There are many ways to successfully treat different joint pains and to get back to an active lifestyle. Cleveland Clinic’s Orthopaedic & Rheumatology Institute is consistently ranked among the top five programs in the nation by U.S. News & World Report, and has a long history of excellence and innovation. With state-of-the-art diagnostics and decades of experience, our physicians and surgeons can evaluate the cause of your joint pain and determine the best treatment for you.
Defining Regenerative Medicine
The use of any substance derived from a living source to treat or prevent disease is often referred to as a “biologic treatment,” since “biologic” comes from the Greek Bios, which means life. Treatments involving the use of cells, plasma or growth factors in orthopaedics are often referred to as orthobiologics. We use the term “regenerative medicine” to refer to the treatments that potentially can repair, replace, or regenerate human cells, tissues or organs to restore or establish normal function. These treatments embrace cellular therapies, including stem cells, growth factors (platelet rich plasma) and scaffolds.
What is Joint Preservation?
“Joint preservation” refers to all types of joint care, but mostly to treatments that avoid the removal and replacement of tissues, for example, joint replacement.
Joint replacement procedures were introduced 60 years ago, and have benefited many millions of people who have experienced progressive pain due to degeneration of tissues in their knees, hips and other joints. Joint replacement has transformed our lives. In fact, in the right patient, it can be one of the most effective and rewarding treatments in all of medicine, relieving pain, restoring function and enabling a return to productive life.
Overall, joint replacement procedures are not to be feared or discounted. However, biomedical science continues to progress. New information is gained daily about stem cells, growth factors and advanced tissue products that may offer hope for improved tissue repair, regeneration and reduced inflammation. When used wisely, these therapies may provide a patient with early stages of joint disease an alternative to joint replacement or sufficient improvement to delay the need for joint replacement for years.
Cleveland Clinic Joint Preservation Center
The Joint Preservation Center is a team of caregivers, physicians, clinical scientists, nurses and therapists who are dedicated to exploring and providing the best possible options to help you avoid surgery.
The Joint Preservation Center is committed to providing clear, honest information and answers to your questions about joint preservation.
For every patient we treat today locally and from all around the world, our goals are the same:
- Reduce pain
- Improve joint function
- Restore productivity
- Restore quality of life
- Avoid or delay joint replacement surgery or any surgery
- Reduce long-term cost to the healthcare system
While traditional therapies are virtually always covered by insurance, most orthobiologic treatments are not. We will offer some orthobiologics without charge, if they are part of a funded clinical trial. However, most patients will need to pay for these treatments. We openly discuss our fees, which are set at very competitive rates.
What Conditions can be Treated through Joint Preservation?
Joint preservation approaches such as orthobiologic therapies can be considered in the treatment of a broad range of conditions that affect tissues in and around joints. In each case, the goal is to repair, augment or regenerate the injured or diseased tissue, and to reduce inflammation that contributes to pain and limits function.
Some of the most common conditions treated with orthobiologics:
Osteoarthritis Also known as degenerative joint disease, this is one of the most common causes of joint pain. It mostly affects cartilage, the hard, smooth and slippery tissue that allows bones to glide over each other in a joint. Healthy cartilage absorbs energy from the shock of weight-bearing activities. However, in osteoarthritis, inflammation in the joint causes cartilage to break down and wear away, allowing bones to rub together and causing pain, swelling and loss of motion in the joint. Osteoarthritis may appear in one or multiple joints in the body.
Osteonecrosis: Also known as avascular necrosis or AVN, osteonecrosis is a condition that results from the temporary or permanent loss of blood supply to a bone. When this happens, the bone tissue dies and may collapse. If osteonecrosis involves bones near a joint, it can lead to collapse of the joint surface. Patients often develop gradual pain.
