Stem Cells are cells in our bodies as children and adults which are important for the growth and healing potential of our body. These cells are one generation from some of the youngest cells present when we are developing in the womb, as an embryo. These stem cells can be found in multiple area of the body as adults and are named based upon the location where they can be obtained.
Stem cells have the ability to perform four functions which are important for regenerative potential: the ability to reproduce (proliferatory potential), the ability to differentiate and mature into a different number of cell lines (multipotentiality), the ability to mobilize in situations of blood vessel formation, and the ability to activate and control cells within their environment (trophic functions). Although all four of these functions can be used to the advantage of regenerative medicine, most scientists have sought to utilize the ability of stem cells to mature into a cell needed for repair. Stem cells also have ability to release growth factors and signaling molecules at a region of healing. For orthopaedic purposes, the mesenchymal stem cell has garnered the most interest due to its direct path to change into cells important for orthopaedic purposes.
Mesenchymal stem cells (MSCs) can be isolated from the bone marrow, lining of a joint (synovial tissue), lining around bones (periosteum), and fat. Cells obtained from different sites are slightly different. The peripheral blood stem cell (PBSC) is a cell that which is present within the blood stream and originates from the bone marrow. In laboratory studies, bone marrow derived, adipose derived, periosteum derived, and synovial derived MSCs as well as PBSCs have illustrated the ability to turn into bone cells, cartilage cells, and fat cells. Additionally, scientists have been able to turn bone marrow derived MSCs and PBSCs into brain cells, heart cells, and liver cells in laboratory study.
Progress with stem cells has been exciting in scientific laboratories and animal studies. However, some work is still required to apply what we have learned to patient care on a daily basis. The Food and Drug Administration (FDA) regulates the use of stem cells to treat patients. They have set up mechanisms to ensure that treatments utilizing stem cells are safe and useful for patients. Treatments involving bone marrow aspirate are currently the only stem cell treatments which orthopaedic surgeons can offer patients outside of clinical trials.
Bone marrow aspirate contains platelets and a patient’s own stem cells, which have the ability to replicate themselves or differentiate into various tissue types. Bone marrow aspirate can assist in treating certain injuries. Sometimes when an injury occurs, the number of stem cells available for tissue regeneration is inadequate. By using bone marrow aspirate, additional stem cells and growth factors can be placed at a site of injury to improve the overall healing process.
Bone marrow aspirate is a complex mixture of platelets, red blood cells, white blood cells, red blood precursor cells, and white blood precursor cells. Initially, the white blood precursor cells were thought to be cells that nurtured the growth of red blood cells alone. These cells were initially termed plastic-adherent cells due to this physical property of the cells. Later, these cells were found to have the ability to reproduce and change into cells of other types, thus acquiring the name mesenchymal stem cells. Initially isolated only on their ability to stick to tissue culture surfaces, when scientists studied these cells they found a broad mixture of cells which had the ability to turn into a number of different cell types. Since bone marrow aspirate and bone marrow aspirate concentrate contains platelets and mesenchymal stem cells, it is a combination growth factor therapy and cell therapy, utilizing the regenerative potential of platelet-rich plasma (PRP) and Mesenchymal Stem Cells.
Platelet-rich plasma a growth factor/cytokine therapy. It involves the isolation of platelets from a patient’s own blood and placing it at a given location. Platelets are found in our blood. They contain growth factors and other signaling molecules which are instrumental in the body’s normal healing response. Growth factors and cytokines are proteins which signal cells in our body. These molecules tell our body to grow or stimulate our body to heal in scenarios. When you have an injury, such as a cut on your skin, platelets are some of the first responders to arrive on the scene to stop the bleeding and stimulate other cells in your body to begin the healing process. Platelet-rich plasma is a tissue product that is made from a patient’s own blood; it is an autograft tissue.
