STEM CELLS IN

ORTHOPAEDICS
Moderator: Dr. NAYANMONI DUTTA
Asst. Professor
Department of Orthopaedics
JMCH
STEM CELL – Definition

 Those cells with:

 Exhibit plastic
adherence
 Possess CD73, CD90,
CD105
 Lack of CD14, CD34,
CD45 & HLA-DR
Stem Cells – Characteristics

 mobilization during
angiogenesis
 differentiation into specialized
cell types
 proliferation and regeneration
 release of immune regulators
and growth factors
 Potenc
Source Types
y
Hematopoietic Totipotent
Embryonic stem cell
Pluripotent

Mesenchymal
Unipotent
stem cell

Oligopotent
Adult Induced
pluripotent
stem cells Multipotent
Kinds of Stem Cells
Stem Cell Type Description Examples

Totipotent Develop into new Early embryo cells (1-3

individual days)

Pluripotent Can form any (over Some cells of

200) cell types Blastocyst (5-14 days)

Multipotent Cells differentiated but Foetal tissue, Cord

can form number of blood, Adult stem cells
other tissues
Stem Cell Type Source Advantages Disadvantages

Embryonic Stem Cells Embryonic Tissue Pluripotent to all 3 Oncogenic potential,

germ layers allogenic rejection,
ethical & legal
constraints
Induced Pluripotent Adult somatic tissue Pluripotent, less Oncogenic potential,
Stem Cells transfected with ethical issues, no modest induction yield
embryonic allogenic rejection
transcription factors

Mesenchymal Stem Multiple Fetal and Can differentiate into Limited differentiation
Cells Adult tissue (umbilical tissues of interest – capacity, modest yield
cord, umbilical blood, bone, tendon, and from host tissue
placenta, skin, bone cartilage ;
marrow, adipose , immunosuppressive
synovium, periosteum, allowing for allo and
dental pulp xeno transplantation
Advantages of MSCs

 ease of isolation
 high differentiation capabilities
 strong colony expansion without differentiation loss
 immunosuppression following transplantation
 Powerful anti-inflammatory properties
 their ability to localize to damaged tissue
MSC Source Differentiation Advantages
Potential
Bone Marrow Chondrocyte, muscle, Highest differentiation
osteoblast, cardiocyte, potential
mesangial cell,
hepatocyte
Adipose Chondrocyte, muscle, Easily accessible, higher
osteoblast, stromal cell colony formation
compared to bone
marrow derived cells
Synovium Adipocyte, chondrocyte, Applicable for cartilage
muscle, osteoblast and tendon healing
Periosteum Chondrocyte, osteoblast Applicable to fracture
non-union healing
MSC Delivery Methods

 Cell Based
 Tissue Engineering Methods
Stem Cells Contd..

 Precursor/Progenitor Cell – partly differentiated cell

 Generated by stem cell
 Eventually divide – give rise to mature cell
 Often committed – develop only along a particular cellular devpt pathway
Division of Stem Cells

 A – Stem Cell
 B – Progenitor Cell
 C – Differentiated Cell

 1 : Symmetric Division
 2 : Asymmetric Division
 3 : Progenitor Cell Division
 4 : Terminal Differentiation
Embryonic Stem Cells

 Derived from inner cell mass of

blastocyst
 Before it implant on uterine
wall
 Can self replicate and are
“Pluripotent”
 Source –
 Excess fertilized egg from IVF
 Therapeutic Cloning (Somatic
Cell Nuclear Transfer)
 Stem cells – divide in culture
Adult Stem Cell

 Undifferentiated cell found in differentiated tissue

 Renew itself and produce all specialized cells of tissue it formed from
 Source – bone marrow, blood stream, cornea, retina of the eyes, the
dentine, liver, skin, pancreas and gastrointestinal tract.
 In contrast to embryonic stem cell – not “Pluripotent”
 Primary Function – Maintain Homeostasis
 Share no common features
Umbilical Cord Stem Cells

 Cord Blood – rich in stem cells – after appropriate HLA matching –

used to treat variety of conditions
 Identical to adult stem cells
 The use of umbilical cord stem cells in orthopaedics is still in a
nascent stage and most studies currently focus on the use of the
adult stem cell.
Stem Cells Therapy

 Type of Genetic Medicine – introduce new cells into damaged tissue to

treat a disease or condition
 Medical researchers believe that stem cell treatments have the
potential to change the face of human disease and alleviate suffering
 Cancer, Type 1 Diabetes Mellitus, Parkinson’s Disease, Huntington’s
Disease, Cardiac failure, Muscle damage, and Neurological disorders
Orthopaedic Application

 Spinal Cord Injury

 Difficult Non-Unions
 Critical Bone Defects
 Spinal Fusions
 Augmentation of Ligament Reconstruction
 Cartilage Repair
 Degenerative Disc Disorders
 Osteoarthritis
 Tendinopathy
Osteoarthritis

