Service Line Roll-out Process - IAME - Home · PRP has several defined effects on human tissues Increased growth factors ... Adivive Lipokit Bone Marrow Derived Culture Expanded “Same

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CENTER FOR

REGENERATIVE MEDICINE

Shane A. Shapiro MD Mayo Clinic Florida Fellow American Academy of Regenerative Medicine @ShaneShapiroMD

Orthopedic Sports and Regenerative Medicine

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Center for REGENERATIVE MEDICINE ©2012

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Disclosure

No relevant financial relationships exist

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Center for REGENERATIVE MEDICINE

The Fountain of Youth, Lucas Cranach the Elder 1472-1553

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Regenerative Medicine in Orthopedics and Sports Medicine

Repair damaged tissue

Prevent further progression

Early work with PRP (platelet rich plasma)

Progressing to stem cells

Create a regenerative environment

Tissue engineering

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The Problem . . .

Osteoarthritis or Degenerative Joint Disease

Aging population

Obesity epidemic

400,000 procedures in 2014

Costing > $7 Billion

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Current Treatment Options for DJD

Recommendations:

NWB Exercise/Phys Therapy

Gentle pain relievers

Occasional steroid injections

Not Recommended:

Glucosamine and Chondroiton

Hyaluronic acid injections

Accupuncture

Iontophoresis/Therapeutic ultrasound

Arthroscopy

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Orthopedic Regenerative Medicine? How Did We Get Here?

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What is PRP?

Autologous blood derived product

Concentrated platelets 2-6x above normal

Growth Factor cascade

Initiates and regulates all phases of the healing cycle

Origins in 1990’s Maxillofacial and Plastic

Surgery applications

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Platelet Rich Plasma

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PRP for Musculoskeletal Pathology

Needle based application

With or w/o tenotomy

Delivered at site of injury via injection

Often applied in a matrix, or scaffold surgically

Called Platelet Rich Fibrin Matrix

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PRP Injection

Venous blood

Centrifuge to 3 parts

Red blood cells

Plasma

Platelet rich cells

Concentrated healing cells re-injected into area of injury

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PRP for Musculoskeletal Pathology

Multiple PRP Systems on the market

FDA approval for concentrating autologous blood

510 (k) equivalent device

3 Types (mechanisms)

Leukocyte and Platelet Rich (Buffy Coat)

5-9x concentration

Variable Manipulation

Can reduce concentrations as desired

Leukocyte Poor and Low Platelet (Plasma Based)

1.5-3x concentration

Castillo, AJSM, 2011

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Application

PRP can be applied activated or inactivated forms

If applied inactivated, growth factor cascade is initiated by contact with target tissue

Activation via thrombin or calcium chloride

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Growth Factor Cascade

Transforming Growth Factor Beta (TGF-B)

Vascular Endothelial Growth Factor (VEGF)

Platelet Derived Growth Factor (PDGF)

Epidermal Growth Factor (EGF)

Fibroblast Growth Factor – 2 (FGF-2)

Insulin-Like Growth Factor (IGF)

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In Vitro

PRP mixed with chondrocytes demonstrated increased release of growth factors needed for cartilage regeneration

Improves in vitro formation of cartilage

Can induce production of osteogenic cells in vitro

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Clinical Trials

Lateral Epicondylitis

First, and still best evidence of clinical efficacy for PRP

Mishra 2006

Peerbooms 2010

Mishra 2014

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Achilles Tendinosis

deVos – JAMA, 2010

Level I design, but subjects were all physical therapy naïve

Source of many insurance denials

Monto – FAI, 2012

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Plantar Fascitis

Monto – FAI, 2014

Good for pain relief

Few attempts to replicate

Jain – The Foot, 2015

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doi:10.1177/1071100713519778Foot & Ankle International January 13, 2014 1071100713519778

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Jumper’s Knee

Liddle – AJSM, 2015

Systematic Review Non-comparative trials

demonstrate improvement

2 RCTs equivocal

More RCTs needed

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Cartilage Regeneration Studies

PRP significantly improves cartilage healing after microfracture

Stiffness closer to normal cartilage with PRP

Still did not produce hyaline cartilage

PRP as a gel rather than liquid demonstrated greater efficacy

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Degenerative Joint Disease

PRP may be a stem cell recruiter

Improves friction coefficient (it’s a lubricant)

Initial clinical trials promising for pain relief synthesis of hyaluron by synoviocytes

TNF alpha

Some recent studies show no superiority to HA Injections, while Meta-Analysis is beneficial

Disease severity stratification may be required to further clarify.