Blood contains red blood cells, white blood cells, and platelets. These elements are suspended in a fluid called plasma. Platelet-rich plasma is made by first taking a small amount of blood from the blood stream. The blood is placed into a device that spins, also known as a centrifuge. The centrifuge separates the blood into layers through spinning. The layer including plasma and platelets is captured. This solution can then be placed at a site where healing or a response of the body is desired.
A complete evaluation of an injury or condition is necessary before Dr Anz can decide if PRP therapy is a consideration for treatment. If it is determined to be an option, the PRP therapy procedure will be scheduled, potentially on the day of evaluation or at a later date. PRP may not provide instant relief for the patient, as treatment with PRP seeks to improve the biology of healing or reduce inflammation related to a mechanical issue. During the procedure, Dr. Anz will inject the PRP solution into the injured area. In certain scenarios, PRP is used to augment a surgical procedure. Dr. Anz will discuss the benefits of using PRP in a given surgical procedure if it will improve the result after surgery.
For additional information, or if you would like to schedule an appointment with Dr. Adam W. Anz, orthopedic surgeon and sports medicine specialist, please contact his Gulf Breeze, FL office today.
Medical doctors often use the term biologics to refer to natural products that are harvested and used to augment a medical process. These products include tissues from a patient’s own body (often called autograft) and tissues from another patient’s body (often called allograft). These products can encompass a wide spectrum of tissues. For the purposes of orthopedics, therapies can be classified into three main categories:
- Growth Factory Therapies
- Cell Therapies
- Tissue Therapies
Growth factor therapies involve the harvest and delivery of growth factors to a site, such as in the setting of using platelet-rich plasma to augment healing after a partial tear of a tendon. Cell therapies involve the harvest and delivery of cells to a site, such as in the setting of cartilage repair with peripheral blood stem cells. Tissue therapies involve utilizing tissue to repair or augment a repair, such as in the setting of a meniscal allograft transplant. Many factors have effects on function, the potential for success, and the FDA regulatory concerns related to these treatments. There is a spectrum of treatments available within biologics. Similar to golf clubs in a golf bag, there are different therapies available for different patient problems.
Food and Drug Administration Regulation
It is important to understand the regulatory affairs concerning biologics in order to understand the potential for how they can be used to help patients. This is especially important for stem cell therapies, as cells are living biologic products. In 1997, the United States Food and Drug Administration (FDA) set forth in the Code of Federal Regulations Title 21 Part 1271, an approach to articles containing or consisting of all human cells, tissues, and cellular/tissue based products intended for implantation, transplantation, infusion, or transfer into a human recipient. These articles were abbreviated HCT/P’s, and the FDA employed a tiered approach to regulation of these articles, based on the FDA’s assessment of patient risk.
Low-risk biologics were set to be regulated by the Public Health Service Act 361 which required only that treatments be prepared involving techniques aimed to prevent the introduction, transmission, or spread of communicable diseases. These products do not require pre-market clinical studies or approval before they can be offered to patients. Higher risk products are regulated under Public Health Service Act 351, whereby they must also undergo animal and human clinical studies in order to prove that they are safe and worthwhile to be used in patient care. This hurdle prevents physicians from offering some stem cell treatments to patients such as cultured stem cell treatments, certain stem cell treatments from fat and blood, and stem cell treatments involving allograft stem cells.
Femeroacetabular Impingment, often referred to as FAI for short, refers to a condition where there is a abnormality of the shape of the bones of the hip joint. FAI can include an abnormality of the femur, bone in the thigh, where it is shaped like a ball (Femoral Head), or FAI can include an abnormality of the pelvic bone where it is shaped like a socket (Acetabulum). A Cam lesion is an abnormality in the shape of the femur where it changes in shape from a tubular structure to a ball. The transition section of the femur is known as the femoral neck. A Cam lesion is a bump at the junction of the femoral neck and femoral head. With certain hip motions, impingement can occur due to Cam lesions. Over time, this abnormal fit/interaction may result in injury to the acetabular labrum and articular cartilage within the hip joint. Cam impingment can occur in athletes whose sport involves significant rotational motion of the hip, including cyclists, golfers, ballet dancers, and football players. Surgical reshaping the femoral head and neck junction is known as femeroplasty and often involves an arthroscopic burr.