Tendinitis and tendon tears: A tendon is a flexible band of tissue that connects muscles to bones. There are many types of tendons, which can be small (e.g., hand or ankle) or large (e.g., patellar tendon in the knee or Achilles tendon in the heel). Tendons transfer the force produced by the muscles to the bone and help generate movement. When people overuse a joint, do a repetitive activity (e.g., musicians or athletes), or have an injury, the tendons may swell and become inflamed, a condition known as tendinitis. If the tendon is damaged and there is a rupture it is known as tendon tear, which could be partial or complete.
Scars and restrictions: Multiple injuries, trauma or performing the same kind of activity over long periods of time increases stress on tendons. Tendons become less flexible and more prone to damage. When this happens, the structure of the tendon is altered, resulting in scars and contractures. This can also happens with age.
Orthobiologic Therapies at the Cleveland Clinic Joint Preservation Center
The Joint Preservation Center defines biological therapies as those therapies that have the potential to go beyond traditional approaches to repair, augment, restore or regenerate injured or diseased tissues.
Orthobiologic therapies may involve the use of new medications or materials derived from tissues.
Increasingly, orthobiologic therapies may involve the collection, processing and transplantation of actual cells. Most often, these cells are collected from the patient’s own bone marrow, fat or blood. All of these therapies are “minimally invasive,” meaning the therapy is accomplished using injections and not surgery.
However, it is important to understand that not all methods advertised or described on the internet are high quality. In fact, many are not appropriate in our opinion. Our Joint Preservation Center carefully screens all available therapies. Those with the greatest evidence of both safety and potential efficacy are incorporated into our portfolio of treatments under active assessment. Treatments within the Joint Preservation Center include:
- Bone marrow concentrate
- Platelet-rich plasma
- Platelet-poor plasma
- Platelet lysate
- Amniotic fluid
- Placental tissue
- Hyaluronic acid
- Neuromuscular Electric Stimulation (NMES)
Bone Marrow Concentrate (BMC)
Bone marrow in each of us contains stem and progenitor cells. Under the right conditions, these will divide and give rise to daughter cells, which have the capacity to generate new tissues. This includes blood, bone, cartilage, fat and blood vessels.
In fact, these cells are necessary to maintain the health of the tissues over time, and to respond to injury.
Bone marrow may be aspirated with a needle from the pelvis. The vast majority of cells in bone marrow are blood-forming cells. However, a small number of cells in bone marrow are referred to as “connective tissue progenitors” or CTPs. CTPs can make bone, cartilage, fat and other fibrous tissues that are important for joint function.
CTPs and other cells in bone marrow can be concentrated by several methods and then injected into sites of diseased or damaged tissue. When injected, CTPs may contribute to new tissue formation. They may also release proteins known as growth factors or cytokines. These growth factors and cytokines may also act on cells that are already in the diseased or damaged tissue to improve their function. Cytokines can both increase or decrease inflammation.
Bone marrow processing methods vary widely. The method of aspiration and processing has a large effect on the number and the quality of the cells as well as the CTPs that are available for use.
The injection of hyaluronic acid (also known as HA, hyaluronan, or “gel injection”) is performed in the office in less than five minutes. In some ways, HA is a traditional therapy, as these injections have been used for over 20 years for treatment of osteoarthritis of the knee. The mechanism of action of this treatment was thought to be only of joint lubrication. However, research has suggested that HA may also have an anti-inflammatory and analgesic effect, as well as having potentially cartilage protective properties.
HA has been proven to be safe. In general, HA is felt to be more effective in younger patients with less severe disease. However, even with a long history of research and clinical use, the effects of HA have been inconsistent. Despite this, many patients have reported substantial pain improvement, sometimes for years. Then again, others do not respond at all. Ongoing research is focused on better prediction of which patients are likely to respond and which patients are not.
Platelet Rich Plasma (PRP)
Platelets, a type of cell present in blood and marrow, can be used as a form of biological therapy. Platelets are much smaller than most cells. In fact, they are formed by the fragmentation of a much larger cell called a megakaryocyte, so platelets themselves do not have a cell nucleus.
