Orthopedic medicine is the study of the musculoskeletal system and how it interacts with the rest of the body: How your muscles, nerves, and physiology interact to make your body move properly and without pain. It is called orthopedic medicine, because it is an approach to orthopedics without the surgical component. Specialists in orthopedic medicine are typically using non invasive or minimally invasive approaches to orthopedic care to help a patient regain an improved quality of life with less pain. Many physicians in this space are using both traditional medical techniques and newer, regenerative medicine techniques. The goal of orthopedic medicine is to keep patients out of the operativing and to perform less invasive procedures than surgery. These procedures are typically done in the office setting and do not require extended rehabilitation, lost time from work, or recovery from general anesthesia.
Regenerative medicine is a branch of medicine that focuses on healing the body by using and stimulating the body’s own innate healing mechanisms, in order to establish normal function and heal previously irreparable tissues. As we age, we accumulate micro stressors throughout our joints, ligaments and tendons, organs, and muscles. Additionally, our overt injuries as a young person create tiny long lasting effects in the body that become noticeable as we age. While there may not be one single thing that causes major dysfunction, the accumulation of these injuries can result in pain and decreased range of motion. When we are young, we have ample healing cells in our bloodstream and in our tissues to help repair the damaged areas. As we age, the amount of stem cells, hormones, and other repair mechanisms that we have in our tissues decline, and our blood flow to injured tissues declines as well. So not only do we have less repair cells available, the few cells that do exist don’t have a great means of getting to where they need to go, and our ability to repair the injured joints, tendons and ligaments decline as well, thus arthritis, pain and chronic injury ensue.
Regenerative medicine aims to improve our body’s ability to heal through a variety of mechanisms. It first causes a mechanical injury directly to the diseased tissue, by introducing a needle to the area. When this happens, blood flow is stimulated to bring healing factors to the newly injured tissue. Regenerative medicine then adds a chemical injury or a healing substance, introduced via a needle, to help decrease pain and heal the injured area. By repairing damaged tissues, we can keep a patient out of the operating and save them time and money in the long run.
Types of Regenerative Medicine
There are multiple facets of regenerative medicine but the three biggest ones for orthopedic purposes are called prolotherapy, platelet-rich plasma and mesenchymal stem cells.
Prolotherapy is the original form of regenerative medicine. It is a process of injecting an irritating solution, such as sugar, into a joint, tendon or ligament, to stimulate healing. The sugar solution works in combination with the injection by introducing a mechanical injury (needles) to the area and a chemical irritant to the area, thereby stimulating and attracting immune cells and growth factors to the area of injury, and thus encouraging healing and tightening down of ligaments and tendons. This type of regenerative medicine is effective for lax ligaments around the vertebrae, joints, or other areas. We often use this after dislocations, whiplash injury, and more.
PLATELET RICH PLASMA
Platelet-rich plasma (PRP) uses platelets from your bloodstream to induce a healing response within the body. Blood is drawn from the patient and processed in such a way that extracts and concentrates the platelets to a precise concentration for injection. The platelets are then injected under imaging guidance, either ultrasound or fluoroscopically, into the injured area. This technique introduces a micro injury, as described above, and also introduces specific healing factors of the bloodstream. In essence, the physician is forcing a very potent and healing blood supply to an area that did not have one. Joints, ligaments and tendons tend to have a poor blood supply on their own, and this declines even further with age. A well-trained physician will know how to appropriately concentrate the blood down to specific concentrations for the treatment area, and will use imaging guidance to inject the PRP back into the body.
Platelets work via a variety of mechanisms. I like to call platelets the general contractors of the blood. Once they are placed into the injured tissue, they serve to release growth factors into the tissue for improved healing. The platelets also use cell to cell communication to call for local stem cells in the blood and in nearby tissues to come into the injured tissue and help in the repair process.
MESENCHYMAL STEM CELLS
Stem cells exist all over the human body, and are in a constant state of evolution within their lifespans. They are circulating in your blood, they are in your bones, in your skin, and surrounding every tissue that is within the human body. The highest concentration of autologous mesenchymal stem cells exists in fat tissue (adipose) and in the bone marrow. They have the ability to differentiate into multiple cells types and thus heal injured tendons, ligaments, muscles, cartilage, and more, thus making them the ideal stem cell type to use for orthopedic medicine1. As mentioned prior, tendons, joints and ligaments have a poor blood supply, thus making it difficult or even impossible to heal those areas. The bloodstream is the highway to healing. Without a good blood supply, the body cannot send healing factors to an injured area. Injecting the body’s own healing cells enables us to bypass the highway and directly give the injured tissues the necessary healing factors for repair. Mesenchymal stem cells are like the master craftsmen of the blood. They work quickly, together, to help decrease inflammation and pain. Stem cells also recruit surrounding stem cells to get into action and help repair the damaged tissue. Stem cells coordinate the healing process by repairing damaged tissue and cleaning up leftover inflammatory particles that were in the area.
In order to access these cells a physician must be well trained in regenerative medicine. To extract bone marrow, the physician uses a small trocar to get into the bone marrow located along the back of the hip. She then advances it far enough into the bone to gently extract the cells. In order to extract fat cells, a physician performs a mini liposuction using a cannula technique, where they get specific fat along the flank, where the highest quality adipose stem cells live.
There are other types of adult stem cells being used in orthopedic medicine. These stem cells are amniotic or umbilical cord blood stem cells. These types of stem cells are not FDA approved and have not been proven to be as effective as autologous use. Additionally, some labs have tested the viability of these so-called “stem cells” and have not actually found any live cells. These types of treatments may be beneficial for a small subset of patients, but they should only be used when the patient is not a good candidate for extraction of their own bone marrow or adipose stem cells. It takes a highly trained physician to be able to perform the bone marrow extraction or the liposuction needed to get autologous stem cells, and thus it is those physicians that should be trusted with deciding which type of stem cell is most appropriate for the patient’s condition. If a clinic cannot offer the patient autologous stem cells as an option for treatment, that clinic and its’ providers are not adequately trained in regenerative medicine and should not be performing these procedures on unsuspecting patients.