Whats new in Orthopedics
Stem Cell Therapy
Stem cell therapy is a form of regenerative medicine that utilizes the body’s natural healing mechanism to treat various conditions.
Stem cells are being used in regenerative medicine to renew and repair diseased or damaged tissues, and have shown promising results in treatments of various orthopedic, cardiovascular, neuromuscular and autoimmune conditions.
Stem cells are present in all of us, acting like a repair system for the body. However, with increased age sometimes, the necessary amounts of stem cells are not present at the injured area. The goal of stem cell therapy is to amplify the natural repair system of the patient’s body by increasing the numbers of stem cells at injury sites.
Types of stem cells
There are two major types of stem cells: embryonic stem cells and adult stem cells.
Embryonic stem cells (ESCs) are stem cells derived from human embryos. They are pluripotent, which means they have the ability to develop into almost any of the various cell types of the body.
As the embryo develops and forms a baby, stem cells are distributed throughout the body, where they reside in specific pockets of each tissue, such as the bone marrow and blood. As we age, these cells function to renew old and worn out tissues and cells. These are called adult stem cells or somatic stem cells. Like embryonic stem cells, adult stem cells can also turn into more than one cell type, but their differentiation is restricted to a limited number of cell types.
Use of stem cells in orthopedics
The unique self-regeneration and differentiating ability of embryonic stem cells can be used in regenerative medicine. These stem cells can be derived from eggs collected during IVF procedures with informed consent from the patient. However, many questions have been raised on the ethics of destroying a potential human life for the treatment of another.
Adult stem cells can be harvested from many areas in the body. These include adipose tissue (fat), bone marrow and peripheral blood. The mesenchymal stem cell is the most commonly harvested. These have the ability to turn into cells that form the musculoskeletal system such as tendons, ligaments, and articular cartilage. To obtain stem cells from the bone marrow, a needle is inserted into the iliac crest of the pelvic bone to extract the stem cells.
Currently, stem cell therapy is used to treat various degenerative conditions of the shoulder, knees, hips, and spine. Stem cells are also being used in the treatment of various soft tissue (muscle, ligaments and tendons) as well as bone-related injuries.
Who is a good candidate for a stem cell procedure?
You may be a good candidate for stem cell therapy if you have been suffering from joint pain and want to improve your quality of life while avoiding complications related to invasive surgical procedures.
Preparing for the procedure
It is important that you stop taking any non-steroidal anti-inflammatory drugs (NSAIDs) at least two weeks before your procedure. Preparing for a stem cell procedure is relatively easy and your doctor will give you specific instructions depending on your condition.
Stem cell procedure
The procedure begins with your doctor extracting stem cells from your own bone marrow. Bone marrow is usually aspirated from your hip region. Your doctor will first clean and numb your hip area. A needle is then introduced into an area of your pelvic bone known as the iliac crest. Bone marrow is then aspirated using a special syringe and the sample obtained is sent to the laboratory. In the laboratory, the aspirate is spun in a machine for 10 to 15 minutes and a concentrated stem cell sample is separated.
Your doctor then cleans and numbs your affected area to be treated and then, under the guidance of special X-rays, injects the stem cells into the diseased region. The whole procedure usually takes less than one hour and you may return home on the same day of the procedure.
You will most likely be able to return to work the next day following your procedure. You will need to take it easy and avoid any load bearing activities for at least two weeks following your procedure. You will need to refrain from taking non-steroidal, anti-inflammatory medications (NSAIDS) for a while as this can affect the healing process of your body.
Stem cell therapy is a relatively simple procedure that avoids the complications associated with invasive surgical procedures. As stem cell therapy uses the cells derived from your own body, it reduces the chances of an immune rejection.
There is a general lack of data about the long-term effects of stem cell therapy as it is a newer procedure and represents a newer form of treatment.
Risks and complications
Stem cell therapy is generally considered a safe procedure with minimal complications; however, as with any medical procedure, complications can occur.
Some risks factors related to stem cell therapy include infection as bacteria, viruses or other pathogens that can cause disease may be introduced during the preparation process.
