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Adipose derived stem cell therapies for treatment of musculoskeletal conditions
2013 ASICS Conference / Journal of Science and Medicine in Sport 16S (2013) e84–e99
Discussion: Despite widespread acceptance amongst experienced clinicians, the concept of intra-pelvic instability remains controversial in the wider medical community. Indeed, rheumatologists still argue it does not exist. Hence, lack of a validated objective outcome measure for intra-pelvic instability has major impacts on access to treatments for these patients and has made research in the area difficult. While our numbers are small, these early results indicate that we may, finally, have a tool that simply and reliably measures intra-pelvic instability. This early data also indicates that prolotherapy to the pelvic ligaments may correct this instability. http://dx.doi.org/10.1016/j.jsams.2013.10.208 9 Use of ultrasound-guided polidocanol injections (using Colour Doppler) to arrest acute bleeding from intramuscular haematomas J. Orchard 1,2,∗ , L. Cutler 2 , P. Williams 2 , T. Touma 2 , P. Farhart 3 , A. Ibrahim 2 1
University of Sydney, Australia Sydney Roosters RLFC, Australia 3 City Edge Physiotherapy, Australia This series of three cases presents a novel medical intervention for uncontrolled bleeding in traumatic intramuscular haematomas. The vast majority of traumatic haematomas in a sporting setting resolve rapidly and cause minimal missed playing time. However a small minority lead to progressive bleeding which continues after rest and can cause the player to miss many weeks. In the worst scenarios uncontrolled bleeding can lead to acute compartment syndrome for which emergency surgery is the only management. Ultrasound-guided injections of polidocanol in sports medicine have been popularised by Scandinavian researchers for sclerosing of neovessels in chronic tendinopathies. In general medicine the major use of polidocanol is as a sclerosant for varicose veins. The mechanism of action is endothelial damage, causing platelets to accumulate and ligate the vessel. It is recommended for intravenous use only in the lowest possible dose with caution to be used in peripheral locations. In this case series, athletes who had suffered massive haematomas secondary to trauma were examined using Colour Doppler US (Sonosite M Turbo). In all cases a suspected vessel with high flow in the haematoma, which was presumed to be the source of the excessive bleeding, was seen. In all cases the vessel was able to be accessed with a needle and polidocanol sclerosant injected. The case in which the sclerosant was injected immediately (30 min) after the injury gave the most dramatic clinical improvement, although the net effect in the other (subacute) cases was considered neutral to helpful. Although it is impossible to know the clinical outcome of these cases without sclerosant usage, the cases do provide a novel medical (non-surgical) acute treatment for massive haematoma. This novel management could certainly be attempted in similar future cases of severe haematoma prior to consideration of acute surgical intervention. 2
http://dx.doi.org/10.1016/j.jsams.2013.10.209
e87
10 Adipose derived stem cell therapies for treatment of musculoskeletal conditions D. Robinson Sydney Sportsmed Specialists, Australia Sydney Sports Medicine Specialists have been using an autologous adipose derived stem cell procedure known as HiQCell for the treatment of musculoskeletal conditions. The half-day procedure, which complies with the Australian TGA’s Biological Framework legislation, is undertaken in a hospital setting and involves harvesting adipose (fat) tissue from a patient’s abdomen, which is then processed to extract a combination of adult mesenchymal stem cells, adipocytes and stromal vascular fraction cells, which are then injected into affected joints or tendons. Adipose tissue provides a rich source of these cell types without the need for culturing and is easily harvested via a minor liposuction procedure. It is thought that the injected cells help to repair and regenerate affected sites by replacing lost or damaged cells, reducing inflammation, improving the function of cells at the site and recruiting cells from other parts of the body to assist in these processes. The HiQCell procedure has been used to treat over 500 joints in approximately 270 patients during the last 18 months; bilateral knee osteoarthritis (OA) being the most common indication. Cell numbers harvested from adipose tissue averaged 36 400 000 and ranged from 1 650 000 to 277 000 000. In patient follow-up data collected to date, HiQCell has achieved a 73% response rate, with an average reduction in pain of 79%. Median VAS pain scores have been observed to decrease from 5.0 at pre-treatment to 1.5 at 6 months post-treatment. All grades of OA across a broad age profile have shown to benefit from the treatment. Since April 2013 an added step in the HiQCell protocol provides the option for patients to cryopreserve (freeze) excess cells from their tissue harvest procedure for future treatment of their musculoskeletal condition. The stored cells are held at a specialist TGA approved facility under liquid nitrogen for an indefinite period of time until required for future injections. Early clinical results indicate that HiQCell is a safe treatment option that bridges the gap in the current OA treatment continuum and offers meaningful clinical benefit for patients. A number of case histories will be presented in support. http://dx.doi.org/10.1016/j.jsams.2013.10.210 11 Reliability of in vivo human Achilles tendon stiffness assessed using acoustoelastography D. Lewis, R. Barrett, M. Ryan ∗ Griffith University, Australia Introduction: Current ultrasound-based sonoelastography methods, such as shear-wave elastography, are constrained to assessing tissue properties under minimal deformation (∼1%). Human tendons, such as the Achilles tendon, undergo relative large deformation (∼8%) during physiological loading, such as with running and jumping. A new post-processing method, acoustoelastography (AE), uses a tissue’s acoustic properties to estimate stiffness under forces resulting in large nonlinear deformation. AE may be particularly well-suited for estimating in vivo tendon biomechanics in humans due to its comparative ease of use (requires only ultrasound) and potential for examining tendon mechanical behavior under high-load conditions. However, AE methodology remains untested in humans; therefore, the purpose
