Stemcells in Orthopaedic suergery.


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Regenerative medicine is now an recognized specialty which has evolved from degerative diseases of Orthopaedic Surgery.Orthobiologics is a current terminology for the application of various cells, cytokines, growth factors.Busy people find it to update and this is an update.

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Stemcells in Orthopaedic suergery.

  1. 1. Dr. A. Chandrasekaran, M.S. Ortho., Ph.D., Consultant Orthopaedic Surgeon, Chennai Orthopaedic care and research centre Chennai -
  2. 2. Acknowledgements Sri Ramachandra University, Dr. Solomon Paul, Ph.D., Dr. P. Venkatachalam, Ph.D., Dr. U Baraneedharan, Ph.D.,
  3. 3. Stem cell 2001 – Complete Human genome sequenced Stem cells hold promise for unlocking life saving secrets
  4. 4. Stem cell classification – based on source
  5. 5. Stem cells possibilities
  6. 6. Stem cell treatments.svg Wikipedia
  7. 7. iPS and ESC As ethical and safety concerns currently forbid application of iPS cells and ESCs in patients we will focus on adult mesenchymal stem cells R. D. Robbins, N. Prasain, B. F.Maier, M. C. Yoder, and R. G.Mirmira, “Inducible pluripotent stem cells: not quite ready for prime time?” Current Opinion in Organ Transplantation, vol. 15, no. 1, pp. 61–67, 2010
  8. 8. Bone marrow derived cells
  9. 9. Marrow stem cells Hematopoietic stem cell 1. CD34 “+” Cells 2. Abundant cells 3. Progenitors 4. Non Adherent Mesenchymal stem cell 1. CD34 “–” Cells 2. Rare cells 3. Total undifferentiated 4. Adherent Bone marrow stem cells - Subtypes
  10. 10. Hematopoietic stem cells
  11. 11. MSC applications
  12. 12. Stem cell action • A. Direct repair • B. Soluble growth factors ,cytokines- Paracrine effect • C.Immunomodulatory effects
  13. 13. Advantages of Mesenchymal Stem cells • Autologous – harvested from the patient themselves • No major ethical constraints – unlike embryonic stem cells • Can be expanded in vitro – unlimited supply of therapeutic cells. • Does not express HLA II antigens • Strong evidence for In Vitro and In Vivo differentiation
  14. 14. Stem cells MSC Colony on day 05 Confluent Monolayer on day 15 Isolation and in vitro expansion of mesenchymal stem cells
  15. 15. Alizarin Red Staining- 21 days Control - Undifferentiated cells Differentiated cells - Nodulation 10 X 10 X
  16. 16. Osteoblast differentiation • Differentiation was seen as early as the first week of induction • Cells became flattened and showed calcium deposition and could be seen as nodules, by the formation of mineralized matrix
  17. 17. Chondrogenic differentiation Control – Undifferentiated cells Chondrocyte – differentiated cells 10 X
  18. 18. Adipogenic differentiation Control – Undifferentiated cells Adipocytes – differentiated cells20 X
  19. 19. Skeletal myoblast differentiation Myotube formation 20 X 20 X
  20. 20. Stem cell application
  21. 21. Avascular necrosis Critical bone defects and non-unions Cartilage repair - acute Spinal cord injury – acute / chronic Intervertebral disc regeneration Articular cartilage regeneration – Rheumatic and Rheumatoid disorders Inflammatory autoimmune disorders Osteogenesis Imperfecta Duchene Muscular Dystrophy Stem cells in Orthopaedics
  22. 22. Role of mesenchymal stem cells in regenerative medicine: application to bone and cartilage repair. Granero-Molto F, Weis JA, Longobardi L, Spagnoli A. Expert Opin Biol Ther. 2008 Mar;8(3):255-68. 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.
  23. 23. 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. MSCs in cartilage repair
  24. 24. Osteochondral Lesions of the Knee 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/JBJS.J.00813 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.