Initial treatment measures for Cam impingement are non-operative and will include rest, activity modification, and physical therapy to strengthen the core musculature area, as well as the muscles around the hip. If a patient continues to have ongoing hip pain, then surgery is usually recommended to correct the bony conflict and address any labral or cartilage problems.
Dr. Anz will use an arthroscopic surgical approach that will consist of keyhole incisions that are made in the skin, which allow a small camera and surgical tools access to the joint. During arthroscopic femoroplasty surgery for the treatment of Cam impingement, the Cam lesion (the bony abnormality) will be removed using an arthroscopic burr. The section of the femur at the head and neck junction is reshaped, creating a smooth transition which eliminates impingment. During this same procedure, Dr Anz will address the labrum and articular cartilage if it is found that damage has occurred to these structures.
Following surgery, physical therapy is very important. A therapy regimen will be prescribed which will work on regaining motion of the hip while protecting repairs. Patients will be required to use crutches for typically 4 weeks and a brace to protect the hip during healing. Physical therapy will be a progressive process incorporating range of motion movements and strengthening exercises.
For more information on FAI impingement of the hip, Cam impingement, or for additional resources on hip impingement treatments including arthroscopic femoroplasty, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute.
The iliopsoas (Psoas) is a muscle that originates within the pelvis and passes over the front of the hip joint before inserting on the femur (thighbone) at the lesser trochanter. As it travels from inside the pelvis to the femur it starts as a muscle and transitions to a tendon. The primary function of the iliopsoas is to flex the hip joint (serve to bring the knee to the chest). In some instances this tendon/muscle can become irritated and/or tight. Athletes and individuals who engage in sports or activities (such as running and sprinting) that involve rapid and repetitive hip flexion are at a greater risk for injury of this muscle/tendon. If the iliopsoas is tight for a long period, it may rub across the front of the hip joint and cause a snapping sensation and/or damage to structures of the hip, a scenario known as psoas impingement. Psoas impingment can be accompanied by significant pain and disability and when accompanied by a snapping sensation and/or sound is referred to as “internal snapping hip syndrome.”
Dr. Anz will evaluate a patients symptoms and physical examination. The first step for treating psoas impingement is a trial of stretching, anti-inflammatories, physical therapy, and rest. In many cases, the inflammation will resolve and the symptoms decrease. A trial of physical therapy is necessary with a goal of guided stretching and hip strengthening.
If pain and snapping sensations do not improve, Dr. Anz may recommend surgery to lengthen the muscle/tendon unit. The iliopsoas is an important stabilizer of the hip joint, so for some patients this may not be the best option. Dr. Anz will determine if this approach will offer the best outcome based on a patient-by-patient basis. When a psoas lengthening is deemed appropriate, he will use an arthroscopic approach. During surgery, keyhole incisions are used at the hip where he can insert a small camera and surgical tools to view the inside of the hip joint and perform the lengthening. To relieve tightness and eliminate the symptoms of the tendon rubbing over the front of the pelvis, Dr. Anz will release the tendon portion of the iliopsoas at the hip leaving the muscle portion of the iliopsoas intact. This lengthening leaves the hip flexor attached to the femur, but releases the tension creating the problem.
Following arthroscopic hip surgery for psoas hip impingement, Dr. Anz will prescribe a through rehabilitation program. This will consist of a progressive plan that will involve week-by-week rehabilitation exercises and a set of recommended protocols. Depending on the length of prior symptoms and associated injury, most patients are able to return to their previous activities within 4-6 months following surgery.
For additional information on the treatment for psoas impingement, or to learn more about arthroscopic hip surgery and partial psoas lengthening, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute.