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Not all studies are positive

PRP to enhance an OCD regenerative process with a hydroxyapatite scaffold had a negative effect on the regenerative process

Sheth et. al. Efficacy of Autologous Platelet Rich Plasma Use for Orthopaedic Indications: A Meta Analysis. J Bone Joint Surg Am. 2012;94:298-307.

Filardo – Am J Sports Med, 2015

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Summary

PRP has several defined effects on human tissues Increased growth factors (PDGF and TGF) both

locally and in circulation

Increased vascularization (VEGF Mediated)

Increased tenocyte proliferation (via gene upregulation)

Increased COL3-COL1 ratio

These in vivo and in vitro findings have yet to be confirmed as clinically relevant in large scale Level 1 trials

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From PRP to BMAC

Bone Marrow Aspiration and Concentration

Similar to PRP, generated by density-gradient centrifugation

Marrow cells secrete growth factors, cytokines, chemokines

MSCs contained in marrow have regenerative, anti-inflammatory and immunomodulatory properties

HSC may play additional regenerative signaling role

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Stem Cell Use in Sports Medicine

“We have had one big revelation in sports medicine over the last 50 years, and that was the arthroscope. I’ve been looking for the next wave, and stem-cell therapy . . . will be it.”

Dr. James Andrews

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Stem Cell Use in Sports Medicine

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Stem Cell Clinics

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600 United States Stem Cell Clinics

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http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj9-_6OluLQAhWH6YMKHbwGAOgQjRwIBw&url=http://regenorthoclinic.com/prp-injections-for-knee-arthritis/&psig=AFQjCNEcfuMuVn-ESurJO1T2d3pvy-z8Qg&ust=1481203208135187

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Stem Cell Basic Science

Friedenstein et al. 1966 Stem Cells in Bone Marrow

Caplan et al. 1970 Tri-lineage potential = MSC

MSC also in adipose, umbilical cord, synovial tissues, etc.

Evolving understanding of the MSC’s role in tissue regeneration

Renewed interest in the HSC for regeneration of non-hematopoietic tissues

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Regenerative Medicine Vocabulary

MSC – Mesenchymal Stem Cell ADSC – Adipose Derived Stem Cell

BMSC – Bone Marrow Derived Stem Cell

HSC – Hematopoietic Stem Cell

IPSCS – Induced Pluripotent

BMAC – Bone Marrow Aspirate Concentrate

SVF – Stromal Vascular Fraction

dHACM – Dehydrated Amnion Chorion Membrane

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BMAC – Earliest access to MSC

Multiple systems

Density Gradient Centrifugation

Low MSC numbers

Marrow quality variable

Moderately Invasive

361 covered***

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Bone Marrow Aspiration and Concentration (BMAC)

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Bone Marrow Early Data

Hernigou – 2005

Hip AVN

Buda – 2010

Knee OCDs

Divatchi- 2011

Knee OA

Jo – 2014

Vansgness - 2014

Meniscus (allogeneic)

Kim - 2014

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BMAC Systematic Review – OJSM 2016

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BMAC Systematic Review – OJSM 2016

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Stem Cells and Arthritis Clinical Trials

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Randomized Blinded Placebo Control Trial

Bilateral Knee DJD

Compared to Saline

One knee gets Saline

One knee gets BMAC

Pre and Post Injection MRI

Full product cellular characterization with flow cytometry

FDA IND 15352

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BMAC Cellular Characterization Variable N Summary

Pre-spin measures

Viability % 24 97.75 (75.2, 99.4)

Mononuclear cells % 25 38.5 (26.0, 57.5)

Total mononuclear cells/ul 25 6100 (1950, 27000)

HSC % 25 3.2 (0.04, 21)

MSC % 25 0.03 (0.00, 0.60)

Total mononuclear cells X MSC % 25 198 (0, 2673)

WBC (1000/ul) 25 13 (3.9, 62.8)

RBC (Mil/ul) 25 3.33 (0.17, 4.44)

HCT % 25 32.0 (1.6, 38.2)

Platelet (1000/ul) 25 95 (7, 399)

Post-spin measures

Viability % 22 97.0 (85.4, 99.6)

Mononuclear cells % 23 56.2 (25.8, 87.9)

Total mononuclear cells/ul 23 16000 (2900, 210000)

HSC % 23 4.4 (1.2, 14)

MSC % 23 0.05 (0, 0.9)

total mononuclear cells X MSC % 23 688 (8.7, 28980)

WBC (1000/ul) 23 31.4 (5.6, 97.2)

RBC (Mil/ul) 23 0.96 (0.63, 3.65)

HCT % 23 8.5 (3.5, 34.0)

Platelet (1000/ul) 22 422 (52, 1515)

Total HSCs injected 23 4620000 (174000, 130200000)

Total MSCs injected 23 34400 (435, 1449000)

The median (minimum, maximum) is given for continuous variables.

