tunneling between bone and cartilage
• Restore normal cell to cell communication .

Do these cells
really provide
benefits or
value?

Bone Marrow Derived Stem Cell
Safety
• Safety-: No adverse events
noted in 78 studies*
• No Adverse events in over
1,000 patients **
• No risk of cancer in over
1873 patients followed for
for over 10yrs. ***
• Most common event is
mild bruising of the pelvis
or joint.
*World J Gastroenterol. 2014 Oct 14;20(38):14051-7
**Lalu MM et al, Safety of Cell Therapy with Mesenchymal
Stromal Cells (SafeCell): A systemic Review and Metanalysis
of Clinical Trials. PLoS One. 2012 Oct 25 7(10) e47559.
***Herniguo P et al, Cancer risk is not increased in patients
treated for orthopedic disesases with autologous bone
marrow concentrate. J Bone Joint Surg Am, 2013 Dec 18:
95(24) 2215-21

Bone Marrow Concentrate Stem
Cell
• Efficacy (Does it Work?)
• Better outcomes of arthritic knees compared to
surgical patients:
• Autologous Chondrocyte Implantation (ACI)
surgery .
• Patients with only one injection improved more
than patients receiving two surgeries.
• *Ref- Autologous bone marrow-derived mesenchymal stem
cells versus autologous chondrocyte implantation: an
observational cohort study. Nejadnik H., American Journal of
Sports Medicine 2010 Jun;38(6):1110

Bone Marrow Concentration Stem Cell
therapy is better than Gel Injections
• Controlled study comparing Allogeneic Bone
Marrow (taken from someone else) to Hyaluronic
injections 15 in each group
• BMC group had significantly improved functional
scores
• MRI was improved in the BMC group
• Stem Cell group did better!
• Vega A, et al, Treatment of Knee Osteoarthritis with Allogeneic
Bone Marrow Mesenchymal Stem Cells: A Randomized
Controlled Trial, Transplantation, 2015 Aug;99(8); 1681-90

Bone Marrow
for Knee Arthritis
• BMC used to treat knee arthritis:
• 840 procedures evaluated
• Patient activity and function
improved
• Pain scores reduced
• 6% of patients had adverse events
(most common was bruising)
• Centeno C, et al, Efficacy of autologous bone
marrow concentrate for knee osteoarthritis with
and without adipose graft, Biomed Res Int.
2014;2014:370621

Bone Marrow Concentrate
Stem Cells for Arthritis
• Larger Group
• 373 patients.
• All patients showed improvement in
pain and function
• Improvement was also seen in
severe arthritic conditions
• Centeno, C et al, A dose response analysis of a specific bone
marrow concentrate treatment protocol for knee osteoarthritis,
BMC Musculoskelet Disord. 2015; 16:258

Long-Term Results Bone
Marrow Concentrate
Stem Cell
• 18 patients followed for 30 months
• No adverse reactions
• All had improved pain and function
scores and positive MRI findings
• Emadedin M., et al, Long-Term Follow up of
Intra-articular Injection of Autologous
Mesenchymal Stem Cells in Patients with Knee,
Ankle or Hip Osteoarthritis, Arch Iran Med. 2015,
Jun;18(6): 336-44

Longer Term Results
of Stem Cell Therapy
for arthritis of knee
and hip
• 1128 patients had 1856
joints injected with
adipose derived stem cells
and PRP.
• Followed for up to 54
months
• No serious side effects
• 63% had at least 75%
improvement
• 91% had at least 50%
improvement
• Obese and higher grade
arthritis took longer to feel
effects.
• Michalek J, Autologous adipose
tissue-derived stromal vascular
fraction cells in patients with
osteoarthritis, Cell Transplant,
2015 Jan 20. doi: 10.3727

Stem Cells improve outcomes of
common surgeries
• Stem Cell Therapy at the time of
surgery can improve the outcome
of:
• High Tibial Osteotomy - Cutting
the bone and moving the joint.
**
• Micro fracture surgery to
stimulate repair of the joint .
• **Wong, KL. et al Injectable cultured bone
marrow-derived mesenchymal stem cells in
varus knees with cartilage defects undergoing
high tibial osteotomy: a prospective, randomized
controlled clinical trial with 2 years' follow-up.
Arthroscopy 2013 Dec;29(12):2020-8
• ***Koh YG et al, Adipose Derived Mesenchymal
Stem Cells with Microfracture vs. Microfracture
Alone: 2-Year Follow up of a Prospective
Randomized Trial, Arthroscopy, 2016 Jan, 32(1)
97-109