The primary purpose of platelets is to induce blood to clot at a site of injury. When platelets are activated, they break open to release granules that contain a rich mixture of growth factors and cytokines. In addition to inducing clotting that controls bleeding, these factors can also stimulate healing and improve repair.
Platelet-rich plasma (PRP) can be prepared using a patient's own blood. A centrifuge is used to concentrate the platelets and to remove red blood cells and white blood cells (also known as leukocytes). Platelets initially remain suspended in the serum or “plasma” component of the blood. However, by spinning at a faster speed they can be concentrated for use in an injection. This is called “PRP.”
Platelet Poor Plasma (PPP)
A patient’s blood can also be used to create platelet-poor plasma (PPP) or a platelet lysate (PL).
Like PRP, PPP is made using a centrifuge, except that the platelets are removed PPP only contains the serum component of the blood. Serum contains many biologically active ingredients in the form of proteins, growth factors and cytokines.
If platelets are stimulated to release their granules before they are removed from the preparation, it is referred to as a platelet lysate (PL). This adds the content of the platelets to content of the serum, increasing the concentration of many growth factors and cytokines.
One problem with PPP and PL is that every preparation in every patient is different. No two preparations are the same. Understanding the composition of these therapies would require measuring hundreds of different factors. This variation limits our understanding of when and how these therapies may succeed and fail.
Preparations from Amniotic Fluid or Placental Tissue Matrix
A large number of products are now sold that are composed of amniotic and placental tissue matrix injections. The enthusiasm for these products stems from the high concentrations of growth factors and cytokines they contain and the belief that they might be helpful in tissue repair or regeneration.
As human babies form in the uterus of their mothers, they are surrounded by tissue that is grown by the fetus, called the amniotic membrane. This membrane has two layers, the amnion and the chorion. Each layer is very thin and contains cells, growth factors and cytokines.
Several companies are now collecting and processing the amniotic fluid or amnion and the chorion tissues from the placenta, with approval of the parents. These are then processed using sterile methods to remove all of the cells, but preserve the proteins, growth factors, collagen and hyaluronic acid elements that might have a therapeutic effect.
These materials thus far appear to be safe. However, their ability to provide predictable and lasting improvement in the treatment of common causes of knee pain has not yet been definitively established. Nor has the best method for processing or delivery of these materials been determined.
Neuromuscular Electric Stimulation (NMES)
Transcutaneous electrical nerve stimulation (TENS) uses a low-voltage electrical current to stimulate nerves in order to produce pain relief. This therapy uses a small, battery-powered machine that is connected to electrodes (wires that conduct electrical current) from the machine to the skin. The electrodes are often placed on the area of pain (e.g., around the knee), creating a circuit of electrical impulses that travels along nerve fibers. The electrical current generates a sensation that is thought to block the pain signal from the nerve to where it is perceived in the brain as pain.
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Research & Outcomes
The Joint Preservation Center is built upon a fundamental partnership with our patients. This partnership is based on a core of founding principles:
- Cleveland Clinic is a national and international leader in regenerative therapies for arthritis, musculoskeletal and rheumatic disease.
- We integrate medical advances in stem cell biology and orthobiologics into new, safe and effective precisely targeted therapies.
- We provide access and education to patients who may benefit from new promising therapies.
Quality and Research
- We measure outcomes (pain and function) of every patient before and after treatment to determine the success or failure of every treatment.
- We implement rigorous and systematic measurements of all orthobiologic treatments we deliver, eliminating ineffective approaches and concentrating on increasingly effective therapies.
- We collaborate with other centers and industry partners to advance the needs of patients and to train the next generation of innovators and caregivers.
- We are committed to advancing the field of musculoskeletal regenerative medicine – worldwide.
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For Medical Professionals
Referring a Patient
Cleveland Clinic welcomes the opportunity to partner with you in caring for your patients. Our dedicated Referring Physician team is available around-the-clock and committed to serving you and your patients.
To refer a patient to the Joint Preservation Center please contact our Medical Professionals Referral Line at 216.444.5338.