Types of Sports Injuries treated with Stem Cells

A wide variety of sports injuries, can be treated including damage to:

• Tendons

• Ligaments

• Muscles

• Cartilage

These injuries may be due to a sudden trauma or chronic overuse.

Stem cells can be applied to an injured area via:

• Direct surgical application: Application of stem cells directly to the torn ligament, tendon, or fractured bone. Gel stem cell application for focal cartilage injuries.

• Stem-cell bearing sutures. A surgeon may repair a torn muscle, ligament, or tendon using a thread-like material that is coated in stem cells. (The suture material itself will dissolve and be absorbed in the body over time.)

• Injection: Stem cells are injected directly into the affected area.

When administering injections, many surgeons use ultrasound or other medical imaging to ensure cells are delivered precisely to the site of damaged tissue.

What makes stem cells special is that they can:

1. Divide and duplicate themselves.

2. Differentiate into different types of cells. A stem cell itself does not serve a specific function, but it can develop into a cell that does, such as a cartilage cell or a muscle/tendon cell.

Stem cells when placed into a certain environment, can transform to meet a certain need. For example, stem cells that are placed near damaged tendon develop into healthy tendon cells. These procedures are widely known as homing and signaling.

Stem Cells from Patients

The process of collecting stem cells is often called harvesting, and is performed from the patient’s adipose tissue, blood, or bone marrow.

• Fat: Through a very small surgical incision (appr. 0.5 cm) adipose (fat) stem cells can be harvested.

• Blood: A blood sample from the patient can be used to harvest peripheral blood stem cells, which are found in the bloodstream.

• Bone marrow: Bone marrow stem cells from the pelvic bone or the tibia are harvested, using a special trocar, needle and syringe. The process is called bone marrow aspiration.

Before fat cell delivery and bone marrow aspiration, a patient is given a local anesthetic and may also be given a sedative.

Mesenchymal stem cells
All three types of stem cells listed above—adipose (fat), peripheral blood, and bone marrow—belong to a category of stem cells called mesenchymal stem cells. These stem cells, sometimes called adult stem cells, can be obtained from the patient’s own body and are being increasingly used for treating sports injuries.

In our center we have certain criteria for recommending stem cell therapy. All cases are examined in a case-by-case basis and special protocols are applied for each one.

The specialized and patient-specific treatment protocols are implemented after detailed clinical and imaging (MRI) examinations, together with the patients lab-exams profile.

According to an athlete's/persons' needs and depending on the sport activity followed, the most suitable stem cell therapy option is chosen, for the best functional and clinical results.

The theories behind stem cell therapy
After years of research we found that when applied to a sports injury, stem cells might:

• Develop into needed musculoskeletal cells, such as tendon, ligament, cartilage, or bone cells

• Facilitate better healing (e.g. encourage the growth of new blood vessels)

• Decrease or prevent inflammation that make conditions worse

• Release proteins (cytokines) that slow down tissue degeneration and/or decrease pain

The three last procedure comprise the paracrine effect.

The ultimate challenge
The stem cell therapy in one study is not necessarily the same as the stem cell therapy in another study. The differences can include:

• Where the stem cells originated—For example, were they derived from the patient’s blood, bone marrow, or fat?

• How stem cells are separated and isolated from the harvested tissue

• The concentration of stem cells (how many cells per treatment)

• The health and age of patients

• How the stem cells are delivered to the injured area—For example, are they injected or applied during surgery?

Combined therapies

Mixing Stem Cells with PRP

Many sports medicine doctors use stem cell therapy in combination with another regenerative medicine therapy, platelet rich plasma (PRP). These physicians believe that PRP can activate the most of the stem cells potential effects.

PRP is derived from a sample of the patient’s blood. In the bloodstream, platelets secrete substances called growth factors and other proteins that:

• Regulate cell division

• Stimulate tissue regeneration

• Facilitate healing

PRP can also be used alone to treat sports injuries, such as tendinopathies.

SIDE EFFECTS & RISK FACTORS

Stem cell therapy, while using a patient’s own cells without or with controlled manipulation and performed in a single, clean and OR environment, is generally considered safe. The most common side effects are temporary swelling and pain. Stem cell injections carry the same risks as any other therapeutic injection, such as a very small risk of infection.

Factors that can increase risk
A patient is at a higher risk of an unwanted reaction if the stem cells are:

• Not the patient’s—though uncommon, stem cell therapy can involve stem cells manufactured in a lab or harvested from another person or animal. In the majority of cases, stem cells are collected from the patient, minimizing the risk of an unwanted reaction.

• Questionably Cultured—taken from the patient and grown in the lab over time without the high standards applied.

• Mixed with other chemicals—additives thought to enhance stem cells’ therapeutic abilities may also add another risk factor.

Regenerative medicine and traditional treatments can be used together to optimize healing.

