Meniscus Tears and Regenerative Medicine

Category: Blog

In this article we will examine the treatment of meniscus injury with stem cell therapy and Platelet Rich Plasma (PRP). We will talk about research from leading medical centers on new and recent findings and we will also discuss new research co-authored by the Magaziner Center for Wellness’s Scott Greenberg, MD in the Journal of Medical Cases. This is a case of a 56 year old man treated at the Magaziner Center for Wellness for chronic meniscus tearing.

What is exciting about this case is that to our knowledge, this is the first case presented in the medical literature of a patient with a before and after arthroscopic evaluation showing the repair of a meniscal tear using SVF (Stromal vascular fraction / stem cells) with PRP (Platelet Rich Plasma) injections.

If you are a patient suffering with long-term knee problems caused by a damaged meniscus or problems related to a Meniscectomy,  you have likely been made aware that your meniscus, or what remains of it, has a limited capacity to repair itself. You may have also been made aware that meniscus related surgery also has a limited capacity to improve your situation. So you have been presented a situation where your knee has limited ability to be fixed and that you will have to wait out the degenerative stages of osteoarthritis until you are ready for knee replacement.

Why Stem Cell Therapy?

If you were given a realistic assessment of your meniscus situation, you were told that osteoarthritis, degenerative knee disease, and possibility of knee replacement were the ultimate outcomes.

This is why researchers are looking at stem cells injections. To present a different option. Stem Cell Therapy is part of a family of treatments that fall under the broad umbrella of “Tissue Engineering” or “Regeneration or Regenerative Therapy.”

While we are very excited to get to our published case study of meniscus repair with stem cells, first we would like to present supportive literature form leading research centers.

How can stem cell injections address meniscus injury?

In recent study published in the journal Stem Cell International, doctors say that the future of meniscus repair is not in surgery, but meniscus tissue engineering and that more research should be given towards maximizing the healing/regenerative properties of stem cells.(1)

Stem cell therapy is a highly effective treatment in which stem cells are injected into an injured area. At the Magaziner Center for Wellness, we use Mesenchymal stem cells (MSCs) for our stem cell therapy injections. Stem cells are responsible for rebuilding and regenerating the body. They are living cells that are able to transform themselves into many different types of tissue, and are therefore able to differentiate into ligaments, tendons, bone, nerve, and cartilage.

Red Zone – White Zone

The problem with the meniscus repair is that it is divided into zones and makes treating the whole meniscus challenging. The outer area that gets a steady blood supply (Red Zone) and has a capacity for healing. The middle area the “Red-White” zone that has limited blood supply and is more challenging to heal, and the avascular zone or the “White zone,” which is thought that repair cannot be made because it has no direct blood supply.

In new studies doctors in China declare that: “The repair of meniscus tissue in the avascular zone (without blood vessels to bring healing components) remains a great challenge, largely owing to their limited healing capacity.” The answer they suggest to heal this area lies with stem cell based tissue engineering. Stem cells, they write, “provide a promising treatment option for damaged meniscus because of their multiple differentiation potential (their ability to change into meniscal and cartilage cells).”(2)

Regeneration of meniscus tissue

In new research, scientists looked at rabbits with massive meniscal defects. Their goal was to see if a single stem cell injection would improve the defect. This is what the researchers wrote: “(stem cells) injected into the knee adhered around the meniscal defect, and promoted meniscal regeneration in rabbits.” This also lead to a preservation of the articular cartilage and subchondral bone.(3)

Doctors at Harvard University found unique characteristics in the stem cells of mice meniscus that could be reawakened by stem cell augmentation. The findings were so optimistic that the Harvard team declared that studying the mouse meniscal stem cells would provide essential information for enhancing therapeutic strategies for treating knee joint injury and disease.(4)

This agrees with other research which strongly supports Stem Cell Therapy as a means to regrow meniscal tissue. From the American Journal of Bone and Joint Surgery:

  • There are limited treatment options for tissue restoration and the prevention of degenerative changes in the knee.
  • Stem cells have been a focus of intense preclinical research into tissue regeneration but limited clinical investigation.
  • In a randomized, double-blind, controlled study, the safety of the intra-articular injection of human mesenchymal stem cells into the knee, the ability of mesenchymal stem cells to promote meniscus regeneration following partial meniscectomy, and the effects of mesenchymal stem cells on osteoarthritic changes in the knee were investigated . . .
  • There was evidence of meniscus regeneration and improvement in knee pain following treatment with mesenchymal stem cells.
  • These results support the study of human mesenchymal stem cells for the apparent knee-tissue regeneration and protective effects.(5)

Repair and regeneration is a far cry from surgical removal: In a recent  study in the New England Journal of Medicine  doctors questioned that while arthroscopic partial meniscectomy is one of the most common orthopedic procedures, there is no evidence it works.