The procedure to either remove or inject the cells also has the risk of introducing an infection to the damaged tissue into which they are injected. Rarely, an immune reaction may occur from injected stem cells.
Single Portal Arthroscopy
Arthroscopy is a minimally invasive procedure during which the internal structure of a joint is examined for diagnostic and treatment purposes. In an arthroscopic examination, small incisions are made in the patient’s skin through which miniature surgical instruments and a pencil-sized instrument with a small lens and lighting system, called an arthroscope, is passed. A single-portal arthroscopy is a new technique that uses a modified arthroscope and instruments to adequately carry out the procedure through a single portal thus improving healing and recovery time.
Click here for more information Single Portal Arthroscopy
Our blood consists of a liquid component known as plasma. It also consists of three main solid components which include the red blood cells (RBCs), white blood cells (WBCs), and platelets. Platelets play an important role in forming blood clots. They also consist of special proteins, known as growth factors, which help with our body’s healing process. Platelet-rich plasma or PRP is a high concentration of platelets and plasma. A normal blood specimen contains only 6% platelets, while platelet-rich plasma contains 94% of platelets and 5 to 10 times the concentration of growth factors found in normal blood, thus greater healing properties.
PRP is a relatively new method of treatment for several orthopaedic conditions such as muscle, ligament, and tendon injuries; arthritis; and fractures. PRP injections can help alleviate painful symptoms, promote healing and delay joint replacement surgeries.
Your doctor will first draw about 10 cc’s of blood from the large vein in your elbow. The blood is then spun in a centrifuge machine for about 10 to 15 minutes to separate the platelets from the remaining blood components.
The injured part of your body is then anesthetized with a local anesthetic. The platelet-rich portion of your blood is then injected into your affected area. In some cases, your doctor may use ultrasound guidance for proper needle placement.
- It is normal to feel some discomfort at the injection site for a few days after your procedure.
- You will be prescribed pain medications by your doctor.
- You may use cold compresses to alleviate your symptoms.
- You will be instructed to stop any anti-inflammatory medications.
- You may resume your normal activities but should avoid any strenuous activities such as heavy lifting or exercises.
Risks and complications
There are very minimal risks associated with PRP injections. Some of the potential risks include
- Increased pain at the injection site
- Damage to adjacent nerves or tissues
- Formation of scar tissue
- Calcification at the injection site
Platelet-rich plasma injections are a promising technique to help relieve painful orthopedic conditions and promote healing. It is a relatively new concept and most patients benefit with alleviation of symptoms and a quicker recovery.
Cartilage Replacement & Transplant Surgery
Articular Cartilage is the white tissue lining the end of bones where these bones connect to form joints. Cartilage acts as cushioning material and helps in smooth gliding of bones during movement. An injury to the joint may damage this cartilage which cannot repair on its own. Cartilage can be damaged with increasing age, normal wear and tear, or trauma. Damaged cartilage cannot cushion the joints during movement and the joints may rub over each other causing severe pain and inflammation.
Cartilage restoration is a surgical procedure where orthopedic surgeons stimulate the growth of new cartilage that restores the normal function. Arthritis condition can be delayed or prevented through this procedure.
Several techniques are employed for cartilage restoration including dietary supplements, microfracture, drilling, abrasion arthroplasty, osteochondral autograft, and allograft transplantation.
Dietary supplements: Dietary supplements such as glucosamine and chondroitin are the non-surgical treatment options for cartilage restoration. Chrondroitin sulphate and glucosamine are naturally occurring substances in the body that prevent degradation of cartilage and promote formation of new cartilage. Chrondroitin sulphate and glucosamine obtained from animal sources are available as over the counter products and are recommended for cartilage restoration. Apart from these various other nutritional supplements are also recommended such as calcium with magnesium and vitamin D as a combination, S-Adenosyl-Methionine and Methylsulfonylmethane.
Microfracture: In this method numerous holes are created in the injured joint surface using a sharp tool. This procedure stimulates healing response by creating new blood supply. Blood supply results in growth of new cartilage.
Drilling: In this method, a drilling instrument is used to create holes in the injured joint surface. Drilling holes creates blood supply and stimulate growth of new cartilage. Although the method is similar to microfracture, it is less precise and the heat produced during drilling may damage other tissues.
