Dr Tom GroganPediatric Orthopedic Surgeon

West Los Angeles

11:00 - 11:55 WS #141: Future Applications of Stem Cell Therapy - An Orthopaedic Perspective

12:05 - 13:00 WS #153: Future Applications of Stem Cell Therapy - An Orthopaedic Perspective

(Repeated)

APPLICATIONS FOR STEM CELL THERAPY

Thomas J. Grogan, MD

June 22, 2019

BACKGROUND

Orthopedic Surgery Residency at UCLA

Fellowships

Adult Reconstruction – NIH

Pediatric Orthopedics – Shriner’s Hospital

Trauma – Munich, Germany

Faculty – UCLA

Assistant Chief – Shriner’s Los Angeles

Currently Private Practice

West Los Angeles, California

Over 40,000 new patients over 22 years

BIOLOGICS IN ORTHOPEDIC SURGERY

Musculoskeletal diseases

Economic impact - $1 Trillion dollars annually

7.4% of GDP

Osteoarthritis leads to chronic pain, disability, difficulty with simple activities of daily living and selfcare

Public awareness may lead to adoption of treatments with little supporting evidence

ARTHRITIS = BIG BUSINESS

43 Million Americans have been told they have “arthritis”

12% of healthcare spending is musculoskeletal

$2.8 Trillion = $336 Billion

20,000 orthopedic surgeons - $16.8 Million each doc

800,000 joint replacements per year

$26,000 per on average

$20.8 Billion dollar industry

STEM CELL PHYSIOLOGY

Stem cells – two common characteristics

Offspring of cell able to reconstitute a functional tissue

Can renew themselves indefinitely

Every second – 15 million blood cells “drop dead”

Bone marrow stem ells keep you alive

MESENCHYMAL STEM CELLS

Adipose Derived Stem Cells (ADSC) versus Stromal Vascular Fraction (SVF)

ADSC – Cultured and expanded in vito

Surface markers – CD73, CD 90, CD 166, CD 105 – but not CD 45 (hematopoetic)

Expanded in 10% Fetal Bovine Serum (FBS)

Fat derived (ADSC) are 500 times more potent than bone marrow derived Stem Cells (BMDSC)

SVF – Fat collected – concentrated to form collection of cells including ADSC

Fat is disrupted / enzymatically broken down

Isolate is centrifuged and washed

Clean room

Can be mechanically isolated

Nano- fat

BIOLOGICS IN ORTHOPEDIC SURGERY

Current cell therapies

Harvest of native tissue – adipose, bone marrow, synovial

Stem cells and progenitor cells – pericytes lining the basement membrane of capillaries

Release by enzymatic digestion - Collagenase

Minimal manipulation

Only 1 in 1,000 to 1 in 1,000,000 cells collected are progenitor or stem cells

Ultimately, expansion in vitro may be key to get enough cells to be maximally effective

STEM CELL HISTORYMESENCHYMAL

2001 – Adipose derived mesenchymal SVF “soup” characterized

Endothelial precursor cells

Macrophages

Smooth muscle cells

Lymphocytes

Periocytes

Source of Adipose Derived Stem Cells

10 – 25 microns in size

Pre-adiposecytes

STEM CELL PHYSIOLOGY

Tissue regeneration – response to an inflammatory process MSC – release

Monocyte chemoattractant protein 1

Growth factors

Cytokines

Paracrine factors

Inflammatory conditions Fracture healing

Ischemia

Myocardial infarction

Arthritis

Lupus

Degenerative disc disease

Diabetes

Pulmonary disease

STEM CELL PHYSIOLOGY

Bone – Organized, highly vascular, dynamic connective tissue

Bone healing –

Inflammatory factors released at fracture site

Signaling molecules, growth factors, pre-inflammatory cytokines, and angiogenic factors

Macrophages – release inflammatory mediators

NK cells – natural killer cells

Stimulates MSC recruitment

Tumor Necrosis Factor (TNF) – promotes cultured BMSC migration via Lucine Rich Alpha Glycoprotein release

STEM CELL PHYSIOLOGY

Humeral factors play a role in healing

Parathyroid hormone – activates MSCs

Circulating hormones –

Low dose BMP-2 and SDF-1

Promote rate of bone healing

Implications for osteoporosis –

Osteoblast versus Osteoclast

BIOLOGICS IN ORTHOPEDIC SURGERY

Platelet Rich Plasma – PRP

Blood = plasma and red blood cells

Centrifugation leads to isolation of various layers – including platelet rich layers with or without leukocytes

Cellular based therapies – SVF, BMD

Mechanical / chemical disruption

Minimally manipulated

Adipose derived, bone marrow, synovial fluid, placenta

ROLE OF PRP IN STEM CELL MEDIATED HEALING

Platelets- when activated initiate cell migration and cell proliferation / differentiation

Exposure to fibrin – platelets become “activated”

Conformational change – release granules containing growth factors and regulatory proteins that stimulate cell growth and repair