HCT: hematocrit; HSC: hematopoietic stem cell; MSC: mesenchymal stem cell; RBC: red blood cell; WBC: white blood cell.

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Randomized Blinded Placebo Control Trial

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Quantitative T2 MRI Cartilage Mapping

Siemens Leonardo workstation

T2 Mapping

Medial Femoral Condyle

Lateral Femoral Condyle

Medial Tibial Plateau

Lateral Tibial Plateau

Patella

No statistically significant differences

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What is a stem Cell?

Building blocks of tissue?

or Master Messengers?

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Old School Thinking

MSC – Tri-lineage potential

Stem Cell Chondrocyte Hyaline

Cartilage

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Elastic Cartilage

Fibro- Cartilage

Hypertrophied

Chondrocyte

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Pericyte Pathway

Trophic, immunomodulatory, paracrine mechanisms

MSC are pericytes

PDGF releases MSC from the basement membrane

HSCs respond to injury in much the same way as MSC

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Is fat better?

Adipose more abundant

Easier, friendlier to harvest than bone marrow

Enzymatic separation of cells from fat currently banned according to the FDA

Use may require BLA

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Adipose Derived Stem Cell Studies

Koh – 2012 Infrapatellar Fat Pad Source

Kim – AJSM, 2015

Fibrin Glue Scaffold

Garza – Journal of Regenerative Medicine, 2015

Koh – Journal of Arthroscopic Related Surgery, 2016

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Fat Derived Stem Cells

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MSC Culture Expansion

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Stem Cells from any source

Grown in specialized medium (with inductive capacity)

Generating high numbers of MSCs

Takes several weeks Costly

Highly technical

Subject to GMP regs

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Amniotic Derived Products

Human progenitor cell “recruiter” Growth factors in amniotic tissue

PDGF, VEGF, EGF, FGF and TGF-B

Amniotic tissues are immune-privileged

rarely evoke an immune response

Interleukin-1 receptor antagonists (IL-1RA) Tissue Inhibitor of Metalloproteinase (TIMP)

Suppress and modulate inflammation and pain

May be “easier” to use than MSC

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Arteriocyte

Arthrex Angel

Biomet Marrowstim

Harvest SmartPrep

Currently unavailable in US

FDA v Regenerative Sciences

Stem Cell Tourism

Cayman, Asia, Carribean, Latin Am

Cytori

Keia Kiso

Lipogems

Adivive Lipokit

Bone Marrow Derived

Culture Expanded “Same Day”

Concentrated (BMAC)

“Same Day” - Enzyme or

Mechanically Prepared

Adipose Derived

Amniofix, AmnioGen

Bio-D, NeoxFlo

AmnioClear

AmnioPro, AmnioMatrix

Amniotic Products

“Stem Like”

SC Signaling Growth Factors

Minimal MSC

Many HSC

Venous Derived?

PRP?

Allogeneic

Osiris

Umbilical Cord Blood

Cartistem

Tissue Gene C

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Stem Cell Regulation

CFR Code of Federal Regulations

Human cells, tissues, and cellular and tissue-based products (HCT/Ps) are defined in 21 CFR 1271 Requires minimal manipulation and Homologous

Use (361)

FDA’s Center for Biologics Evaluation and Research (CBER)

Approved Biologics License Application (BLA) Required in order to lawfully market a drug that is

also a biological product (351)

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FDA Draft Guidances

Recommendations for applying Title 21 of the Code of Federal Regulations (CFR) Part 1271 Minimal Manipulation – Dec 2014

Homologous Use - Oct 2015

Same Day Surgical Exception – Oct 2014

HCT/Ps from Adipose Tissue – Dec 2014

Guidance, when finalized, will improve understanding of the definitions in 21 CFR and how to apply the regulatory criterion to HCT/Ps.

Public Hearing – Silver Spring, MD

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Manimal Manipulation

Minimal manipulation means:

Processing that does not alter the original structural characteristics of the tissue

Processing that does not alter the relevant biological characteristics of cells or tissues

Not combined with another substance

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Homologous Use

“Recipient cells or tissues that are identical (e.g., skin for skin) to the donor cells or tissues”

“Recipient tissues that perform one or more of the same basic functions in the recipient as the cells or tissues performed in the donor”

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What should we do?

