OSTEOARTHRITIS
Recently, I have had a number of patients interested in orthobiologic injections for the treatment of knee osteoarthritis. Having failed a corticosteroid injection(eg. Cortisone) or viscosupplementation injections (eg. Orthovisc, Euflexxa, Synvisc, Supartz etc.), many patients are not yet ready to turn to knee replacement surgery. Orthobiologics are another alternative to total knee replacement, but beware, they are not the golden goose. All orthopedists want to help patients reduce pain and suffering from knee osteoarthritis, but if one panacea existed, we would all be using it.
Most of these Orthobiolgics work by reducing pain and inflammation. Studies are mixed in their efficacies and outcomes. First and foremost, no current large prospective well constructed studies demonstrate that we have the ability to significantly “re-build” articular cartilage. However, patient reported outcomes are promising with many of these orthobiologics. As an orthopedist, it is hard to recommend one treatment over another for various reasons. Specifically, depending on where you live, the cost of these procedures can be extremely expensive since they are usually not covered by insurance. I have seen out of pocket pricing ranging from $300-$7500 depending on the strategy employed. Certainly, one does not have to travel far from home to find providers who are currently using these techniques. I would recommend all patients do their research carefully into the different techniques available to them and have a long discussion with your orthopedist about their efficacy. Below is a very brief summary of the three most common orthobiologics being used for knee osteoarthritis (PRP, Autologus Stem Cells, and Amniotic Fluid):
Platelet Rich Plasma (PRP):
Platelet-rich plasma therapy, sometimes called PRP therapy or autologous conditioned plasma (ACP) therapy, attempts to take advantage of the blood's natural healing properties to repair damaged cartilage, tendons, ligaments, muscles, or even bone. This is an in-office procedure that involves a blood draw, preparation of the PRP, and the injection:
Experts are unsure exactly how PRP therapy may alleviate symptoms for certain orthopedic conditions such as knee arthritis. Doctors who use PRP therapy to treat osteoarthritis theorize that the platelet-rich plasma might:
• Inhibit inflammation and slow down the progression of osteoarthritis
• Stimulate the formation of new cartilage
• Increase the production of natural lubricating fluid in the joint, thereby easing painful joint friction
• Contain proteins that alter a patient's pain receptors and reduce pain sensation
It could be that platelet-rich plasma does all of these things, or none. More large-scale, high-quality clinical studies are needed before scientists can know.
Autologus Stem Cell Treatment:
The human body is made of billions of specialized cells that form specific organs like the brain, skin, muscles, tendons, ligaments, joints, and bone. Each day these cells go through a degenerative and regenerative process. As older cells die, new cells are born from stem cells with the unique capability of being able to create multiple types of other cells. However, when tissues are injured, the degenerative process exceeds this regenerative process, resulting in structures that become weaker, painful and less functional. While there are several types of stem cells, those that are best at promoting musculoskeletal healing (tendon, ligament, cartilage and bone) are found in bone marrow.
In the procedure, your physician usually takes a small bone marrow sample through a needle, as well as a blood draw from a vein in the arm. The marrow is rich in Mesenchymal Stem Cells, which are responsible for healing damaged tissues. The stems cells are isolated from the marrow sample and platelets are isolated from the blood sample. After preparation, these two components will be reinjected directly into the knee using advanced imaging guidance.
Amniotic Fluid Injections:
Amniotic fluid for osteoarthritis of the knee has been growing in popularity in recent months. Research continually shows that amniotic fluid, and amniotic tissue based products, are able to reduce pain and inflammation in joints afflicted with osteoarthritis, and even have longer lasting beneficial effects than other treatment options, all while showing a lower risk of side effects and complications.
Amniotic stem cells are a mixture of stem cells that can be extracted from the amniotic fluid and amniotic membrane after a pregnant woman has delivered her baby. The amniotic fluid surrounds the fetus during development in the uterus and it is contained by the amniotic membrane.
Research has demonstrated the regenerative potential of amniotic membrane stem cells. Animal studies showed cartilage defects can be enhanced by the implantation of mesenchymal stem cells, and in the treatments of various pathological conditions of joints with no single unfavorable reaction. Hence, amniotic membrane is an exciting new treatment option that patients with chronic musculoskeletal pain might want to consider.
Disadvantage: Amniotic fluid doesn’t contain a lot of embryonic stem cells. Hence, the restorative effect may be only incrementally better then steroid or viscosupplementation (hyaluronic acid) injections.
