Cartilage regeneration in OA – Using Body Fat Stem Cells
Based on literature review by Pak J. et al., in 2017
2009-10 – Dr. Ralph Bright
In 2009, we treated our first patient. She had moderate osteoarthritis which had given her continuous pain for the past five years. The pain ranged from a 2.5 to a 10, with 10 being pain equivalent to her child delivery pain. Twelve days after her injection she was pain-free and has remained so. This lady also had a rotator cuff syndrome in her right shoulder. This shoulder has remained pain-free also. In both her wrists she had rheumatoid arthritis with pain and swelling. For this she had been taking methotrexate, prednisone, Celebrex, and up to 12 Panadol per day. After Day 12 she was only taking methotrexate. At eight weeks we stopped the methotrexate such that she was now taking no medication whatsoever. Blood testing revealed that her cold reactive proteins (CRP) dropped from 23mg/ml to 7.7mg/ml at 10 weeks. However at 13 weeks we noted that her CRP had started to rise again although she remained asymptomatic. At 20 weeks she had a flare-up of her rheumatoid arthritis in her left wrist for which she took prednisone. She remains pain-free and asymptomatic in her knee and shoulder. In 2010, we treated our next six patients. They all showed significant improvement, most marked in the first month and plateauing after four months, as demonstrated by the WOMAC questionnaire scores. We have not been able to demonstrate any improvement radiographically. Three patients had other disease processes in other areas of the body which improved with injections into the knee. One has not needed to use his asthma medication since having the injection. Two showed a 90% improvement in spine pain. Two patients had some swelling in the joints after injection, but this cleared within two weeks. There had been no permanent adverse events. There have been no infections.
Ref: Bright, R. (2010). Adipose Derived Stromal Cells to Treat Joint Disease. Journal of Cosmetic Surgery & Medicine, Volume 5(Issue 3).
2011 – Pak et al.
Pak reported a case series of treating patients with OA of the knees with autologous adipose SVF and regenerating cartilage-like tissue This SVF, with platelet rich plasma (PRP) and HA, was then injected into the knee joints of two patients. After 3 months, the visual analog score (VAS) for pain, functional rating index (FRI), and range of motion (ROM) of the patients were assessed and shown to be improved along with MRI evidence of cartilage regeneration.
2012 – Koh et al.
Koh and Choi also reported a retrospective cohort study treating 25 OA patients with autologous adipose SVF with autologous PRP. These adipose SVFs with autologous PRP was percutaneously injected into the knees of 25 patients with OA after performing arthroscopic debridement and lavage. The article states that the mean Lysholm knee scoring scales, Tegner activity level scales, and VAS scores improved significantly in the treated group compared to the control group. No imaging studies were carried out. No major side effects were reported.
2013 – Pak & Koh et al.
Pak et al. reported a retrospective cohort study involving 91 patients with various orthopedic conditions. Between the period of 2009 and 2010, Pak et al. treated 91 patients with OA of the knees, OA of the hips, and osteonecrosis of the femoral heads with percutaneous injections of autologous adipose SVFs along with autologous PRPs and HAs. The study reported the average efficacy of the regenerative treatment to be 65% at 3 months without any serious side effects and without any development of tumors. Some of the side effects reported were swelling and tendonitis.
Koh et al. reported a case series involving 18 patients with OA of the knees receiving autologous adipose SVF. After a few months, the patients were evaluated with Western Ontario and McMaster Universities osteoarthritis index (WOMAC) scores, Lysholm knee scoring scales, and VAS scores and MRI studies. The patients improved on all criteria, including the cartilage whole-organ MRI scores. No serious complications were reported.
2014 – Koh & Bui et al.
Koh et al. reported a case series involving second-look arthroscopy results in 35 patients with knee OA treated with autologous adipose SVF. In this report, Koh et al. incorporated arthroscopic guidance when injecting the knees with adipose SVF. Initially, the patients underwent arthroscopic examinations with debridement and lavage. Afterward, autologous adipose SVF with autologous PRP were injected under arthroscopic guidance. About 12.7 months after treatment, second-look arthroscopy was performed. The results showed that the mean International Knee Documentation Committee (IKDC) and Tegner activity level scales significantly improved, but 76% of the patients had abnormal repair tissue observed during arthroscopy.