Define our cellular therapies

Effort to conduct and recognize the value of well designed studies.

Work with industry and regulatory agencies, not against

Recognize best practices Understand what we can do and what we cannot

Think of the needs of the patients

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Definitions of a Stem Cell

International Society for Cellular Therapy Standardized definition

FDA has commented as well

Currently no FDA approved BLAs for MSC products

Lack of consistency in definitions of MSC

CD73+, CD90+, CD105+,

CD11b-, CD34-, CD45-, HLA-DR-

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The Future of Human Cell Therapy

21st Century Cures Act Passes House of Representatives

in December ‘16

Easier Access to “Stem Cell Therapy”

Questions re: Patient Safety

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Stem Cells and Arthritis Clinical Trials

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Randomized Controlled Trials

Autologous Same Day SVF - Mayo Florida

FDA IND

Generate higher numbers of MSCs

Follow patient pain

Pre and Post MRI

Study synovial fluid

Autologous Culture Expanded - Mayo Rochester

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FDA IND

150 million AMSCs

Pre and Post Arthroscopy

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Regenerative Medicine Consult Service

The Mayo Clinic Center for Regenerative Medicine is embedded in all three sites and across all three shields.

Regenerative Medicine Clinic in Florida will enhance opportunities to engage patients in clinical studies and potential therapies Orthopedics

Dermatology

Plastic Surgery

Neurology

Gastroenterology

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Regenerative Medicine Procedure Suites

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Stem Cell Therapy Bill of Rights

1. There is no board certification in Cell Therapy. It is best to get it from a physician specialist in the disease you have who also has expertise in regenerative medicine. 2. Exhaust all conventional therapies first. 3. For clinical trials, IRB is the gold stamp of approval and you should ask for the minutes to demonstrate that it is IRB approved. 4. If you get a non-compliant trial you are paying to be a research subject in a for profit experiment. If “it is a proven treatment” ask what the actual data are. Good clinical trials should be able to provide this. 5. An FDA approved therapy or device will likely be able to be billed to medical insurance. An FDA allowed therapy may not be billed depending on whether or not your insurance considers it experimental. Many studies pay for the cost of the treatment. 6. There are no guarantees. What is the success rate, how do they measure it and more importantly what is their complication rate? Have they tracked complications? If so, for how long? What exactly are they giving you? 7. There are many sites that patients can utilize to gather more information. These include the FDA website, the NIH website, International Society for Stem Cell Research (ISSCR) and the site to look at current clinical trials in the world; Clinical Trials.gov. 8. Take extra care if offered cells grown in the lab. Cells are not perfect copy machines. When cells divide they are not twins and stem cells can intentionally undergo asymmetric division. Ask how the clinic validates that the cells grown after amplification are the same as at the beginning. How do you know it is safe? 9. What are the possible side effects? How many patients have been treated? How long have they been followed? 10. Who owns the cells after they are taken from you. Are they going to be commercialized if there are any cells left over?

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Education Building a Regenerative Medicine Workforce

Mayo Medical School ► Reg Medicine Selective Curriculum integration

Mayo Graduate School ► Regenerative Medicine Graduate Course

► Regenerative Sciences Training Program

Mayo School of Graduate Medical Education

► Target career development of residents/fellows

► Mayo Foundation Scholars

Mayo School of Health Sciences ► Support for scholarship, training and education

Mayo School of Continuous Professional Development

► Sponsorship of regenerative medicine symposia

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Stem Cell References Minimal Manipulation of Human Cells, Tissues, and Cellular and Tissue-Based Products: Draft Guidance for

Industry and Food and Drug Administration Staff. FDA. Available at: http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/CellularandGeneTherapy/UCM427746.pdf. Accessed November 4, 2015.

Homologous Use of Human Cells, Tissues, and Cellular and Tissue-Based Products: Draft Guidance for Industry and FDA Staff. FDA. Available at: http://www.fda.gov/downloads/biologicsbloodvaccines/guidancecomplianceregulatoryinformation/guidances/tissue/ucm469751.pdf. Accessed November 4, 2015.

Antonioli E, Piccinato CA, Nader HB, Cohen M, Goldberg AC, Ferretti M. Modulation of Hyaluronan Synthesis by the Interaction between Mesenchymal Stem Cells and Osteoarthritic Chondrocytes. Stem cells international. 2015;2015:640218.