Discussion: Despite widespread acceptance amongst experienced clinicians, the concept of intra-pelvic instability remains controversial in the wider medical community. Indeed, rheumatologists still argue it does not exist. Hence, lack of a validated objective outcome measure for intra-pelvic instability has major impacts on access to treatments for these patients and has made research in the area difficult. While our numbers are small, these early results indicate that we may, finally, have a tool that simply and reliably measures intra-pelvic instability. This early data also indicates that prolotherapy to the pelvic ligaments may correct this instability. http://dx.doi.org/10.1016/j.jsams.2013.10.208 9 Use of ultrasound-guided polidocanol injections (using Colour Doppler) to arrest acute bleeding from intramuscular haematomas J. Orchard 1,2,∗ , L. Cutler 2 , P. Williams 2 , T. Touma 2 , P. Farhart 3 , A. Ibrahim 2 1
University of Sydney, Australia Sydney Roosters RLFC, Australia 3 City Edge Physiotherapy, Australia This series of three cases presents a novel medical intervention for uncontrolled bleeding in traumatic intramuscular haematomas. The vast majority of traumatic haematomas in a sporting setting resolve rapidly and cause minimal missed playing time. However a small minority lead to progressive bleeding which continues after rest and can cause the player to miss many weeks. In the worst scenarios uncontrolled bleeding can lead to acute compartment syndrome for which emergency surgery is the only management. Ultrasound-guided injections of polidocanol in sports medicine have been popularised by Scandinavian researchers for sclerosing of neovessels in chronic tendinopathies. In general medicine the major use of polidocanol is as a sclerosant for varicose veins. The mechanism of action is endothelial damage, causing platelets to accumulate and ligate the vessel. It is recommended for intravenous use only in the lowest possible dose with caution to be used in peripheral locations. In this case series, athletes who had suffered massive haematomas secondary to trauma were examined using Colour Doppler US (Sonosite M Turbo). In all cases a suspected vessel with high flow in the haematoma, which was presumed to be the source of the excessive bleeding, was seen. In all cases the vessel was able to be accessed with a needle and polidocanol sclerosant injected. The case in which the sclerosant was injected immediately (30 min) after the injury gave the most dramatic clinical improvement, although the net effect in the other (subacute) cases was considered neutral to helpful. Although it is impossible to know the clinical outcome of these cases without sclerosant usage, the cases do provide a novel medical (non-surgical) acute treatment for massive haematoma. This novel management could certainly be attempted in similar future cases of severe haematoma prior to consideration of acute surgical intervention. 2
http://dx.doi.org/10.1016/j.jsams.2013.10.209
e87
10 Adipose derived stem cell therapies for treatment of musculoskeletal conditions D. Robinson Sydney Sportsmed Specialists, Australia Sydney Sports Medicine Specialists have been using an autologous adipose derived stem cell procedure known as HiQCell for the treatment of musculoskeletal conditions. The half-day procedure, which complies with the Australian TGA’s Biological Framework legislation, is undertaken in a hospital setting and involves harvesting adipose (fat) tissue from a patient’s abdomen, which is then processed to extract a combination of adult mesenchymal stem cells, adipocytes and stromal vascular fraction cells, which are then injected into affected joints or tendons. Adipose tissue provides a rich source of these cell types without the need for culturing and is easily harvested via a minor liposuction procedure. It is thought that the injected cells help to repair and regenerate affected sites by replacing lost or damaged cells, reducing inflammation, improving the function of cells at the site and recruiting cells from other parts of the body to assist in these processes. The HiQCell procedure has been used to treat over 500 joints in approximately 270 patients during the last 18 months; bilateral knee osteoarthritis (OA) being the most common indication. Cell numbers harvested from adipose tissue averaged 36 400 000 and ranged from 1 650 000 to 277 000 000. In patient follow-up data collected to date, HiQCell has achieved a 73% response rate, with an average reduction in pain of 79%. Median VAS pain scores have been observed to decrease from 5.0 at pre-treatment to 1.5 at 6 months post-treatment. All grades of OA across a broad age profile have shown to benefit from the treatment. Since April 2013 an added step in the HiQCell protocol provides the option for patients to cryopreserve (freeze) excess cells from their tissue harvest procedure for future treatment of their musculoskeletal condition. The stored cells are held at a specialist TGA approved facility under liquid nitrogen for an indefinite period of time until required for future injections. Early clinical results indicate that HiQCell is a safe treatment option that bridges the gap in the current OA treatment continuum and offers meaningful clinical benefit for patients. A number of case histories will be presented in support. http://dx.doi.org/10.1016/j.jsams.2013.10.210 11 Reliability of in vivo human Achilles tendon stiffness assessed using acoustoelastography D. Lewis, R. Barrett, M. Ryan ∗ Griffith University, Australia Introduction: Current ultrasound-based sonoelastography methods, such as shear-wave elastography, are constrained to assessing tissue properties under minimal deformation (∼1%). Human tendons, such as the Achilles tendon, undergo relative large deformation (∼8%) during physiological loading, such as with running and jumping. A new post-processing method, acoustoelastography (AE), uses a tissue’s acoustic properties to estimate stiffness under forces resulting in large nonlinear deformation. AE may be particularly well-suited for estimating in vivo tendon biomechanics in humans due to its comparative ease of use (requires only ultrasound) and potential for examining tendon mechanical behavior under high-load conditions. However, AE methodology remains untested in humans; therefore, the purpose