KEN MAUTNER, MD EMORY SPORTS MEDICINE Clincal Application of PRP and Stem Cells in Knee Osteoarthrits

____________________________ 1 If WBC are present (+) the % of neutrophils should also be reported. 2 The method of exogenous activation should be reported. April, 2015

Clinical application of Platelet Rich Plasma for Knee Osteoarthritis

AJSM, 2013

1 injection2 injections

AJSM, 2015

AJSM, 2015

AJSM, 2015 Considerations:  Leukocyte Rich (LR) PRP (1.1x baseline)  Freeze/ thaw creates a Platelet Lysate  This is not PRP  PRP was activated with CaCl prior to injection  HA produced sustained benefits at 1 year  Contradicts most studies on HA

AJSM, 2014

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Considerations:  sdsadsa

Phase II Study Grade 3-4 Alhback Tibiofemoral OA

Conclusion of PRP and OA PRP is a promising treatment for Knee Osteoarthritis  When compared to Hyaluronic acid, PRP seems to have improved outcomes in most studies  L- PRP preferred over L+ PRP Pain and function is improved clinically best at 6 months but also at 1 yr in most studies  Effects are on local environment  Might serve as preventative for further damage  Unlikely to “regenerate” cartilage

Injectable Stem Cells for Cartilage Disorders of the Knee

Types of Injectable cells for Cartilage Autologous  Bone Marrow  BMA  BMC  Culture/ expanded  Adipose Derived Stem Cells  Lipo-aspirate  SVF  Culture/ expanded Allogenic  Placental Derived Stem Cells

Case Reports in Humans Knee OA treated successfully with MSCs using platelet lysate technique  Expanded and cultured  There was a decrease in the VAS by 95%  Increase in ROM by 5 degrees  Increase in cartilage by 19% as measured by MRI at 6 mo follow- up Centeno CJ, Busse D, Kisiday J, Keohan C, Freeman M, Karli D. Increased knee cartilage volume in degenerative joint disease using percutaneously implanted, autologous mesenchymal stem cells. Pain physician May- Jun;11(3):

Case Reports in Humans Pre- injection cartilage meniscus 6 months Post- injection cartilage meniscus

MSC/ Human Studies Prospective study of 6 females who underwent injection of MSCs without addition of growth factors  1 year follow up  Decrease in mean pain on VAS, joint function, and walking distance compared to baseline No adverse events reported  3 out of 6 showed improvement on MRI in cartilage thickness, extension of repair tissue over subchondral bone, and decrease subchondral edema Archives of Iranian medicine July, 2012

41 patients (75 knees)  84% -- BMAC + ADSC alone  8% -- injection stem cells + Arthroscopy  6% -- injection stem cells+ Arthroscpy/ microfracture  1 -- injection stem cells + Arthroscopy/ HTO Separated by K-L grade of OA  Gr 1: 12, Gr 2: 24, Gr 3: 33, Gr 4: 6 f/u with VAS and functional scales at 3,6, and 12 months 2014

Poor results related to K-L OA Grade 2014

Compare registry database from 2 different procedures for knee OA  A: 616 Injection of BMAC/ PRP/PL to knee  B: 224 Injection of BMAC/PRP/ PL + ADSC to knee  ADSC placed under collateral ligament at area of meniscal damage on most painful side of knee.

Results  Improvement rating (0-100%): 66.2% Group A 74.1% Group B  Improvement LEFS: Inc by 7.9 Group A Inc by 9.8 Group B  Improvement NPS: 4 to 2.6 Group A  Improvement NPS: 4 to 3-3 Group B No significant difference between groups

Lipogems

Meniscus Regeneration 55 patients s/p partial medial meniscectomy 7-10 days later, single injection given into knee joint of allogenic stem cells  Control: Hyaluronic Acid  A: 50,000,000 allogenic stem cells  B: 150,000,000 allogenic stem cells JBJS, 2014

Stem cells, 2014

Emory Stem Cell Data Retrospective Outcome Survey  Preliminary Data  First 150 patients who had injectable stem at Emory  December, August, 2014  Questionnaire > 6 mo. from procedure  Results  60 patients responded (72 joints) BMAC or BMAC + ADSC 23 Hips 32 Knees 17 others  Currently have data on Pain, Function  Will correlate to K-L, BMI, Age, Sex, Psych. profile

Pain Pre and > 6 mo. post

Function Pre and > 6 mo. post

Conclusions for stem cells and cartilage disease Stem cell therapy in orthopedics designed for cartilage repair Injectable bedside treatment is still evolving  Early clinical data for pain relief/ improved function is promising  Data for cartilage “regeneration” is limited Type of stem cells (BMAC vs ADSC) among many factors to be studied to refine procedure