BMC as an Alternative to TKA and Rotator Cuff Support in the Elderly

BMC as Alternative for TKA

I disposed in the previous post of the notion that you lose all of your bone marrow-based MSCs if you are elderly. That conclusion is based on one of Dr. Philippe Hernigou’s presentations during the recent national ASIPP conference. Dr. Hernigou is the pioneering physician who has been working with bone marrow concentrate (BMC) for treating orthopedic pathologies for more than 30 years. He also has MSC data on all of the BMC preparations he has used to treat his patients, so when he says that the elderly on average have more than 500 MSCs per mL of bone marrow he knows of what he speaks. And 500 MSCs per mL of bone marrow is well above none, which is what is claimed by those who hawk non-BMC therapies. I will cover in this post the part of his ASIPP presentation in which he reviewed clinical outcomes of using BMC percutaneous injections in the elderly to support rotator cuff repair and to postpone a TKA (total knee arthroplasty/replacement).

Several years ago, when I first asked Dr. Hernigou whether or not BMC therapy was effective in the elderly, he quite reasonably asked me what my definition of “elderly” was. I responded that in the USA, folks over the age of 60 or so were considered to be elderly. He laughed, and then clarified that in Europe you weren’t elderly until the age of 80 or so. How civilized. So, the patient population he focused on in his talk was at least 80 years of age or older.

However, Dr. Hernigou indicated at the start of his presentation that the elderly certainly suffer from a reduction of stem cells not just in their bone marrow, but in other tissues, including bone, tendons and muscles. The stem cell levels are reduced, but not to zero. He said that as a consequence, the elderly needed to have their local tissue stem cells augmented with their own concentrated bone marrow from the iliac crest to support their natural healing process.

He provided an especially vivid example of the benefit of augmenting a surgical procedure with autologous BMC for elderly patients who suffered from a recurrent rotator cuff tear. These patients had a standard of care primary rotator cuff repair, which subsequently failed. The second repair also failed. While the first two surgeries were done arthroscopically, he indicated that the third surgery usually was an open procedure. Bone marrow was aspirated from the patient’s iliac crests and concentrated. The BMC was distributed so that 4 mL was injected into the repaired tendon, 8 mL was injected into the subchondral compartment of the greater tuberosity beneath the insertion point of the repaired tendon, and 4 mL was injected into the associated muscle about 4 cm away from the repair. The injection into the muscle is done to limit fatty infiltration commonly found in patients with complicated rotator cuff tears.

The primary outcome that is tracked in this type of recurrent tendon tear pathology is the frequency of a third rupture. After a 15-year follow-up, there were 4 out of 30 patients with BMC augmentation who ended up with another rupture. However, 18 out of 30 control patients suffered another rupture, despite having been matched for the usual patient demographics (BMI, gender, age, etc.) and having received the same surgical procedure, but without BMC augmentation. That is more than a 4-fold increase in the frequency of a third rupture for the control group compared to the BMC-treated group. Another trend Dr. Hernigou highlighted was that of the patients who received a total of more than 50,000 MSCs in their BMC treatment all had an intact tendon after a milestone of 15 years. From this clinical data, Dr. Hernigou concluded that there was a clear benefit to using BMC in treating complex pathologies like recurrent rotator cuff tears in the elderly, as well as younger patients. And there is a need to harvest more bone marrow to have a higher total MSC content available for injection.

To conclude his presentation, Dr. Hernigou reviewed the results from another clinical study in which BMC was used to treat knee OA in the elderly (>80 years of age). This group of patients was eligible for bilateral total knee arthroplasty (TKA), and had undergone a TKA in one knee, but received a BMC injection into the femoral condyle and tibial plateau of the other knee.  A total of 40 patients were tracked for an average of 8-years follow-up.

Obviously, there were major differences in the length of hospital stay for the two treatments. TKA patients remained in the hospital on average for eight days, but the stay was just one day for patients when they had the BMC percutaneous injection into the subchondral compartments of their femoral condyle and tibial plateau. Patients receiving BMC-treatment had no medical complications, whereas when the patients underwent the TKA procedure, there were a large number of medical complications, including 30% of the patients needing a blood transfusion.

In terms of therapeutic benefit, three of the TKA knees had additional surgery, with two knees requiring revision and one knee received surgical attention for a hematoma at 1-month. In contrast, one knee with BMC treatment required a TKA after 6-years. Overall, the two treatment groups achieved the same level of functionality and pain relief, as determined by the KSS, since the BMC-treated knees had an average score of 80.3, while the TKA joints had a value of 78.3.

Dr. Hernigou suggested that the improvement in quality of life achieved by the elderly patients treated with BMC could be attributed to a resolution of bone marrow lesions, decreased erosion of whatever cartilage was present (or the formation of fibro-cartilage—a less durable version of articular cartilage), and a neovascularization of the subchondral bone compartments on both the femoral condyle and the tibial plateau. After hearing Dr. Hernigou’s presentation on the therapeutic effectiveness of MSCs in the elderly, I think it is fair to say that the naysayers don’t have a leg to stand on when they attempt to fool physicians with their mis-informed opinions on the MSC content of bone marrow depots in the elderly.

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