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13 January 2019
By Prof Dr. Med Philip Schoettle, MD, PHD, Medical Director, Knee and Hip Institute Munich, Germany, and stem cell therapy surgeon and orthopaedic specialist at Okyanos Center for Regenerative Medicine, Freeport, Bahamas
Like most classically trained orthopaedists, a decade ago I was highly sceptical of stem cells and their therapeutic value. Today, as a treating physician at the Knee and Hip Institute in Munich, Germany, and at the Okyanos Center for Regenerative Medicine in Freeport, Bahamas, I’m a passionate believer. For friends, family and patients with knee problems due to tissue and cartilage issues, I recommend stem cell treatments well before a knee replacement, provided their condition hasn’t progressed to bone-on-bone damage.
But not all stem cell treatments are equal. The right types of cells in the right potency affect clinical outcomes. Expert physicians who can properly deliver the cells are critical and carefully matching the patient’s condition to the proper therapeutic is essential.
These factors determine whether I treat a patient with orthopaedic surgery, a combination of scoping or surgery with adjunctive stem cell treatments, or stem cell treatments alone.
Stem Cell Sources
There are multiple sources of adult stem cells. The most commonly thought of is bone marrow. We’ve done bone marrow transplants for 50 years, using the stem cells from bone marrow and transplanting them into the recipient. Another source is adipose, or fat tissue, recognised in the last 20 years as a very rich source of stem cells.
However, as we age bone marrow becomes fibrotic and fatty. So, we end up with fewer stem cells as we get older. At baseline there are few therapeutic cells for tissue repair in bone marrow, in contrast to fat, which maintains its stem cell population and is a much richer source of therapeutic cells – including mesenchymal stem cells, which are really the conductor or the regulator of the stem cell repair. So, fat turns out to be a very rich supply of stem cells, which is maintained throughout our life and has been shown by multiple groups to be very effective in tissue repair.
Adult stem cells have multiple functions and come in different types, but ultimately what they do is lead to healing. Mesenchymal stem cells (MSC) activate the bone marrow system and other stem cells to start repairing tissue. Mesenchymal stem cells are known as the conductor of the repair process. Endothelial progenitor cells are the foundation of building new blood vessels. They can inhibit the immune system and be anti-inflammatory, and they can activate other stem cells in the body and force them to start repairing tissue.
Beyond MSCs: SVF and its Benefits
Stromal vascular fraction, or SVF, is a mixture of stem cells that exist in our adipose, or fat, tissue. SVF contains mesenchymal stem cells and endothelial progenitor cells as well as endothelial cells. As we age, we don’t lose mesenchymal stem cell function from fat as we do from bone marrow. There are multiple forms of SVF that vary in potency and usability. At Okyanos, we use enzyme-derived SVF because studies have shown that it is the most potent form of SVF. It produces a very rich mixture of stem cells that can be delivered two ways: by injection into joints and organs that have been injured, and by IV to activate the endogenous stem cell system and induce a better repair for the patient.
SVF is also an autologous treatment, because the patient’s own cells are returned to them – released from the fat – and delivered by injection directly to the area in need as well as intravenously to help activate the body’s own endogenous system. Other clinics that use fat-derived stem cells often only deliver the mesenchymal fat-derived stem cells, not the SVF. These mesenchymal stem cells have been cultured, leading to changes in the stem cells that can adversely affect their ability to induce tissue repair. Studies have suggested that delivering the mixture of the SVF is better than delivering any single stem cell type.
At Okyanos, the most common conditions that patients present with are orthopaedic. The adult stem cell treatments can be given as an adjunct to surgical treatment or as a primary therapy. We perform liposuction and isolate the SVF with an enzyme. Then, we directly inject the patient’s cells into the joint space. Finally, the patient receives an IV infusion of stem cells, again, to get the bone in a healing state.
Currently, the Tissue Genesis Icellator is the best point-of-care system for processing enzyme-derived SVF with a safe and sterile single-use cartridge. Designed and made in the U.S., based on research by the U.S. Department of Defense and NASA, the Icellator is approved for use in Japan, South Korea and the Bahamas, all regulated medical jurisdictions. It is also being used in multiple FDA cleared trials in the U.S., but is not yet approved for clinical use there or in Europe. Using SVF processed by the Icellator delivers the greatest number and best mixture of cells, at the highest potency, as the cells are freed from the fat matrix.
The combination of mesenchymal stem cells and endothelial progenitor cells can decrease inflammation, induce stem cells to be recruited to the joint space, and help nourish the cartilage by bringing blood supply. The goal of microfracture surgery, which is quite popular, is to get stem cells out of the bone marrow space and into the joint space to promote repair. By delivering stem cells directly to the joint, we create the same conditions for healing, without causing more harm. The added IV infusion activates bone marrow that might sit right at the end of the bone near the joint to encourage stem cell support of that tissue.
In addition to treating knees, shoulders, hips and other joints, adult stem cell therapy can really improve or prevent severe osteoarthritis by either regrowing cartilage or decreasing inflammation of bone edema. With early treatment, we can preserve and enhance patient function through prevention of the progression or repair of the loss of cartilage, and the severe pain that accompanies bone-on-bone damage. When treating people later, our goal is to preserve or enhance patient function through the regrowth of cartilage or decrease the bone inflammation and edema such that the patient gets relief and can return to activities of daily living.
The benefits last quite some time, months to years at this point. We’re seeing patients with significant visual analogue scale scores – meaning less pain, more activity, and more motion.
The goal at Okyanos for treating any condition is an enhancement in quality of life. We want patients to go back to the tennis court, back to the golf course, back to being fully active with restored joint function.
A Promising Future
Today, I’m an orthopaedic surgeon who loves what I do, but my whole thinking has turned around. Instead of focusing on surgical options, I think about what can be done with high potency SVF. Now I discuss with my patients how we can achieve natural healing and regeneration through stem cell therapy and avoid surgery.
Stem cells are the future in treating orthopaedics. Regenerative medicine has value in many more fields as well, but with orthopaedics, outcomes are measurable. Someone not able to walk without pain and can walk afterwards is a quantifiable success. Radiographic tools, such as MRIs and x-rays, show the reconstructive changes stem cells can have on injury or degeneration. Much of the pain caused by inflammation in orthopaedics is reduced by stem cells. I see stem cell treatments growing in importance, as improvements in SVF therapy, rich cell yields and precision delivery continue to speed patient healing.