Anderson Knee and Shoulder Center

Stem cells, PRP, and HA, oh my! We are not in Kansas anymore. Part 2


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The Anderson Knee and Shoulder Center, located at 2100 Webster Street, Suite 309 in San Francisco, office of top San Francisco Orthopedic surgeon Dr. Lesley Anderson. Dr. Anderson aim to be among the San Francisco and Marin's best knee and shoulder surgeons, She help patients choose the best nonsurgical or surgical options for knee, and shoulder. She uses the newest technologies/treatments for arthritis, cartilage and ligament injuries as one of the top Bay Area Specialist.

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Update on PRP

I have just presented a comprehensive talk on the use of biologics in orthopedics, focusing on arthritis. There are more marketing websites than ever claiming cures and improvement from everything from back pain to arthritis to rotator cuff disease not to mention tendinitis. (Ah yes, and hair restoration and ED). I hope to give some perspective and recommendations to be a better consumer.

Over the last year there has been a number of very nice studies that have come out comparing PRP (platelet rich plasma), Hyaluronic acid (“Lubricant injections”) to placebo (salt water). PRP has be shown significantly better over steroids, HA and placebo. Pain has decreased longer, and function has improved.

We have recently reviewed our first 2 years of patients that have received adipose (fat) cell therapy (ADSC). This includes a combination of stem cells and other growth factors and regenerative cells. Over 75% of patients would do it again, although 25 % said they did not see a change and 6 went on to have a total knee replacement.

The best candidates, in my opinion, are those that have had part of their meniscus removed, and/or early- moderate arthritis in the knee., These are the patients whose joints go on to wear out more quickly. If we can change the healing environment in the joint to be more regenerative, we hope we can slow the progression of arthritis, along with weight reduction, exercise and occasionally braces.

There have been studies that show the cartilage health is improved with cell therapies on MRI, and that the rate that the joint space narrows is slowed or stays the same. This is very positive. We have seen the joint narrowing stabilize and in some, get wider.

The value of using PRP for tendinitis of the rotator cuff and for surgical treatment of rotator cuff tears is still controversial. Injecting PRP has not been shown to be superior to placebo in general in a large blinded study, although pain is less and there is no harm. Other studies which are smaller, disagree with this. The use of a membrane of PRP has been shown to improve the healing and reduce the re-tear rate in patients undergoing surgery for larger tears. We first started using this membrane in 2004 and have had a similar positive experience.

The use of stem cells in the treatment of rotator cuff disease is more promising. Laboratory studies show that adipose derived stem cells (from the fat) does increase the healing of tendons in animal models. I think this is a very hopeful option for patients that have small full-thickness tears or partial tears with pain. We have just started offering this in our clinic. The use of stem cells has been shown to be safe when harvested from fat and/or bone marrow. Whether it will allow a tendon to revert to morea normal structure is hopeful, but studies are very limited. There was one MRI study that showed the tendon damage reversing. So this is exciting!

The use of PRP (platelet rich plasma) is a very straightforward procedure taking blood in the office, spinning it, separating the red cells from the platelets, then concentrating the platelets. It is then injected into areas of tears, inflammation or the joint. There have been several excellent studies that have shown it is superior and last longer than cortisone or hyaluronic acid or lubricant injections Treatments can be repeated, unlike cortisone, which has its long-term negative effects. More recent studies suggest at least 2 treatments, while some are advocating for 3.

In regards to stem cell injections into joints for arthritis, it has shown to be safe, and effective in pain relief. These are usually done in the office under local anesthesia. We have recently started offering the option of injecting ADSC into the knees at the time of arthroscopic surgery in patients that have mild to moderate osteoarthritis, that are having surgery for other reasons. We are hopeful that this will slow down the rate of degeneration of the knee and allow some healing to occur.

You should be aware that “stem cell” treatments are still considered experimental /investigational in the State of California. There are no guarantees that either treatment will bring the desired results, but the risks are small as these are your own cells.

American Journal of Sportsmedicine Vol 46, No. 14, 2018 Intraarticular Mesenchymal Stem Cells for the Human Joint. A systematic review; McIntyre et al.

Knee Surgery, Sports Traumatology, Arthroscopy 2018 26;3342-3350 Intra-articular injections of expanded MSC with and without PRP are safe and effective in Knee osteoarthritis.; Bastos,R et al.

Arthroscopy Jan 2019 Vol 35 No 1 p106-117 Intraarticular injection of PRP is Superior to Hyaluronic Acid or Saline in the Treatment of Mild-Moderate Osteoarthritis: A Randomized, Double Blind, Triple Parallel, Placebo-Controlled Clinical Trial Lin et al

Arthroscopy Jan 2019 Vol 35 No 1 p 277-288 Intraarticular Mesencymal Stem Cells in Osteoarhtritis of the Knee: A Sysyematic Review of the Clinical Outcomes and Evidence of Cartilage Repair. Ha et al.

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