 MSC –
 Potent anti-inflammatory properties
 Regenerative potential
 MSC injection into elderly patients (age>65years) with Knee OA
 88% demonstrated improved cartilage status at 2-year follow-up
 no patient underwent a total knee arthroplasty during this time period
 Unicompartmental knee OA with varus alignment undergoing high
tibial osteotomy and microfracture
 reported improved clinical, patient-reported, and magnetic resonance
imaging (MRI)-based outcomes in a group receiving a preoperative MSC
injection compared to a control group
Articular Cartilage Repair

 Limited potential of chondrocytes to replicate or migrate to state of

pathology
 Programmed growth factor release and alteration of anatomic micro-
environment to facilitate regeneration and repair of chondral surface.
 Autologous stem cell – microfracture into bone marrow – fibrin clot
formation containing platelets, growth factors, vascular elements and
MSCs
 Synovial derived stem cells – excellent chondrogenic potential
 Gobbi & Colleagues – focal chondral defect of 9.2cm2 about the knee –
complete hyaline- like cartilage coverage in 80%
Tendinopathy
 Godwin & Colleagues - Equine models – autologous bm-MSCs –
superficial digital flexor tendinopathy – 141 race horses – Reinjury just
27.4%
 Machova Urdzikova and colleagues – Achilles tendinopathy – 40 rats –
more native histological organisation and improved vascularization
 Human treatment of tendinopathies with stem cells has been scarcely
studied to date
 Pascual-Garrido and colleagues – 8 patients – Refractory Patellar
Tendinopathy – Autologous bm-MSCs – successful results at 2-5 year
follow up – significant improvements in 100% of patients
Spinal Cord Regeneration

 Injury to neural tissue results in a permanent deficit

 Isolation and preparation of specific adult stem cells have evolved to
the capacity to differentiate into neural phenotypes from all three
neural lineages: neurons, astrocytes and oligodendrocytes.
 In animal experiments different varieties of adult stem cells ie –
 olfactory ensheathing cells,
 cultured spinal cord stem cells
 dermis-derived stem cell
have been implanted in a rat model of spinal cord injury
 these showed ability to incorporate into spinal cord, differentiate and
improve the locomotor capability
 The presence of neural stem cells [NSC] in the adult mammalian
spinal cord suggests the latent capacity of regeneration of injured
spinal cord if the NSC are activated properly.
 Akiyama- MSCs isolated in culture from mono nuclear layer of bone
marrow- direct injection – can remyelinate demyelinated spinal cord
axons
SPINAL CORD INJURY STEM CELL
TREATMENT PROTOCOL (OUTLINE)

 The standard protocol takes 4 weeks

 The first two days: medical evaluation, blood testing, and bone marrow
collection
 8 intrathecal (spinal canal) injections of expanded/non-expanded cord blood-
derived stem cells (2 per week)
 4 intravenous injections (IV) expanded cord blood-derived stem cells (1 per
week)
 2 intrathecal (lumbar puncture) injections of bone marrow-derived stem cells
(during final week)
 2 intravenous injections (IV) bone marrow-derived stem cells (during final
week)
 19 physical therapy sessions (throughout stay)
 Medical consultation for hormone evaluation
Critical Bone Defects and Non-
unions
 Critical defect - loss of a portion of bone that fails to heal and requires
a bone reconstruction to prevent a non-union defect.
 The ideal modality so far - autologous bone grafting - amount of the
autologous bone graft that can be harvested remains limited and
osteoporosis precludes its use
 Some investigators have directed their attention towards the use of
autologous non hematopoetic /progenitor cell contained in the adult
bone marrow stroma (also referred to as adult stromal cell).
 Two methods have been employed in the pre-clinical and clinical
protocols while managing the critical defects. In one of the protocols
the stem cells were directly injected at the lesion site and in other
they were expanded ex vivo before being implanted.
Meniscal tears

 Meniscal tears in the avascular zone - limited capacity to heal

 Pre-clinical study - Sprague-Dawley rats - transplanting mesenchymal
stem cells into meniscal defects - MSC could survive and proliferate in
the meniscal defects
 In Humans – Vangsness & colleagues – knees with partial medial
meniscectomy – allogenic stem cells – increase in meniscal volume
and decreased pain – compared to hyaluronic acid
 MSC transplantation appears promising new strategy for treatment
of meniscal tears in avascular zone.
Rotator Cuff Repair

 Rat Models – Valencia Mora & Colleagues – no difference in terms of

biomechanical property but lesser inflammation – more elastic repair
& lesser scar formation
 Oh & Colleagues – rabbit subscapularis tear model – reduced fatty
infiltration at site of chronic rotator cuff tear
 Augmented Rotator Cuff Tear – mixed results – arthroscopic bone
marrow aspiration of proximal humerus and subacromial bursa
Anterior Cruciate Ligament
Reconstruction
 Bm-MSCs – genetically modified with BMP2 and bFGF – mechanically
sound tendon-bone interface in ACL
 Jang & Colleagues – Non-autologous Human Umbilical Cord MSCs – in
rabbit ACL reconstruction Model – lack of immune rejection and
enhanced tendon-bone healing and decreased to tibial & femoral
tunnel widening
 Kanaya & Colleagues – improved histological scores & improved
biomechanical integrity
 Sylvia & Colleagues - graft-to-bone site of healing in ACL
reconstruction – 20 patients – no difference
Muscular Dystrophies