Bone Marrow Concentrate
Stem Cell For Hips
• Bone Marrow Concentrate Used to
Treat Hip Arthritis caused by loss of
blood supply – Avascular Necrosis
• 534 patients followed for up to 18
yrs
• Over 84% of the patients did not go
onto a hip replacement.
• Hernigou, P, et al, Cell Therapy of hip necrosis with autologous
marrow grafting , Indian J Orthop.2009 Jan-Mar; 43(1): 40-45

Arthroscopy vs. Stem Cell

Scope vs. Scope and Stem Cell
• Varma HS, The new avenues in the management of osteo-
arthritis of knee--stem cellsJ Indian Med Assoc. 2010
Sep;108(9):583-
• 50 patients split into 2 groups. Group A-
Scope, Group B- Scope +Stem Cell.
• Followed with Visual Analog Pain Scales (0-
10), and osteoarthritis outcome scores.
• Patients in Group B- with Stem cells
had reduced pain, improved activity
and quality of life scores.

Second Look
Arthroscopy
• 16 of 30 had second look
arthroscopy- 87.5% had neutral
or improved results with 62.5%
showing very positive (18.7%)
or positive (43.8%)
improvement.

Joint
Replacement
vs. Stem Cell

Joint
Replacement
Surgery
What is it?
Resurfacing and Re-alignment
procedure- Joint is given new
surface along with new
mechanical alignment
Titanium and cobalt chrome
with plastic liner.

Joint Replacement
• Safety :
• A retrospective review of 169,406 patients receiving
either a total knee or total hip replacement. The
overall complication rate was 16% for inpatient joint
replacement.
• Another study reviewing over 405,379 total hips found
that the complication rates were found in 3.4 % in the
first hip replacement but increased to 10.9% with
revision (re-do) hip replacements.
• Complications increase with : Patient age over 70;
malnutrition, obesity, cardiac history; smoking
history; and diabetes

Joint Replacement
• Efficacy: The Gold Standard - American Academy of
Hip and Knee Surgeons (AAHKS) reports:
• Reliable- over 90% of patients have pain relief
• Reproducible- over 90% relief of pain.
• Durable- 80-85% of patients will still have the
same joint replacement 20 yrs from the date of
their surgery.

Patient Satisfaction after
Joint Replacement
• Although total joint replacement can
provide reliable results, many patients
have “issues” and continued symptoms.
• Approximately 27%- 30% of patients
after a total hip or knee are
dissatisfied . * **
• *Lam, YF et al, A Review of the Clinical Approach to Persistent
Pain Following Total Hip Replacement, HongKongMedJ , 2016
Dec: 22(6): 600-7
• **Wylde, V et al, Total Knee Replacement: Is it Really and
Effective Procedure for All?; Knee, 2007, Dec 14 (6): 417-23

Joint Replacement Costs
• Cost : The average charge by a
hospital for a joint replacement is
approximately $35,000 and the 2017
Consumers Report Blue Book Value
for the cost in the Detroit Area is
$21,626 for a knee replacement and
$21,698 for a total hip.
• Average out of pocket cost for
Medicare recipients in Lebanon, New
Hampshire without secondary
insurance was $4,275 in 2011.

Convenience of Joint
Replacement
• Pre-operative class and history and
physical
• Pre-operative occupational therapy
• Visit with family doctor and possibly
specialists
• Hospital stay of 1-3 days
• Require someone to help 24/7 for 3
weeks
• Sedentary work in 3 weeks
• High demand jobs 3 months
• Physical therapy for 6-8 weeks
• Injections or pills to prevent blood clots

Stem Cell Vs. Knee
Replacement
• White Paper from University of Paris:
• 60 patients all 85 yrs or older.
• Group A- Bilateral Knee Replacement
• Group B- Bilateral intra-marrow stem
cell
• Group C- One knee replaced and other
with stem cell

Stem Cell Vs.
Knee
Replacement
• Average follow up is
over 6 yrs (range from 2-
15 yrs )
• Stem Cell Group had
• Faster improvement in
functional outcome of
Knee Society Score (KSS)
• Stem Cell Group
average improvement
was 16.3 pts
• Knee replacement
group average
improvement was only
8.9 pts

Stem Cell Vs. Knee
Replacement
• Knee Replacement Group had :
• Higher analgesic use
• Longer hospital stay (20 vs 2
days)
• Higher Transfusions ( 29.3% vs.
0%)
• More blood clots ( 12% vs 2%)
• Longer use of crutches (4 weeks
vs 1 week )
• More medical complications

Stem Cell Vs. Knee
Replacement
• Stem Cell had higher patient
satisfaction:
• When asked to point to the knee
they preferred,
• 70% pointed to the stem cell knee!