  25. 25. 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)
  26. 26. Stem Cells in OA
  27. 27. 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
  28. 28. Cell transplantation can potentially increase proteoglycan production induce disc regeneration or slow the process of degeneration Transplantation of autologous disc cells and Chondrocyte derived from costal cartilage has been demonstrated to slow disc degeneration Brisby H, Tao H, Ma DD, Diwan AD. Cell therapy for disc degeneration: potentials and pitfalls. Orthop Clin North Am 2004; 35:85-93. Intervertebral disc
  29. 29. Autologous bone marrow transplantation in patients with sub acute and chronic spinal cord injury. Centre for Cell Therapy and Tissue Repair, Charles University, Prague, Czech Republic. Syková E, Homola A, Mazanec R, Lachmann H, Konrádová SL, Kobylka P, Pádr R, Neuwirth J, Komrska V, Vávra V, Stulík J, Bojar M. Cell Transplant. 2006;15(8-9):675-87. 20 patients with complete SCI who received transplants 10 to 467 days post injury. The follow-up examinations were done at 3, 6, and 12 months after implantation by two independent neurologists We compared intra-arterial (via catheterization of a. vertebralis) versus intravenous administration of all mononuclear cells in groups of acute (10-30 days post-SCI, n=7) and chronic patients (2-17 months post injury, n=13). Improvement in motor and/or sensory functions was observed within 3 months in 5 of 6 patients with intra-arterial application, in 5 of 7 acute, and in 1 of 13 chronic patients. It is evident that transplantation within a therapeutic window of 3-4 weeks following injury will play an important role in any type of stem cell SCI treatment.
  30. 30. Bone marrow aspirate concentrate
  31. 31. Autologus bone marrow Connolly et al.1991 Atrophic Pseudarthrosis. Percutaneous autologous bone marrow injection 20 Healing capacity comparable to autologous cancellous bone grafting J. F. Connolly, R. Guse, J. Tiedeman, and R. Dehne, “Autologous marrow injection as a substitute for operative grafting of tibial nonunions,” Clinical Orthopaedics and Related Research, no. 266, pp. 259–270, 1991
  32. 32. BMAC in AVN hips Hernigou andBeaujean2002 [*] Osteonecrosis femoral head. Injection of autologous bone marrow concentrate116(189 hips)Very good results in early stages Injection of greater number of progenitor cells transplanted had better outcomes. Gangji et al.2004 [**]Osteonecrosis femoral head. Injection of autologous bone marrow concentrate 13 (18 hips). Significant reduction of pain, progression and improvement of function Hernigou et al.2009 [***] Osteonecrosis femoral head. Injection of autologous bone marrow concentrate 342(534 hips). High amount of progenitor cells as predictor for successful outcome *P. Hernigou and F. Beaujean, “Treatment of osteonecrosis with autologous bone marrow grafting,” Clinical Orthopaedics and Related Research, no. 405, pp. 14–23, 2002 **V. Gangji, J. P. Hauzeur, C.Matos, V. deMaertelaer,M. Toungouz, and M. Lambermont, “Treatment of osteonecrosis of the femoral head with implantation of autologous cells. A pilot study,” Journal of Bone and Joint Surgery: Series A, vol. 86, no. 6, pp. 1153– 1160, 2004. ***P. Hernigou, A. Poignard, S. Zilber, and H. Rouard, “Cell therapy of hip osteonecrosis with autologous bone marrow grafting,” Indian Journal of Orthopaedics, vol. 43, no. 1, pp. 40–45, 2009.
  33. 33. 342 patients (534 hips) with Avascular Osteonecrosis at early stages (Stages I and II) Treated with core decompression and autologous bone marrow grafting obtained from the iliac crest Patients were followed up from 8 to 18 years.
  34. 34. 69 hips with stage I osteonecrosis demonstrated total resolution of osteonecrosis based on pre and postoperative MRI studies For the 371 other hips without collapse at the most recent follow up (average 12 years), the abnormal signal persisting was seen on T1 images as intralesional area of low intensity signal with a disappearance of marginal band like pattern. THR was necessary in 94 hips
  35. 35. Best indication for the procedure is symptomatic hips with osteonecrosis without collapse. Patients who had the greater number of progenitor cells transplanted in their hips had better outcomes.