In the study, doctors asked patients to have a real surgery or a fake (sham) surgery without knowing which one they would get. The results? “In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.”(6)

The case of a 56 year old man with meniscus tear presented in the journal Medical Case Histories

The research: Intra-Articular Implantation of Stromal Vascular Fraction Plus Platelet Rich Plasma in a Degenerative Meniscal Injury
Kristin Comellaa, Scott Greenberg, MD, Laura Ross. J Med Cases. 2018;9(7):221-225

The presented case study was completed on a 56-year-old male with a chronic meniscus injury. To our knowledge, this is the first case presented in the medical literature of a patient with a before and after arthroscopic evaluation showing the repair of a meniscal tear using SVF (Stromal vascular fraction) plus PRP (Platelet Rich Plasma).

The patient’s knee problems:

  • The patient described a pinching pain with noticeable edema (swelling). In addition, his knee was unstable.
  • Two prior MRIs obtained before treatment confirmed a tear of the posterior horn of the medial meniscus.
  • The posterior horn of the medial meniscus showed decreased size with increased degeneration in two MRIs over a 3-year period.
  • Questionable small tears extending to the superior and inferior articular surface are visible. The images also showed irregular fraying of the inferior articular surface of the posterior horn of the medial meniscus.
  • An additional MRI taken 1 month prior to treatment confirmed a new partial-thickness free edge tear of the inner margin of the medial meniscus which was also confirmed with arthroscopic imaging.

The patient’s treatment:

The patient was injected with a combination of a 5 mL whole fat graft and Stromal vascular fraction (SVF) suspended in approximately 4 mL of platelet rich plasma into the problem area.

What is Stromal vascular fraction (SVF)? Is it stem cells?

  • Stromal vascular fraction (SVF) from adipose (fat tissue) is a mixture of adipose derived stem cells/ mesenchymal stem cells and cells that help with new blood vessel formation that bring healing circulation of blood to the area. These would be the pericytes and progenitor/endothelial cells. SVF also contain the repair cells, the fibroblasts, that are involved with the growth of new collagen and the formation of new cartilage and soft tissue.
  • Due to the high amount of regenerative stem cells from adipose tissue, SVF may offer a new option for degenerative disease and tissue damage.

Follow up treatments

  • After the initial treatment, the patient received five additional PRP injections of 2.5 mL at 3 – 4 week intervals.
  • The patient was monitored over a 12-month period for safety (including severe adverse events (SAEs) and adverse events) and quality of life parameters. There were no reported SAEs or other safety complications during the procedure or the follow-up time period.

A brief explanation of Platelet Rich Plasma or PRP: Blood platelets carry cells, proteins, and other growth and healing factors that initiate repair and attract the critical assistance of stem cells. PRP therapy’s natural healing process intensifies the body’s efforts by delivering a higher concentration of platelets. To create PRP therapy, a small sample of your blood is drawn (similar to a lab test sample) and placed in a centrifuge that spins the blood at high speeds, separating the platelets from the other components. The concentrated platelet rich plasma (PRP) is then injected into and around the point of injury, jump-starting and significantly strengthening the body’s natural healing signal. Because your own blood is used, there is no risk of a transmissible infection and a very low risk of allergic reaction.

Results

  • The patient demonstrated reduction of pain with clearly visible repair on the arthroscopic evaluation.
  • The patient expressed an overall improvement in quality of life and willingness to repeat PRP treatments.

The Validation

  • Arthroscopic evaluation showed new tissue formation and resolution of meniscus defects.

Conclusion

This case study demonstrated that intra-articular injection of SVF plus PRP in a knee meniscal injury can be safely completed in an outpatient setting. The procedure was well tolerated with no reported severe adverse events  and adverse events. The patient experienced a reduction in pain with an improved quality of life including increased activity.

Most cases of stem cell and PRP treatments are successful, yielding positive results. We have had pro-athletes, who had been sidelined, resume their high-intensity career. We have witnessed elderly patients, who were once wheelchair-bound, walk again without assistance.

If you would like to explore this treatment option for your degenerative knee problems. Please contact our office.

REFERENCES:

1 W, Guo W, Han S, Zhu Y, Liu S, Guo Q. Cell-Based Strategies for Meniscus Tissue Engineering. Stem Cells International. 2016;2016:4717184. doi:10.1155/2016/4717184.
2. Hana Yu, Adetola B Adesida and Nadr M Jomha1. Meniscus repair using mesenchymal stem cells – a comprehensive review.Stem Cell Research & Therapy 2015, 6:86 doi:10.1186/s13287-015-0077-2
3. Hatsushika D, Muneta T, Horie M, Koga H, Tsuji K, Sekiya I.  Intraarticular injection of synovial stem cells promotes meniscal regeneration in a rabbit massive meniscal defect model. J Orthop Res. 2013 Sep;31(9):1354-9. doi: 10.1002/jor.22370. Epub 2013 Apr 17.
4. Gamer LW, Shi RR, Gendelman A, et al. Identification and characterization of adult mouse meniscus stem/progenitor cells.Connect Tissue Res. 2016 Dec 22:1-8. doi: 10.1080/03008207.2016.1271797.
5.Vangsness CT Jr, Farr J , Boyd J et al. Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial meniscectomy: a randomized, double-blind, controlled study. J Bone Joint Surg Am. 2014 Jan 15;96(2):90-8. doi: 10.2106/JBJS.M.00058.
6. Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TL; Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med. 2013 Dec 26;369(26):2515-24. doi: 10.1056/NEJMoa1305189.