Am I a
candidate for
Stem Cell?
• Rare or no giving away,
locking or catching from
loose bodies or meniscus
tears.
• OR
• My joint gives away or
catches less than 2 times
per week.
• If your joint is stable
with no or very rare
episodes of catching or
giving away, you can
consider cell based
therapies.

Am I a
Candidate for
Stem Cell?
• My knee or joint has mild
to moderate swelling not
requiring any draining
• OR
• My knee swells but not
enough to stop all my
activities for more than 2
days.
• If your joint has only rare
episodes of swelling and
you do not require
draining more than 4
times per year, you can
consider cell based
therapy

Am I a
Candidate for
Stem Cell?
• Knee angle is LESS than
than 8 of knocked knee or
10 degrees of bowlegged
angle.
• OR
• You notice the bow in
your leg even with your
pants on.
• If you have mild to
moderate bowing of your
joint and you do not
notice the bow under
your pants, you can
consider cell based
therapies

Am I a Candidate for
Stem Cell?
• Range of Motion within 20 degrees
of normal
• OR
• You can get dressed by yourself
without any assistance.
• If you have mild to moderate loss
of motion of the joint and can dress
yourself without any aids, you
should consider cell based
therapies.

If you have two or more of these risk factors, you
should consider cell based therapies
• Body Mass Index over 40
• Depression
• Chronic use of narcotics
• Renal Failure
• Hepatitis or liver disease
• Blood clot history
• Previous surgical infections
• Diabetes
• Stroke history
• Previous heart disease

If you have any of the following, you
should consider cell based therapy.
• Not willing to undergo surgical treatment for my
joint .
• Do not have anyone to take care of me 24/7 for up
to 3 weeks
• Do not wish to or can not take off work up to 3
months
• I am not willing to commit to up to 2 months of
therapy.

Benefits of Cell
Based Therapy
• No to little time off work or
activities
• No or little need for supervision
at home
• No prolonged pain or recovery
• No or very limited narcotics

Benefits of Cell
Based Therapy
• Lower Risk!
• Most have less than 1%
risk of complications
• Ability to perform on
overweight patients
• Medical complications
such as blood clots,
infections, diabetes or
heart disease have little
effect on the treatment
• No addiction risk
• No hospital stay
• Everyone’s welcome!

Bone Marrow Concentrate Stem
Cell
• How is this done?
• Muscle relaxer's and pain
pills given .
• Lying on your stomach or
side .
• Area is made numb
• Needle is introduced into
the back part of your pelvis
• Bone marrow is taken with
little to no pain.

Bone Marrow
Concentrate Stem Cell
• Bone Marrow Processing
• Patented sterile system separates out
the bone marrow concentrate from
the plasma proteins and red blood
cells.
• Bone marrow concentrate also
contains increased concentration of
platelet rich plasma.

Bone Marrow
Concentrate Stem Cell
• Not covered by insurance
• Cost $3,995 which includes:
• Bone Marrow Derived Stem Cells
• Filtered Plasma Proteins
• Platelet Rich Plasma
• Given all at once.

Our Results
• November 2013- Present
• WOMAC/ VAS / Radiographic/ AE
• 344 patients (292 knees , 41 hips, and 11 other)
• All comers and techniques- 82.5% improvement with average 50%
or more.
• Less than 10% have converted to arthroplasty.
• Majority K/L grade 4
• Stepwise improvement in scores overtime.

Sample Radiograph
PRE Procedure
6 mo post
This is not representative of all patients and an increase in joint space does
not always result in functional improvement.

Sample Procedure
• https://www.dropbox.com/s/gzqn815gg6ckrg8/9a
%20In%20Office%20Procedure%20.mov?dl=0

Summary
• Arthritis is a math problem
• Damage > Repair
• Reduce Destruction
• Reduce pressure
• Weight Control
• Shoe Wear
• Shoe Wedge
• Brace
• Nutrition
 Increase Repair
 Glucosamine
 Hyluronic Injections
 PRP
 Stem Cells

Stem Cell Summary
• Adult Stem Cells from
Bone:
• Still experimental
• Promising short term
results
• Decreased Pain
• Improved Function
• Low to no complications
• Not Regulated
• Not Covered by Insurances

Question and Answers
Edward G. Loniewski, DO, FACOS, FAOAO
Brighton, Michigan
Orthopedics and Stem Cell Therapy

Arthritis relief without surgery

Recommended

Recommended

More Related Content

Similar to Arthritis relief without surgery

Similar to Arthritis relief without surgery (20)

Recently uploaded

Recently uploaded (20)

Arthritis relief without surgery