 Myoblast transfer therapy - transplantation of committed mouse

precursor cells into the muscle cells - limited success in clinical trials.
 Mouse models of DMD – myoblasts transplanted into dystrophic
muscle – repaired small proportion of dystrophic muscle
 Gussoni – in immunodeficient mice – marrow derived cell can migrate
into areas of induced muscle degeneration – participate in
regeneration of damaged muscle fibres
Osteogenesis Imperfecta

 Pereira – infused BMSCs from normal mouse into OI mouse – MSCs

homed in bones produced normal levels of COL1 – partial restoration
of osteogenesis imperfecta phenotype
Intervertebral Disc

 Crevenston - MSCs were injected into the coccygeal discs of rats

using 15% hyaluronan gel as a carrier
 14 days – stem cells still present but number reduced
 28 days – return to initial number and viability 100%
 Increase in disc height – suggests increased matrix synthesis
Spine Fusion

 In a study - murine model of spine - genetically engineered MSC into

the paravertebral muscles.
 These MSCs that conditionally express bone morphogenetic protein-
2(BMP-2) - the extent and quantity of the newly formed bone can be
monitored by controlling the duration of rhBMP-2 gene expression.
 Use of marrow derived stem cell along with allograft to achieve spinal
fusion - supported by many authors when significant quantity of
osteogenic tissue is required.
Spine Fusion Contd..

 Secondly it has been hypothesized that mesenchymal stem cells are

deficient at fusion site in certain situations [e.g. smokers,
posterolateral fusion beds, cases of failed fusions]
 In such scenarios introduction of stem cells - bone healing and
shorten the duration of spine fusion.

 Cinotti - Cultured MSCs with porous Ceramic scaffold – higher rate of

fusion than ceramic alone
Physis Injury

 Injury to physis – bony bridge between metaphysis and epiphysis –

25-35% some shortening and angular deformity
 Chen – implantation of MSCs into growth plate – significant reduction
in growth arrest in rabbit tibia
 Ahn – MSCs embedded in 10% Gelatin in Gelfoam with TGF-beta3 –
growth plate defects in rabbit – reduced angular deformity in partial
physeal defects
Challenges and the Road Ahead

 Controversy involving stem cell research - legislation, ethics and public

opinion, cost and concentration methods. Legislations regarding the use
of stem cells vary among different countries.

 Researchers argue that many of the embryos created by in vitro

fertilization programs are surplus to requirements and are in any case
normally destroyed. These can be potentially used for the derivation of
ES cells.

 Costs involved in stem cell research is astronomical and thus is limited to

centers that can invest huge sums of money for various projects.
Is it dangerous???

 The transported stem cells could form tumors and have the possibility
of becoming cancerous if cell division went out of control.
 Challenges that clinicians face while using the adult stem cell -
concentrating the cells.

 The normal concentration of stem cells in samples drawn from

marrow is many a times considered inadequate. Various techniques
like filtration, culture expansion and sieving are employed for this
purpose.

 Problems
 Dosage
 lack of activity of the recombinant factor
 inability to sustain the presence of a factor for an appropriate length of
time.
 forming unwanted tissues and teratocarcinomas
Conclusion

While both schools of thought seem correct, another group feels its too
early to comment….

However, there still exists a great deal of social and scientific

uncertainty surrounding stem cell research, which could possibly be
overcome through public debate, future research, & further education
of the public.
Bibliography

 Essential Orthopedics Principles & Practice by Manish Kumar Varshney

 CAMPBELLS OPERATIVE ORTHOPAEDICS
 Turek’s Orthopaedics Principles & Their Applications -8E
 Schmitt A, van Griensven M, Imhoff AB, Buchmann S. Application of stem
cells in orthopedics. Stem cells international. 2012 Oct;2012.
 Saltzman BM, Kuhns BD, Weber AE, Yanke A, Nho SJ. Stem cells in
orthopedics: a comprehensive guide for the general orthopedist. Am J
Orthop (Belle Mead NJ). 2016 Jul 1;45(5):280-326.
 Lee EH, Hui JH. The potential of stem cells in orthopaedic surgery. The
Journal of Bone & Joint Surgery British Volume. 2006 Jul 1;88(7):841-51.
 Bahney CS, Miclau T. Therapeutic potential of stem cells in orthopedics.
Indian Journal of Orthopaedics. 2012 Feb;46:4-9.
Flexor Zones of Hand
Dr. Debasis Tarai
THANK YOU