  36. 36. Before Surgery 4 weeks after core Decompression / BMAC Application 8 weeks after core Decompression / BMAC application
  37. 37. 20 Years, Male – Pre operative
  38. 38. 20 Years, Male – Pre operative MRI
  39. 39. Bone Marrow Aspiration 60 / 120 / 240 ml Centrifugation 14 minutes 10 / 20 /40 ml Conc., Bone Marrow Aspirate Concentrate
  41. 41. Marrow aspiration
  42. 42. 1 2 3 4
  43. 43. 5 6 7 8
  44. 44. BMAC Infiltration
  45. 45. Immediate post operative
  46. 46. 6 weeks
  47. 47. 4 months
  48. 48. 4 months CT SCAN
  49. 49. 4 months F18 PET SCAN
  50. 50. 4 months F18 PET SCAN
  51. 51. 4 months F18 PET SCAN
  52. 52. 4 months F18 PET SCAN
  53. 53. 4 months F18 PET SCAN
  54. 54. 4 months F18 PET SCAN
  55. 55. Case 1 – 1year
  56. 56. Case 2 – hip 3
  57. 57. Case 2 – hip 3
  58. 58. Case 2 – hip 3
  59. 59. Case 2 – hip 3
  60. 60. Case 2 – hip 3
  61. 61. Case 2- hip 3 – 4 months
  62. 62. Case 3 , hip 4,5 Pre op Post op
  63. 63. Case 3 , hip 4,5
  64. 64. Post op 1yr
  65. 65. Case 4, hip 6,7
  66. 66. Case 4, hip 6,7. Pre op Immediate post op 6 weeks po
  67. 67. Case 5- hips 8,9
  68. 68. Case 5- hips 8,9
  69. 69. Case 5- hips 8,9 – 6 weeks
  70. 70. 3months follow up
  71. 71. 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 Jäger*,1, Eva M. Jelinek1, Kai M. Wess1, Axel Scharfstädt1, May Jacobson2, Sherwin V. Kevy2 and Rüdiger Krauspe1
  72. 72. 25 years male Traffic accident 2.5 years back Lost other limb above knee Allograft failed 20 cm gap Stem cells in a large gap non union
  73. 73. Allograft
  74. 74. After allograft removal  20 cm gap  Tibialisation of fibula  Segmental transfer
  75. 75. Internal bone transportation
  76. 76. Rapid transportation
  77. 77. Good regeneration BMAC Stem cell infiltration
  78. 78. Stage II
  79. 79. After completion
  80. 80. 18 months follow up
  81. 81. 18 months follow up
  82. 82. 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.
  83. 83. Delayed union
  84. 84. Non union
  85. 85. Animal experiment
  86. 86. Mesenchymal stem cells
  87. 87. Gold Nanoparticles Promote Osteogenic Differentiation of Mesenchymal Stem Cells Gold Nanoparticles Promote Osteogenic Differentiation of Mesenchymal Stem Cells through p38 MAPK PathwayACS Nano, 2010, 4 (11), pp 6439–6448 DOI: 10.1021/nn101373r
  88. 88. Stem cell therapy Application of Stem Cells in Orthopedics Andreas Schmitt,1, 2 Martijn van Griensven,2 Andreas B. Imhoff,1 and Stefan Buchmann1, 3Stem Cells International Volume 2012, Article ID 394962, 11 pagesdoi:10.1155/2012/394962
  89. 89. Arthroscope and PRP in AVN Arthroscopic management and platelet-rich plasma therapy for avascular necrosis of the hip Jorge Guadilla • Nicolas Fiz • Isabel Andia •Mikel Sa´nchez Knee Surg Sports Traumatol Arthrosc Springer-Verlag 2011 DOI 10.1007/s00167-011-1587-9
  90. 90. Arthroscopy and PRP in AVN Arthroscopic management and platelet-rich plasma therapy for avascular necrosis of the hip Jorge Guadilla • Nicolas Fiz • Isabel Andia •Mikel Sa´nchez Knee Surg Sports Traumatol Arthrosc Springer-Verlag 2011 DOI 10.1007/s00167-011-1587-9
  91. 91. BMAC vs PRP • Both human BMACs and PRP may provide therapeutic benefits in bone tissue engineering applications. These fractions possess a similar ability to enhance early- phase bone regeneration. • In Vivo Comparison of the Bone Regeneration Capability of Human Bone Marrow Concentrates vs. Platelet-Rich Plasma • Weijian Zhong1,2, Yoshinori Sumita1, Seigo Ohba1, Takako Kawasaki1, Kazuhiro Nagai3, Guowu Ma2, Izumi Asahina11 Department of Regenerative Oral Surgery, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan, 2 Department of Oral and Maxillofacial Surgery, College of Stomatology, Dalian Medical University, Dalian, Liaoning, China, 3 Transfusion and Cell Therapy Unit, Nagasaki University Hospital, Nagasaki, Japan • PLoS ONE | 1 July 2012 | Volume 7 | Issue 7 | e40833