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Bannuru RR, Schmid CH, Kent DM, Vaysbrot EE, Wong JB, McAlindon TE. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis. Annals of internal medicine. 2015;162(1):46-54.

Bond M, Davis A, Lohmander S, Hawker G. Responsiveness of the OARSI-OMERACT osteoarthritis pain and function measures. Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society. 2012;20(6):541-547.

Buda R, Vannini F, Cavallo M, Grigolo B, Cenacchi A, Giannini S. Osteochondral lesions of the knee: a new one-step repair technique with bone-marrow-derived cells. The Journal of bone and joint surgery. American volume. 2010;92 Suppl 2:2-11.

Caplan AI. Adult mesenchymal stem cells for tissue engineering versus regenerative medicine. Journal of cellular physiology. 2007;213(2):341-347.

Caplan AI, Correa D. The MSC: an injury drugstore. Cell stem cell. 2011;9(1):11-15.

Chen FH, Tuan RS. Mesenchymal stem cells in arthritic diseases. Arthritis research & therapy. 2008;10(5):223.

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Cheng NC, Estes BT, Awad HA, Guilak F. Chondrogenic differentiation of adipose-derived adult stem cells by a porous scaffold derived from native articular cartilage extracellular matrix. Tissue engineering. Part A. 2009;15(2):231-241.

Chu CR. The Challenge and the Promise of Bone Marrow Cells for Human Cartilage Repair. Cartilage. 2015;6(Suppl 2):36S-45S.

Coleman CM, Curtin C, Barry FP, O'Flatharta C, Murphy JM. Mesenchymal stem cells and osteoarthritis: remedy or accomplice? Human gene therapy. 2010;21(10):1239-1250.

Davatchi F, Abdollahi BS, Mohyeddin M, Shahram F, Nikbin B. Mesenchymal stem cell therapy for knee osteoarthritis. Preliminary report of four patients. International journal of rheumatic diseases. 2011;14(2):211-215.

Eseonu OI, De Bari C. Homing of mesenchymal stem cells: mechanistic or stochastic? Implications for targeted delivery in arthritis. Rheumatology. 2015;54(2):210-218..

Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. The American journal of sports medicine. 2009;37(11):2259-2272.

Gormeli G, Gormeli CA, Ataoglu B, Colak C, Aslanturk O, Ertem K. Multiple PRP injections are more effective than single injections and hyaluronic acid in knees with early osteoarthritis: a randomized, double-blind, placebo-controlled trial. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2015.

Ham O, Lee CY, Kim R, et al. Therapeutic Potential of Differentiated Mesenchymal Stem Cells for Treatment of Osteoarthritis. International journal of molecular sciences. 2015;16(7):14961-14978.

Hegde V, Shonuga O, Ellis S, et al. A prospective comparison of 3 approved systems for autologous bone marrow concentration demonstrated nonequivalency in progenitor cell number and concentration. Journal of orthopaedic trauma. 2014;28(10):591-598.

Jo CH, Lee YG, Shin WH, et al. Intra-articular injection of mesenchymal stem cells for the treatment of osteoarthritis of the knee: a proof-of-concept clinical trial. Stem cells. 2014;32(5):1254-1266.

Kim JD, Lee GW, Jung GH, et al. Clinical outcome of autologous bone marrow aspirates concentrate (BMAC) injection in degenerative arthritis of the knee. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie. 2014;24(8):1505-1511

Kim YS, Choi YJ, Koh YG. Mesenchymal Stem Cell Implantation in Knee Osteoarthritis: An Assessment of the Factors Influencing Clinical Outcomes. The American journal of sports medicine. 2015;43(9):2293-2301.

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Kim YS, Choi YJ, Lee SW, et al. Assessment of clinical and MRI outcomes after mesenchymal stem cell implantation in patients with knee osteoarthritis: a prospective study. Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society. 2015.

Kim YS, Choi YJ, Suh DS, et al. Mesenchymal stem cell implantation in osteoarthritic knees: is fibrin glue effective as a scaffold? The American journal of sports medicine. 2015;43(1):176-185.

Kim YS, Kwon OR, Choi YJ, Suh DS, Heo DB, Koh YG. Comparative Matched-Pair Analysis of the Injection Versus Implantation of Mesenchymal Stem Cells for Knee Osteoarthritis. The American journal of sports medicine. 2015.

Koh YG, Choi YJ, Kwon SK, Kim YS, Yeo JE. Clinical results and second-look arthroscopic findings after treatment with adipose-derived stem cells for knee osteoarthritis. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2015;23(5):1308-1316.

