Stem Cell Injection Therapy


You’ll be pleased to know that our doctors are experts in not only the standard treatments for sports & musculoskeletal injuries but also in the newest treatment methods, such as stem Cell injection therapy.  One of the most exciting recent developments in the treatment of chronic musculoskeletal conditions is the use of adult mesenchymal stem cells (MSCs).

Drs. Tortland & Kozar were the first in New England to offer this treatment, and they remain the region's leaders in office-based stem cell treatment for musculoskeletal conditions.  They see patients from all over New England and beyond. 

Please contact us to schedule an appointment. Our doctors can evaluate your injury and see if you are a candidate for stem cell injection therapy.


What are Adult Mesenchymal Stem Cells?

Stem Cells are undifferentiated cells that have the potential to become other, more specialized types of cells. Stem cells are broadly categorized as either "embryonic" or "adult." As the name implies, embryonic stem cells are derived from human fetuses, whereas adult stem cells are obtained from, well, adults!

Currently there are over 70 proven therapies using adult stem cells, while there are none using embryonic stem cells. This is in part because scientists have had tremendous difficulty controlling how embryonic stem cells differentiate; they have a nasty habit of causing tumor formation, including teratomas. Adult stem cells, on the other hand, do not suffer from this pitfall.

Mesenchymal stem cells
, or MSCs, are multipotent stem cells that can differentiate into a variety of cell types, including: osteoblasts (bone cells), chondrocytes (cartilage cells) and adipocytes (fat cells). This has been demonstrated in ex vivo cultures and in vitro or in vivo. MSCs are obtained from the bone marrow, most commonly the back of the iliac crest (the "hip bone").




MSCs can differentiate into many different cell types, as indicated in the diagram below.





How Are MSCs Obtained?

Harvesting MSCs for injection therapy is done right in the office. In most cases the stem cells are obtained from the bone marrow (they can also be obtained from fat; see below).  The skin is numbed first with a little Novocain. Next, the hip bone is numbed with more Novocain. A special needle is then passed through the cortex of the bone into the marrow cavity. This is a painless procedure in most cases. The liquid marrow is then very slowly drawn into a syringe. Once an adequate amount of liquid marrow is obtained, the needle is removed and a bandage applied.

The syringe containing the liquid marrow next is placed in a special centrifuge. The marrow is spun and the stem cells are highly concentrated and passed into a new syringe from which the injection(s) are given.

The entire procedure takes about an hour and is minimally uncomfortable.

How Are Stem Cell Injections Given?

All of our stem cell, PRP, and prolotherapy injections are given under direct ultrasound guidance. We first numb the skin with a little Novocain. Then, using ultrasound, we guide the needle to the precise location and inject the stem cells. The ultrasound guidance insures both accurate and safe injections. (Drs. Tortland & Kozar are nationally-recognized experts in musculoskeletal ultrasound.)

Following injection, for weight bearing joints (ankles/feet, knees, hip) patients need to avoid bearing weight for 24-48 hours. But it is critical that the joint NOT be immobilized. Gentle protected movement is critical to stimulate healing. For non-weight bearing joints, gentle protected movement is generally encouraged, but forceful or aggressive activity, such as sports, is prohibited. Your doctor will give you more specific post-injection activity guidelines.

Treatment Protocol

In our office, in cases where the stem cells will be injected into a joint, we prefer to perform a dextrose Prolotherapy treatment first, 3-4 days before the stem cell procedure. The prolotherapy helps prepare the joint biologically for the healing process generated by the stem cells.

About 2 weeks after the stem cell procedure, a PRP injection is commonly given. This helps keeps the stem cells active. Another PRP treatment may then be given about 2 months later.

How Often are Injections Given?

In most cases, patients respond very well to just one round of treatment. However, 2-3 treatments may be needed in very severe cases. Treatments are never given more frequently than every 6-12 months.

What Conditions Might Benefit From Stem Cell Injections?

Stem cell injections are most commonly used for the treatment of conditions that have failed or responded incompletely to other more conservative treatments. Conditions include, but are not limited to:

  • Osteoarthritis of the joints
  • Chronic partial Rotator Cuff tears
  • Persistent partial tendon tears, such as tennis elbow, plantar fasciitis, quadriceps and patellar tendon tears.
  • Partial muscle tears
  • Meniscal (cartilage) tears in the knee
  • Chondromalacia patella (patellofemoral syndrome)

Are There Risks Associated With Stem Cell Treatment?

Any injection is potentially at-risk for causing infection, bleeding, nerve damage. Risks will also vary depending on the structure(s) being injected. However, because we are using your own cells, you cannot be allergic to the treatment! Also, because the injections are done under ultrasound guidance, the risks of damaging surrounding structures, or of injecting the wrong location, are almost completely eliminated. Your doctor will review the complete risks of treatment with you. Nonetheless, the risks of treatment are extremely low.

Are Stem Cell Treatments Covered by Insurance?

Currently stem cell injections are still considered experimental. Most insurance plans, including Medicare, do NOT pay for stem cell injections.

When Can I Expect to See Improvement?

On average, most patients start to see signs of improvement anywhere from 4-8 weeks after the completion of the complete treatment protol. This can be less overall pain, an ability to do more activity before pain sets in, and/or faster recovery from pain.

What is the Success Rate?

Studies suggest an improvement rate as high as 80-85%, though some arthritic joints, namely the hip, do not respond as well (60% at best). Some patients experience complete relief of their pain. In the case of tendon and ligament injuries the results are generally permanent. In the case of joint arthritis, how long the treatment lasts depends partly on the severity of the condition. Mild arthritis may not need another round of treatments. More advanced arthritis, on the other hand, typically requires a repeat course of treatment, usually in 1-3 years.