Platelet derived growth factors - PDGF

Flash freezing at -70 degrees Celsius – activates platelets

Freeze 15 minutes – thaw to 37 degrees

Leukocytes in PRP release growth factors involving the NF-LoB pathway

STEM CELL RESEARCH

Currently –

385 ongoing mesenchymal stem cell trials

Over 4,000 studies have been published

STEM CELL DATASTROMAL VASCULAR FRACTION

Chinese J. of Trauma 12:92 (2009)

27 NZW rabbits

ADSC + calcium alginate gel

Calcium alginate gel only

Controls

Group 1 – sig improved healing

Chinese J. of Trauma 14:6 (2011)

20 NZW rabbits – tenotomy healing

Placebo vs. SVF

Superior rate of healing, neo-tendon formation, collagen deposition in SVF group

STEM CELL DATASTROMAL VASCULAR FRACTION

Journal of Medical Case Reports 5:296 (2011)

Anecdotal evidence of healing

Osteonecrosis hips , Osteoarthritis knees

SVF, PRP, HA, Calcium Alginate

Journal of Medical Engineering (2013)

Mouse Model – articular injury created with needle, sacrifice at 45 days

SVF group – 62% surface healing – 35% new cartilage

Control group – 53% surface healing – 15% new cartilage

STEM CELL DATASTROMAL VASCULAR FRACTION

Clinical Journal of Sports Medicine - Feb 2013

Use of PRP (alone)in DJD

6 ml. PRP – 1 year follow-up (including MRI)

Pain down 41.7% @ 6m, 55.9% @ I year

AAOS Poster – Chicago 2013 – SVF + PRP

Yun-Jin Choi, MD Seoul, Korea

30 Patients – OA knee – 24 month follow-up

25 women, 5 men – average age 70.2

45 Million cells on average injected via arthroscopy

Results: Significant improvement in Lysolm joint score and decrease in VAS scores (P<.001)

BONE MARROW DERIVED MCSS MRI FOLLOW-UP

Shin et al. – KSSR 2018 Sept. 30(3)

Meta analysis – 8 studies with follow up MRI

Pain and functional outcomes significantly improved at final follow up in all studies

VAS, WOMAC, HSS Knee, Lysholm score

MRI taken at final follow up – no significant difference compared to baseline

PRELIMINARY EXPERIENCE

Safety

Efficacy

Appropriateness Criteria

PRELIMINARY EXPERIENCE

Efficacy

Joints followed every 3 months with weight bearing x-rays

Follow pain med usage

PROSPECTIVE STUDY

IRB approved study – 2,586 patients

All treated with mini-liposuction extraction under sub-dermal anesthesia

Point of care centrifugation and cell separation utilizing GMP coagulase

Further centrifugation, filtration, and deployment

82% of all patients – improved results up to 5 years of follow-up

VAS scale 0 to 10

Rest standing walking running

All BMIs showed improvement, although higher BMI – less

No difference to SVF alone or SVF + PRP (total injected)

3159 SVF to 1459 SVF + PRP

RELEASE OF SAFETY PAPER – 2,586 PATIENTS

Prospective Study of Adipose Derived Stromal Vascular Fraction Containing Stem Cells for the Treatment of Knee Osteoarthritis

Mark Berman, MD, Elliot Lander, MD, Thomas Grogan, MD, Walter O’Brien, MD, and Jonathan Braslow, MD

INTERESTING RESULTS

Patients in general very satisfied – especially as we refine the selection criteria

No injected patient has gone on to joint replacement

Knees improve the fastest, shoulders 6 – 8 months

IV SVF seems very helpful

Sometimes nice surprises

Does no harm

APPROPRIATENESS CRITERIA

What does not work

Bone on bone osteoarthritis

Osteochondral defects

Chondrolysis

Infection

BONE MARROW STEM CELLSEXPANDED

Deployment options

Scaffolding material

Hydroxyapetite

Fibrin glue

Collagen

Collagen membrane

Nejadnik (2010) – BMSC periosteal flap vs. Autologous Chondrocyte Implantation (ACI)

72 patients 24 month follow-up

Both improved quality of life

Men did better than women

Under 45 better than over 45 in the BMSC group

ACI - cost $35-40,000

STEM CELL – NEXT ACT

Will replace Iliac Crest Bone Graft

Aspiration from Iliac crest is problematic

Need to aspirate from multiple injection sites to yield 30 ml

Bleeding dilution caused by aspiration is major issue

Spinal fusions / arthrodesis prime indications

Osteonecrosis – cell instillation following core decompression

Tissue engineering

Manipulating cells towards specific tissue types

Chondrogenesis – need truly hyaline cartilage versus fibrocartilage

STEM CELL – NEXT ACT

Future directions

Modulate / facilitate fracture healing

Delayed unions / non-unions

Facilitate spinal fusions

Osteoporosis treatment

Adjunct to or even replace biphosphanate therapies

Improve ligament healing

Aseptic necrosis – Avascular necrosis treatment

Limb ischemia

Spur vascular neogenesis

CONCLUSIONS

Procedure is safe

Effectiveness on a patient to patient basis

Response is probably dose dependent

PRP is probably a useful adjunct to cell based therapy

CONCLUSIONS

Data will drive the future

THANK YOU!