Koh YG, Jo SB, Kwon OR, et al. Mesenchymal stem cell injections improve symptoms of knee osteoarthritis. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2013;29(4):748-755.

Kon E, Filardo G, Drobnic M, et al. Non-surgical management of early knee osteoarthritis. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2012;20(3):436-449.

Kuroda K, Kabata T, Hayashi K, et al. The paracrine effect of adipose-derived stem cells inhibits osteoarthritis progression. BMC musculoskeletal disorders. 2015;16(1):236.

Kuroda R, Ishida K, Matsumoto T, et al. Treatment of a full-thickness articular cartilage defect in the femoral condyle of an athlete with autologous bone-marrow stromal cells. Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society. 2007;15(2):226-231.

Lee AS, Ellman MB, Yan D, et al. A current review of molecular mechanisms regarding osteoarthritis and pain. Gene. 2013;527(2):440-447.

Orozco L, Munar A, Soler R, et al. Treatment of knee osteoarthritis with autologous mesenchymal stem cells: a pilot study. Transplantation. 2013;95(12):1535-1541.

Orozco L, Munar A, Soler R, et al. Treatment of knee osteoarthritis with autologous mesenchymal stem cells: two-year follow-up results. Transplantation. 2014;97(11):e66-68.

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Mendicino M, Bailey AM, Wonnacott K, Puri RK, Bauer SR. MSC-based product characterization for clinical trials: an FDA perspective. Cell stem cell. 2014;14(2):141-145.

Sampson S, Botto-van Bemden A, Aufiero D. Autologous bone marrow concentrate: review and application of a novel intra-articular orthobiologic for cartilage disease. The Physician and sportsmedicine. 2013;41(3):7-18.

Taylor-Weiner H, Graff Zivin J. Medicine's Wild West--Unlicensed Stem-Cell Clinics in the United States. The New England journal of medicine. 2015;373(11):985-987.

Terzic A, Nelson TJ. Regenerative medicine primer. Mayo Clinic proceedings. 2013;88(7):766-775.

Turner LG. Federal Regulatory Oversight of US Clinics Marketing Adipose-Derived Autologous Stem Cell Interventions: Insights From 3 New FDA Draft Guidance Documents. Mayo Clinic proceedings. 2015;90(5):567-571.

Vangsness CT, Jr., Farr J, 2nd, Boyd J, Dellaero DT, Mills CR, LeRoux-Williams M. Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial meniscectomy: a randomized, double-blind, controlled study. The Journal of bone and joint surgery. American volume. 2014;96(2):90-98.

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Wyles CC, Houdek MT, Behfar A, Sierra RJ. Mesenchymal stem cell therapy for osteoarthritis: current perspectives. Stem cells and cloning : advances and applications. 2015;8:117-124.

Zhong W, Sumita Y, Ohba S, et al. In vivo comparison of the bone regeneration capability of human bone marrow concentrates vs. platelet-rich plasma. PloS one. 2012;7(7):e40833.

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Leukocyte rich or Leukocyte Poor?

Leukocyte rich injections create inflammatory reponse in rabbit patellar tendon

Horse flexor digitorum superficialis tears result in increased scar with elevated WBC injections

Adverse reactions in human trials not related to leukocyte concentration

Neutrophils may be a catabolic agent

Release catabolic enzymes

Monocytes appear constructive

http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/CellularandGeneTherapy/UCM427746.pdf

http://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/CellularandGeneTherapy/UCM427746.pdf

http://www.fda.gov/downloads/biologicsbloodvaccines/guidancecomplianceregulatoryinformation/guidances/tissue/ucm469751.pdf

http://www.fda.gov/downloads/biologicsbloodvaccines/guidancecomplianceregulatoryinformation/guidances/tissue/ucm469751.pdf

3/20/2017

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Activated vs. non-Activated

Activation releases GF

90%GF released in 10 minutes

Wounds treated with PRP vs. thrombin activated PRP showed 90% closure at 15 days vs. 26 days

Unactivated PRP treated wounds had 2x higher levels of myofibroblasts and angiogenesis

FDA requirements for use of biologic/cellular therapies: HCT/Ps 21 CFR1271.3(f)]

?Considered minimal manipulation - FDA.gov

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PRP Classification

Type Leukocytes Activation

Type 1 Increased No

Type 2 Increased Yes

Type 3 Minimal No

Type 4 Minimal Yes

A >5x Plts

B <5x Plts

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