In sports medicine, regenerative medicine treatments are typically used to repair or replace damaged cartilage, tendon, and ligament tissues.

Physicians who recommend regenerative medicine treatments for sports injuries hope to:

• Amplify the body’s natural healing abilities

• Encourage the growth of new tendons, ligaments, or cartilage tissue

The goal is to reduce pain and improve function.

Rest, physical therapy, bracing, and taping
Regenerative medicine is not a substitute for traditional nonsurgical treatments, such as rest, bracing, taping, and/or physical therapy to improve flexibility and strength.

References:

1. Teng C, Zhou C, Xu D, Bi F. Combination of platelet-rich plasma and bone marrow mesenchymal stem cells enhances tendon-bone healing in a rabbit model of anterior cruciate ligament reconstruction. J Orthop Surg Res. 2016;11(1):96.

2. Wang C, Iversen MD, Mcalindon T, et al. Assessing the comparative effectiveness of Tai Chi versus physical therapy for knee osteoarthritis: design and rationale for a randomized trial. BMC Complement Altern Med. 2014;14:333.

3. Andia I, Maffulli N. Biological Therapies in Regenerative Sports Medicine. Sports Med. 2016;

4. Chahla J, Dean CS, Moatshe G, Pascual-garrido C, Serra cruz R, Laprade RF. Concentrated Bone Marrow Aspirate for the Treatment of Chondral Injuries and Osteoarthritis of the Knee: A Systematic Review of Outcomes. Orthop J Sports Med. 2016;4(1):2325967115625481.

5. Herberts CA, Kwa MS, Hermsen HP. Risk factors in the development of stem cell therapy. J Transl Med. 2011;9:29.

TYPES OF DEGENERATIVE JOINT DISEASES TREATED WITH STEM CELLS

SURGICAL & MINIMAL INVASIVE OPTIONS

A surgeon can follow one of the following treatments either alone or combined:

Arthroscopic lavage and debridement

Marrow tapping techniques/Abrasion arthroplasty

Subchondral drilling

Microfracture

Osteochondral autografting—mosaicoplasty

Osteochondral allografting

New generation techniques

Autologous cell techniques: ACI & MACI

Growth factors-PRP

Stem cells: Adipose (fat) cells and bone marrow cells

Stimulators of cell metabolism

(ACI autologous chondrocyte implantation, MACI matrix-induced autologous chondrocyte implantation, PRP platelet rich plasma)

ARTHROSCOPY AND MIS TECHNIQUES

First noted by Burman in 1935, washout of the injured synovial joints had been proven to be the best frontline treatment of chondral lesions. Arthroscopic lavage washes out inflammatory mediators, loose cartilage and collagen debris that may lodge in the synovium and cause synovitis and effusion. Debridement of cartilage (chondroplasty) removes loose flaps or edges that mechanically impinge on the joint. Debridement chondroplasty may be done by several techniques including curettage, and mechanical debridement with a shaver, although this technique does not leave smooth cartilage and may cause more cartilage breakdown.

STEM CELL THERAPY

In 1994, using a rabbit model, Wakitani et al. reported that pluripotential stem cells, isolated from bone marrow, synovium or periosteom, could repair osseous and chondral defects.

In 1995, Grande et al. reported that mesenchymal stem cells repaired cartilage defects and subchondral bone.

Giannini et al published the first paper on stem cell transplantation in a single procedure ("One-Step") for treating chondral lesions, which in this case were talar chondral lesions.The postoperative histological evaluation showed the presence of regenerated tissue at several stages of remodeling, although none of these patients subjected to histological examination presented fully hyaline cartilage.

Along these lines, Gobbi et al published the first case of stem cell transplantation using the one-step procedure to operate on a knee, with two years of follow-up. The procedure consisted of using stem cells together with scaffolds of types I and III collagen. The patients presented significant improvements in all the scores evaluated, and tissue resembling hyaline cartilage was found in the histological tests. No adverse reaction or postoperative complications were found.

TREATING MESSAGES

For good regeneration of tissue lesions and osteochondral defects, cells (cultured, fragments, mesenchymal stem cells, etc.), bioscaffolds (natural/synthetic), as well as chondroinductive (TGF) and osteoinductive (BMP) growth factors and stimulators are required. Concomitant problems, ligament tears and/or ligament instabilities should be treated before or simultaneously with cartilage resurfacing.

There is no “gold standard” in the treatment of cartilage defect/tissue lesions or the choice of treatment option. We use patient-specific algorithms, relying especially on surface area of the defect/site of lesion, on surgeon experience and on appropriate stem cell therapy protocol.

Rehabilitation depends on treatment mode used and on defect/lesion personality (classification and qualification). Return to functional work and sport is possible in all procedures, but takes different periods of time.

Concerning the cartilage lesions, more time is required to return to contact sports, especially after allograft procedures and sometimes permanent moderation of activities should be considered.