Abrasion Arthroplasty: High speed metal-like object is used to remove the damaged cartilage. This procedure is performed using an arthroscope.
Osteochondral Autograft Transplantation: Healthy cartilage tissue (graft) is taken from the bone that bears less weight and is transferred to the injured joint place. This method is used for smaller cartilage defects.
Osteochondral Allograft Transplantation: A cartilage tissue (graft) is taken from a donor and transplanted to the site of the injury. Allograft technique is recommended if larger part of cartilage is damaged.
Autologous Chondrocyte implantation: In this method, a piece of healthy cartilage from other site is removed using arthroscopic technique and is cultured in laboratory. Cultured cells form a larger patch which is then implanted in the damaged part by open surgery.
Osteoarticular transfer system (OATS): Osteoarticular transfer system (OATS) is a surgical procedure to treat isolated cartilage defects which usually 10 to 20mm in size. The procedure involves transfer of cartilage plugs taken from the non-weight bearing areas of the joint and transferring into the damaged areas of the joint.
This procedure is not indicated for wide spread damage of cartilage as seen in osteoarthritis.
The procedure is usually performed using arthroscopy. During the procedure, the plugs taken are usually larger and therefore only one or two plugs are needed to fill the area of cartilage damage. The area of damaged cartilage is prepared using a coring tool which makes a perfectly round hole in the bone in the area of damage. The hole is drilled to a size that fits the plug. Next the plug of normal cartilage is harvested from a non-weight bearing area of the knee, is then implanted into the hole that was created in the damaged area. The size of the plug used should be slightly larger than the hole so that it fits into the position. This procedure allows the newly implanted bone and cartilage to grow in the defected area.
Possible complications of OATS include donor site morbidity causing pain, avascular necrosis, and fracture. Other complications such as hemarthrosis, effusion and pain may also occur. Following OATS rehabilitation is recommended by use of crutches and limiting the range of motion.
The sacrum is a triangle shaped bone found in the base of the spine. The iliac bones are the two large bones that form the pelvis. The sacrum and the iliac bones or ilium are connected together by strong ligaments and the junction where these bones meet is referred to as the sacroiliac joint. The hip area plays an important role in supporting the entire upper body weight during body movements (standing, walking, sitting, bending, etc.). This generally leads to wearing and tearing of the cartilage at the sacroiliac joint resulting in sacroiliac joint dysfunction. The people suffering from sacroiliac joint dysfunction may experience low back pain, inflammation, stiffness and pain in the leg, thigh, groin and hip. This condition is initially treated non-surgically with anti-inflammatory and analgesic medicines, sacroiliac joint belt, physical therapy and cortisone injections. If the nonsurgical methods do not prove to be effective then your doctor might recommend you to undergo sacroiliac fusion. Sacroiliac fusion is a surgical procedure which involves fusing of the iliac bones and sacrum for stabilization.
Your doctor may recommend sacroiliac fusion surgery if you are experiencing severe sacroiliac joint dysfunction due to arthritis, injury due to accidents or falls, being overweight, uneven leg lengths, gout, and spondylitis.
Sacroiliac joint dysfunction is diagnosed with X-ray, CT-scan and MRI. The medical history details are collected and you will have to undergo certain clinical examinations before surgery.
The surgical procedure involves fusing of the painful sacroiliac joint. The articular cartilage is scraped from the ends of both bones. The two bones are held together with the help of screws and plates until they fuse (grow together into one bone). This actually stops the movement between the bones and hence annihilates the joint pain.
It might take 6 months for you to recover completely. You can start the rehabilitation program after 6-8 weeks of surgery. Your doctor may use heat/ice packs, massage, electrical stimulation and ultrasound to decrease the muscle spasms and provide pain relief. Physical therapists will guide you with safe exercises and you will be able to resume your daily activities gradually.
Risk and Complications
As with any surgery, risks and complications can occur. These may include:
- Nerve damage
In many patients, the benefits of surgery outweigh the complications as the surgery can help relieve the debilitating pain and discomfort of sacroiliac joint dysfunction.