The acetabular labrum is a type of cartilage that covers the rim of the hip socket (known as the acetabulum). It may be injured as a result of a sports accident or an acute injury such as a hip dislocation or subluxation. It also can be injured gradually with time in settings of femeroacetabular impingment. The labrum exists to provide stability to the hip joint mainly by creating a negative pressure seal at the hip, this aids smooth hip motion and flexibility. Damage to the labrum may be a major source of hip pain and weakness for athletes. However, not all labral tears are associated with hip pain. Some studies have shown that they may exist in patients without pain/dysfunction at the hip.
If a acetabular labral tear is identified, it is important to determine that it is associated with pain from the hip joint. When a labral tear is identified, strengthening the muscles around the hip joint will improve function and decrease pain in most instances. If initial strengthening measures do not improve a patient’s symptoms, Dr. Anz may recommend a hip labral repair using hip arthroscopy. During this procedure, Dr. Anz will use a small camera and tiny instruments to enter the hip and view the acetabular labrum and surrounding structures. Treatment for the actual tear will involve shaving and smoothing out the torn portion of the labrum (debridement) and/or reattaching healthy segments with sutures (repair). Repair involves sutures (strong string-like material) and absorbable anchors (strong screw-like implants) which have been developed specifically for the hip. The sutures and anchors are used to secure the labral tissue to the base of the acetabulum.
In some situations the labral tissue may be damaged beyond repair. This can occur in scenarios where femeroacetabular impingment has been present for many years. In these instances, Dr. Anz may perform reconstruction of the labral tissue using a graft. The graft will come from the patient or from a cadaver in order to reconstruct the damaged labrum. The goal of labral repair or reconstruction surgery is to restore the negative pressure seal which the labrum creates, thus restoring near-normal biomechanics of the hip.
Following hip labral repair surgery, Dr. Anz will prescribe a week-by-week rehabilitation protocol to follow. This will be a progressive process where the patient works with a therapist to regain full range of motion and strength back to the hip joint. Depending on the exact nature of the surgery and complexity of the injury, recovery is estimated at 4-6 months.
For additional information on labral tear repair surgery, or to learn more about arthroscopic hip surgery, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute.
The gluteus medius and gluteus minimus are muscles which are important for motion and stability of the hip joint. They are key to activities of daily living as well as sporting activities. The muscles originate on the pelvis and insert on the femur, at the greater trochanter. The greater trochanter is an area near the top portion of the femur (thighbone). In some instances the tendinous attachment of these muscles can undergo degeneration and/or detachment at their insertion site on the greater trochanter. This injury to the tendon can result in hip weakness, pain, and/or disability. Surgeons have recently begun utilizing arthroscopic surgery techniques for repair of these tendons where they insert on the greater trochanter.
In patients with hip pain and weakness, Dr. Anz will first evaluate for signs of tendon injury. If the gluteus muscles are found to be injured, some can improve with rest and therapy to strengthen muscles around the hip. Anti-inflammatory medication and stretching can also help decrease symptoms for some patients. If pain and functional limitations persist, surgery to repair the tendon at the attachment site may be helpful. The arthroscopic repair of the gluteus medius and/or minimus tendons is usually accompanied with removal of surrounding tissue that has become irritated, including inflammed greater trochanter bursal tissue. Additionally, a tight band of tissue overlying the area, the iliotibial band, may also be released. In some instances, can help decrease pain associated with inflammed bursal tissue, also know as bursitis.
During surgery, the torn gluteus medius or minimus tendon will be reattached to the native attachment site near the top of the femur on the greater trochanter. Suture anchors are embedded in the bone and strands of suture are then passed through the pulled-off portion of the tendon using specialized passing instruments. By tying these sutures, the torn tendon is once again attached to the bone.
Following arthroscopic hip surgery for a gluteus medius repair or gluteus minimus repair, patients will need to avoid certain hip motions and exercises for 6 weeks. A brace helps to decrease stress at the repair site during this time as well.
For more information on arthroscopic hip surgery or for additional resources on the repair of a gluteus medius or minimus tear, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute.
