Another minimally-invasive treatment that’s available for osteoarthritis is adipose tissue therapy or micro-fragmented fat injections. But what are they? How do they work? Are they effective?
Here to answer these questions, and more, is leading consultant orthopaedic surgeon Professor Adrian Wilson.
What is the benefit of giving someone an injection of micro-fragmented fats?
We’ve known of the benefits of using adipose tissue for a long time. In fact, it was plastic surgeons that first took note of fat when they grafted for certain areas of damage and defect with cosmetic surgery. If you filled it with a fat graft, they noticed the skin had a rejuvenated appearance that seemed to do something positive for the skin. From that, over the last 20 years, we’ve learnt a lot about the cells within the fat that are very important for healing, regeneration and for improving problems such as osteoarthritis.
Can you be more specific about what cells within the fat that are actually doing any good?
Within the fat are stem cells; they are called pericytes and those pericytes are pre-stem cells and they become active stem cells once they undergo a certain type of reaction which is caused by, for instance taking them from the body and then injecting them. That will activate the pericytes. You’ve got two different types of stem cells.
In terms of treatment; you’ve got pure stem-cell treatment where we take those fat cells, those pericytes, and we expand those in a laboratory over a two or three-week period, then inject those intravenously or into the joints. Or we can use what’s called minimally-invasive stem cells which is using fat, filtering it, fragmenting it and washing it. It’s that filtered and fragmented fat that has a very good effect in terms of managing pain, swelling and trauma from surgery or from injury, or indeed from the ageing process and osteoarthritis.
Is adipose tissue therapy for everyone?
Fat and stem cells from fat can be used for anyone. The advantage of fat in the adult population is that, in individuals over the age of say, 40, 50, where they’re getting a bit older, we don’t see the activity falling off in terms of the stem cells. It’s actually maintained. In someone that is 80 or 90, if they’ve broken their leg, they still heal and indeed their fat is still active.
How can it be used in orthopaedics?
The system that we use for micro-fragmented fat is called Lipogems®. There are many different types out there but we like this system because it has some good scientific evidence. In fact, there are now over a hundred peer-reviewed articles supporting the use of micro-fragmented fat with the Lipogems® system. Over 30 of those are in our field of orthopaedics.
To be specific about how we would use it, there are two main ways in which we use this. The main way is to manage the pain of osteoarthritis and the most common joint that we inject is the knee. We’ve treated over 2,000 people at the regenerative clinic with this treatment and 80 per cent of them have had an injection to their knee, and it seems to work extremely well.
That’s based on our results, and we’ve collected a lot of data, and also the results from Hospital for Special Surgery in New York; it’s used at Harvard, it’s used at Duke University and it’s used at multiple high-profile clinics around Europe. Many of them in Europe are now using this treatment. In fact, there’s a lovely study just about to come out at Antwerp University by Professor Peter Verdonk showing significant pain reduction at two years in osteoarthritic knees.
What is the success rate of adipose tissue therapy in orthopaedics?
Most people quote about 80 per cent success in the patients that have this. In terms of the patients that we’re treating, the majority have got at least patches of bare bones, so they’re what we call ‘Grade 4 arthritics’.
A lot of our critics would say, “How does that work?”, “How can you inject someone with bone-on-bone arthritis with an injection of fat, and make their knee feel more comfortable?”. What I say to that is; first of all, there’s good evidence for it so we’re very glad to have that but what the basic explanation is; there is no great correlation between the amount of wear and tear and the amount of pain. So, you could have a very small area of damage in your knee and you can’t walk up and down the stairs, you can’t sleep, you can’t function. You could have a completely globally-destroyed joint and still play tennis and run around with no pain. So just because you’ve got arthritis, doesn’t mean you’re going to have pain.
What the anti-inflammatory injection does, is hundreds of key proteins are released by the fat and the pericyte working with one another like a mobile pharmacy, to use Professor Kaplan’s explanation, that reduce inflammation and pain. That can persist for a very long time. We have patients at three years that are still reporting a high-level of benefit from their injections.
What are the possible risks and side effects?
Fortunately, it’s a very safe procedure. There is a risk of bruising because we normally take the fat from the abdomen, the tummy area. This problem is rare and it normally settles within a day or two. There is a risk from the anaesthetic which is a sedation, as opposed to a general anaesthetic, but of course we’ve made that very safe. There is a risk of introducing infection to any joint we inject, but to our knowledge no one has had a deep infection from the use of Lipogems® in the knee globally. We haven’t seen that in our clinic.
We’ve seen some adverse reactions; people say “Wow, my knee feels worse.” Fortunately, that’s really uncommon and if it does occur, it normally settles really quickly. The biggest risk is it doesn’t do you any good, you feel like it’s been a waste of you time, and you’re a so-called ‘non-responder‘. Of course, that is very disappointing for the patient – and for us – but there is a failure rate of around 20 per cent. If you put that into context, there’s also a failure rate of 20 per cent with a total knee replacement. If that goes wrong, the consequences are much more significant.
Who is an ideal candidate for the adipose tissue procedure?
It’s somebody who has got arthritis. We know it works best in the knee but we also often treat the hip, the shoulder and the thumb. The level of their arthritis can be up to grade four, so it can be completely destroyed and it can be in more than one compartment. In other words, it can be a ‘global disease.’ We would rather get to people earlier, in the earlier phases of arthritis but often people don’t present until it’s gone that far and the camel’s back has finally broken. In terms of age, there’s no age cut-off. We offer this to very elderly people and young people.
On an ‘escalator of treatment‘ before you get to that point where you say “I want to have that procedure”, there are many different things you can try:
- Unloaded bracing for the knee
- Hyaluronic Acid
- Advanced N-Stripe PRP
- Bone marrow aspirate
- Micro-fragmented fats
These are the non-surgical options, plus physiotherapy and lifestyle modifications of course, that anyone can try before they undergo surgery.
Then I say to patients, “In terms of surgery, if you want, we have”:
- Knee joint distraction, which often isn’t discussed with patients who are at the end of the road with their knee;
- Partial knee replacement;
- An osteotomy, which something we are well-known for;
- Then of course, there’s total knee replacement.
Anyone with arthritis has all of those option and the question is ‘At what point do you want to have each intervention?’ If you would like to start with something that’s less invasive, micro-fragmented fat is often a very good option.