Below are the nominal success rates for a few joints after one stem cell treatment:

KNEE ARTHRITIS
% of patients experiencing >25% improvement in their symptoms:

  • @ 1 month after treatment:  >60%
  • @ 12 months:  almost 80%
  • @ 3 years:  >90%

% improvement noted in symptoms:

  • @ 1 month after treatment:  40%
  • @ 12 months:  >50%
  • @ 24 months:  60%
  • @ 3 years:  almost 70%

A second treatment (done in the following 6-12 months) increases the % outcome by an additional 15-20 points.  Patients who respond to a second treatment see an almost 50% additional improvement over the results of the first procedure.

HIP ARTHRITIS
Hip arthritis is a very different condition than is knee arthritis, for reasons not well understood.  As a result, arthritic hips responds differently, and less successfully, to Stem Cell treatments than do knees.  There are at least 2 factors that independently predict a less favorable outcome for Stem Cell treatment of hip arthritis: age and hip range of motion.  Patients younger than 55 do better than those older, and patients with significantly restricted hip range of motion do not fare as well as those with better motion.

% of patients experiencing >25% improvement in their symptoms:

  • < 55 y.o.:  50-62% saw improvement
  • > 55 y.o.:  38-50% saw improvement

Average % improvement noted in symptoms:

  • < 55 y.o.:  38-44% improvement
  • > 55 y.o.:  22-31% improvement

So you can see that not only do older patients not do as well as a group, but they also experience less of a significant improvement when they DO get better.  But BOTH younger and older groups do not do as well as patients with knee arthritis.  The improvement for significant range of motion restrictions is even poorer.

This does not mean that stem cell treatment does not help hip arthritis.  It simply means that it does not help as often or as well as it does for knee arthritis.

SHOULDER ARTHRITIS
The shoulder seems to do almost as well as the knee in most cases:
% of patients experiencing >25% improvement in their symptoms:

  • @ 1 month after treatment:  48%
  • @ 12 months:  70%
  • @ 2 years:  80%

% improvement noted in symptoms:

  • @ 1 month after treatment:  28%
  • @ 12 months:  >50%
  • @ 2 years:  almost 70%

SHOULDER - ROTATOR CUFF
In those receiving stem cell treatment for rotator cuff injury, over 70% of patients treated get at least 70% improvement in their symptoms.

Will Stem Cells Regrow New Cartilage In My Joint?

The goal of treatment is to reduce pain and to improve function. While there is some weak evidence that treatment occasionally does result in increased cartilage thickness, the important point to keep in mind is that the cartilage lining the joint surfaces has no pain fibers! For example, often we see patients with knee or hip arthritis where the joint that does NOT hurt has WORSE arthritis on x-ray! Pain from arthritis is very complex and involves far more than just how thick the cartilage is.

Will Stem Cell Treatment Help Me Avoid A Joint Replacement?

This is a frequently asked question. In the case of mild arthritis,stem cell treatment may halt the development of further arthritic decay. However, in advanced arthritis, as noted above the goal of treatment is to reduce pain and improve function. In some cases the arthritis is so severe that stem cell treatment is not a viable option. In severe or advanced osteoarthritis stem cell treatment may help delay the eventual need for a joint replacement, but it is rarely a treatment that eliminates the need for it. Some patients are not surgical candidates because of other medical conditions. Other patients simply do not want joint replacement surgery under any circumstance. In these cases stem cell treatment may be a viable treatment option, but it is not a permanent solution in these specific situations--treatments will need to be repeated periodically (typically every 2-3 years).  However, at the very least, research suggests that the improvement in symptoms seen with stem cell treatments roughly equals that seen with joint replacement.

What Does Stem Cell Treatment Cost?

At Valley Sports Physicians the cost of stem cell treatment is based on the level of complexity involved in treating a given area(s). In addition, the cost of the stem cell treatment reflects the cost of the complete treatment protocol, as outlined below:

  • Pre-stem cell prolotherapy treatment (for arthritic joints only): $200-$400
  • Stem cell treatment: $2400-$2600
  • Post-stem cell PRP treatment (for arthritic joints only): $700-$900
  • Total Cost:
    • Tendon or ligament: $2400-$2600
    • Arthritic joint: $3300-$3900

Fat Grafting

In the case of moderate-to-large tendon and muscle tears, such as rotator cuff, tennis elbow, and Achilles, stem cell treatment alone may be less effective because the liquid stem cell solution has less tendency to stay in the tear; it leaks out. In order to combat this we often will combine stem cells with fat concentrate to create a gel that fills the defect and promotes more effective healing.

Likewise with more advanced joint arthritis, the fat acts a matrix to help hold the platelets in place and also helps activate them to release their growth factors more effectively. Think of a garden trellis that helps hold a growing vine in place. In fact, for moderate-to-advanced arthritis, our standard treatment is to combine the stem cell solution with the fat due to the fact that it seems to work that much better than stem cells alone alone.

The fat is harvested from the patient's belly, buttocks, "love handles," or hips using a gentle liposuction technique. (The amount harvested generally is NOT enough to have a cosmetic effect.) The fat is concentrated via centrifuge, and the resulting fat concentrate is subsequently mixed with the stem cells to create a gel. The gel fills the tear in the case of tendons/muscles, and helps maintain more constant contact with the joint surfaces in the case of arthritis.

Fat grafting adds an additional $700 to the cost of treatment.