In another study reported by Koh et al. in 2014, the clinical results and second-look arthroscopy findings were compared between an autologous adipose SVF/PRP injection group and a PRP-only group. This study involved 44 patients undergoing open-wedge high tibial osteotomies (HTO). The autologous adipose SVFs were injected with autologous PRP in 23 patients under arthroscopic guidance and the other 21 patients were injected with autologous PRP alone under arthroscopic guidance. After 24 months of the treatment, the results showed that the autologous adipose SVF/PRP group showed significantly greater improvement than the PRP-only group, as measured by VAS for pain, Knee injury Osteoarthritis Outcome Score (KOOS) subscales for pain and symptoms, and second-look arthroscopic evaluation. Arthroscopic exams showed fibrocartilage regeneration in 50% of the adipose SVF/PRP group versus 10% in the PRP-only group. However, the Lysholm score was similarly improved in both groups.
Bui et al. reported a case series involving 21 patients with OA of the knees. The patients were treated with autologous adipose SVF with PRP. The adipose SVF was obtained from digesting 50–100 ml of lipoaspirates originating from the abdomen. Then, the autologous adipose SVF with autologous PRP was injected percutaneously into the diseased knees. After 8.5 months of treatment, all 21 patients showed improved VAS pain score and the Lysholm score.
2015 – Koh, Michalek & Kim et al.
Koh et al. reported another case series involving second-look arthroscopy results of 30 patients with OA of the knees treated with autologous adipose SVF obtained from 120 g of adipose tissue from the patients’ buttocks. The autologous adipose SVF was injected with PRP under arthroscopic guidance. Of the 30 patients, 16 patients underwent second look arthroscopies about 25 months after the initial treatment. Of the 16 patients, 10 patients (63%) had improved cartilage, 4 patients (25%) had maintained the cartilage, but 2 patients (12%) failed in healing cartilage defects. The study reported that all patients showed significant improvement in OA outcome scores (KOOS), VAS pain scale, and Lysholm score.
In another study, Kim et al. compared the efficacy of autologous adipose SVF alone to that of autologous adipose SVF with fibrin glue. The fibrin glue was used as a scaffold for stem cells to attach. This study involved 54 patients with knee OA. 37 patients were treated with autologous adipose SVF only and the other 17 patients were injected with autologous adipose SVF with fibrin glue. After about 28 months, the mean IKDC score and Tegner activity level scale in both groups were compared and had improved significantly; the improvement was comparable in both groups. However, in second-look arthroscopies, International Cartilage Repair Society (ICRS) scores were better in the adipose SV with fibrin glue group.
Michalek et al. reported a multi-center case-control study involving 1114 patients with OA of the knees and hips from four different countries (USA, Czech Republic, Slovakia, and Lithuania). These patients were percutaneously injected with autologous adipose SVF and followed for average 17 months. No serious side effects were reported and no incidents of cancer were reported. The clinical effects, measured on the basis of pain, non-steroid analgesic usage, limping, extent of joint movement, and stiffness, all improved. At 12 months after treatment, 63% of all patients reported approximately 75% symptom improvement and 91% of all patients reported approximately 50% of symptom improvement.
2016 – Pak & Fodor et al.
Pak et al. published a case series reporting that addition of autologous adipose ECM along with the SVF may also be effective when used together with autologous PRP and HA. The mixture was injected into the knees of three patients with OA of the knees. Three months after treatment, all three patients’ symptoms, measured using FRI, ROM, and VAS pain score, improved. In addition, comparison of pre-treatment and post-treatment MRI data of all three patients demonstrated cartilage-like tissue regeneration.
Fodor et al., another group in the USA, reported clinical improvement of 8 knee OA patients treated with autologous adipose SVF obtained by digesting 150–250 ml of lipoaspirates. All patients attained full activity with decreased knee pain. WOMAC scores, VAS pain scale score, ROM, and timed up-and-go (TUG) results all improved. The improvement in WOMAC scores and VAS scores were maintained at 1 year. No major side effects were observed.
“Stem Cells have a great clinical potential to treat various orthopedic disorders as seen in human studies. Adipose SVF may be worthwhile to try in individuals for whom medical treatment has failed and for whom surgical options are not available”.
REF: Pak, J., Lee, J., Park, K., Park, M., Kang, L. and Lee, S. (2017). Current use of autologous adipose tissue-derived stromal vascular fraction cells for orthopedic applications. Journal of Biomedical Science, 24(1).