Articular cartilage is a soft, fibrous tissue that covers the ends of bones within a joint, allowing for smooth, low-friction motion. Articular cartilage can become damaged through trauma associated with sporting accidents, femeroacetabular impingment, or as a result of the normal aging process. While certain structures within the hip joint may be capable of healing, articular cartilage has an extremely low healing potential. Chondroplasty is a procedure intended to remove mechanical symptoms related to cartilage injury and help prevent further injury to the cartilage. The goal is to delay the onset or progression of arthritis of the hip, which is often the result of cartilage damage.
When articular cartilage becomes damaged, loose flaps of cartilage may cause mechanical symptoms and/or can break off and become lodged in the hip joint. Eventually, cartilage damage may leave exposed bone resulting in bone-to-bone grinding sensations and a loss of joint motion. This is often associated with hip pain and hip stiffness, thus limiting movement and function. Arthroscopic hip chondroplasty is a procedure that Dr. Anz performs to remove mechanical symptoms and improve function. The approach has been shown to be most successful in patients with small, partial thickness injuries where the damage has not yet reached the bone itself and when the deforming force causing the cartilage injury can also be removed, such as in the setting of CAM femeroacetabular impingment. During this procedure, which is performed arthroscopically using tiny keyhole incisions, the loose flaps of cartilage are removed. Using a camera (arthroscope), Dr. Anz will be able to visualize where the loose pieces of fragmented cartilage are located, and will remove them. He will also address other abnormalities in the same surgery. In patients who are found to have exposed bone from loss of cartilage with good intact surrounding cartilage a microfracture procedure may also be performed to regenerative tissue. Although microfracture cannot restore normal cartilage, it does produce functional tissue.
Following arthroscopic hip chondroplasty, Dr. Anz will prescribe a thorough physical therapy and rehabilitation program. This will be a progressive process and will work on restoring motion, strength and full function of the hip joint. Patients who undergo a microfracture procedure can expect to be on crutches for 8 weeks.
For more information on arthroscopic hip surgery, including chondroplasty of the hip for articular cartilage treatment, please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute.
Dr. Adam Anz is trained in hip arthroscopy and uses this approach to treat a number of hip conditions. Hip arthroscopy uses tiny, keyhole incisions to insert a small video camera (known as an arthroscope) and surgical tools inside the hip joint. The camera projects onto a high-definition video screen giving Dr. Anz and his surgical team a clear picture of structures in and around the hip. This allows first-hand analysis of injury and can be done in order to repair and correct problems.
Historically, hip surgery has involved an open approach to the joint. This involves making an incision on the skin and approaching the joint with a surgical dissection. Arthroscopic hip surgery has advanced in recent years making it possible to treat some problems with smaller incisions and without a surgical dissection. While not all hip problems can be treated with hip arthroscopy, this technique opens the door for treatment of some hip injuries with a less invasive manner.
Dr. Anz uses an arthroscopic approach to address the following acute and degenerative conditions of the hip:
- Femeroacetabular Impingment (also known as FAI Impingment)
- Acetabular Labral Tears
- Psoas Tendon Pathology and Internal Snapping Hip Syndrome
- Removal of Loose Bodies
- Iliotibial Band Snapping and Trochanteric Bursitis
- Articular Cartilage and Chondral Damage
- Gluteus Medius and Minimus Tears
- Hip Instability
Following hip arthroscopy, it is important to follow the rehabilitation regimen that is set forth by Dr. Anz and by your physical therapist. Recovery following surgery is a partnership between the doctor, physical therapist, and patient. The results of the surgery are most effective when a post-operative rehabilitation program involving physical therapy and exercises are implemented daily. Dr. Anz can make recommendations for physical therapists in your area to help facilitate this process.
To learn more about hip arthroscopy, or to schedule a consultation please contact the Gulf Breeze, Florida orthopedic surgeon, Dr. Adam Anz located at the Andrews Institute.