  92. 92. Platelet rich plasma The hundreds of soluble proteins released from both plasma and platelets include VEGF-A, PDGF, FGF, EGF, HGF, and IGF. These angiogenic activators collectively promote vessel wall permeability and recruitment, growth and proliferation of endothelial cells . Blair P, Flaumenhaft R (2009) Basic biology and clinical correlates. Blood Rev 23:177–189
  93. 93. PRP preparation
  94. 94. MSC and tissue engineering Mao and colleagues demonstrated that when human mesenchymal stem/progenitor cells were seeded in micropores of 3D calcium phosphate scaffolds, followed by infusion of gel-suspended CD34+ hematopoietic cells, greater vascularization was seen in mice than when mesenchymal cells were used alone. Scientist Combines Blood And Mesenchymal Stem Cells To More Rapidly Generate Bone Tissue Tuesday, December 16, 2008 - Stem Cell Research News
  95. 95. Stem cell tracking
  96. 96. Allogenic cell transfer • Likely to form teratomas with injection of un differentiated mesenchymal cells in knee joints, cardiac and spinal cord. • As ethical and safety concerns currently forbid application of iPS cells and ESCs in patients
  97. 97. STAP cells • Stimulus triggered acquisition of pluripotency (STAP) is a cellular reprogramming phenomenon that was recently reported in two papers (Obokata, Nature, 2014a,b). • In this reprogramming process, upon strong external stimuli, neonatal somatic cells are converted into cells that express pluripotency-related genes, such as Oct3/4,and acquire the ability to differentiate into derivatives of all three germ layers in vitro and in vivo • . Yamanaka takes issue with claims STAP cells are safer than iPS option
  98. 98. Figure 1. Pre-Operative MRI Amariglio N, Hirshberg A, Scheithauer BW, Cohen Y, et al. (2009) Donor-Derived Brain Tumor Following Neural Stem Cell Transplantation in an Ataxia Telangiectasia Patient. PLoS Med 6(2): e1000029. doi:10.1371/journal.pmed.1000029
  99. 99. Figure 2. Intra-Operative View Amariglio N, Hirshberg A, Scheithauer BW, Cohen Y, et al. (2009) Donor-Derived Brain Tumor Following Neural Stem Cell Transplantation in an Ataxia Telangiectasia Patient. PLoS Med 6(2): e1000029. doi:10.1371/journal.pmed.1000029
  100. 100. Sentiments and religion
  101. 101. Research and application
  102. 102. Quote • Blood grouping is done for transfusion, • HLA typing is done for Organ transplant, • Genome mapping for oncogenes and other inheritable diseases will be required before allogenic stem cell transfer.
  103. 103. Summary • ips can cause teratomas and malignancy • Allogenic cells can be used when their genome is mapped • Autologus expanded cells may be used
  104. 104. BMSCs is a very promising tool for regenerative medicine Further engineering such osteogenic cells in scaffolds would allow us to repair bone defects Cord blood is generally used for haemopoietic disorders and not in musculoskeletal tissues Conclusion
  105. 105. 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:   56. International Society for Stem Cell Research. Patient Handbook on Stem Cell Therapies, 2008 Dec 3; Available from: 