current topics in sports medicine - university of new england · david j cormier, do dpt....
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Your name and credentials
Current Topics In Sports Medicine
Acting Head Team Physician University of New Hampshire
Wentworth Douglass Hospital Sports Medicine
David J Cormier DO DPT
Disclosures
bull No disclosures
Outline
bull Case 1
ndash Tendonopathy
ndash Orthobiologics
bull Case 2
ndash OA
ndash Orthobiologics
Goals Objectives
bull Participants will understand the theory and
interest in orthobiologics
bull Participants will be familiar with different
orthobiologic options
Case 1
bull 40 Year old woman presents with right lateral
hip pain for 2 months Her pain is worse with
walking especially hills She is unable to lay on
her right side at night She denies back pain
bull Exam
bull Limited hip ROM in flexion pain with ER
bull Full ROM Lumbar Spine
bull Intact Myotomes Dermatomes Reflexes
Case 2
bull Femoral internal rotation knee valgus foot
pronation with navicular drop during single leg
squat with contralateral hip drop
bull Weak hip abduction 45
bull Pain to palpation at the Greater trochanter
Diagnosis
Treatment
bull Palpation guided corticosteroid injection
ndash 6 weeks of relief
ndash Pain came back worse
ndash Repeat injection
ndash Pain came back
ndash Repeat for a total of 5 steroid injections
ndash Referred to Sports Medicine
Sports Medicine Clinic
bull Continued lateral hip pain
bull Pain to palpation over the GT
bull Trendelenberg gait ndash worsening
bull Hip Abduction 25
bull We obtained an MRI
MRI
MRI
MRI
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Disclosures
bull No disclosures
Outline
bull Case 1
ndash Tendonopathy
ndash Orthobiologics
bull Case 2
ndash OA
ndash Orthobiologics
Goals Objectives
bull Participants will understand the theory and
interest in orthobiologics
bull Participants will be familiar with different
orthobiologic options
Case 1
bull 40 Year old woman presents with right lateral
hip pain for 2 months Her pain is worse with
walking especially hills She is unable to lay on
her right side at night She denies back pain
bull Exam
bull Limited hip ROM in flexion pain with ER
bull Full ROM Lumbar Spine
bull Intact Myotomes Dermatomes Reflexes
Case 2
bull Femoral internal rotation knee valgus foot
pronation with navicular drop during single leg
squat with contralateral hip drop
bull Weak hip abduction 45
bull Pain to palpation at the Greater trochanter
Diagnosis
Treatment
bull Palpation guided corticosteroid injection
ndash 6 weeks of relief
ndash Pain came back worse
ndash Repeat injection
ndash Pain came back
ndash Repeat for a total of 5 steroid injections
ndash Referred to Sports Medicine
Sports Medicine Clinic
bull Continued lateral hip pain
bull Pain to palpation over the GT
bull Trendelenberg gait ndash worsening
bull Hip Abduction 25
bull We obtained an MRI
MRI
MRI
MRI
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Outline
bull Case 1
ndash Tendonopathy
ndash Orthobiologics
bull Case 2
ndash OA
ndash Orthobiologics
Goals Objectives
bull Participants will understand the theory and
interest in orthobiologics
bull Participants will be familiar with different
orthobiologic options
Case 1
bull 40 Year old woman presents with right lateral
hip pain for 2 months Her pain is worse with
walking especially hills She is unable to lay on
her right side at night She denies back pain
bull Exam
bull Limited hip ROM in flexion pain with ER
bull Full ROM Lumbar Spine
bull Intact Myotomes Dermatomes Reflexes
Case 2
bull Femoral internal rotation knee valgus foot
pronation with navicular drop during single leg
squat with contralateral hip drop
bull Weak hip abduction 45
bull Pain to palpation at the Greater trochanter
Diagnosis
Treatment
bull Palpation guided corticosteroid injection
ndash 6 weeks of relief
ndash Pain came back worse
ndash Repeat injection
ndash Pain came back
ndash Repeat for a total of 5 steroid injections
ndash Referred to Sports Medicine
Sports Medicine Clinic
bull Continued lateral hip pain
bull Pain to palpation over the GT
bull Trendelenberg gait ndash worsening
bull Hip Abduction 25
bull We obtained an MRI
MRI
MRI
MRI
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Goals Objectives
bull Participants will understand the theory and
interest in orthobiologics
bull Participants will be familiar with different
orthobiologic options
Case 1
bull 40 Year old woman presents with right lateral
hip pain for 2 months Her pain is worse with
walking especially hills She is unable to lay on
her right side at night She denies back pain
bull Exam
bull Limited hip ROM in flexion pain with ER
bull Full ROM Lumbar Spine
bull Intact Myotomes Dermatomes Reflexes
Case 2
bull Femoral internal rotation knee valgus foot
pronation with navicular drop during single leg
squat with contralateral hip drop
bull Weak hip abduction 45
bull Pain to palpation at the Greater trochanter
Diagnosis
Treatment
bull Palpation guided corticosteroid injection
ndash 6 weeks of relief
ndash Pain came back worse
ndash Repeat injection
ndash Pain came back
ndash Repeat for a total of 5 steroid injections
ndash Referred to Sports Medicine
Sports Medicine Clinic
bull Continued lateral hip pain
bull Pain to palpation over the GT
bull Trendelenberg gait ndash worsening
bull Hip Abduction 25
bull We obtained an MRI
MRI
MRI
MRI
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Case 1
bull 40 Year old woman presents with right lateral
hip pain for 2 months Her pain is worse with
walking especially hills She is unable to lay on
her right side at night She denies back pain
bull Exam
bull Limited hip ROM in flexion pain with ER
bull Full ROM Lumbar Spine
bull Intact Myotomes Dermatomes Reflexes
Case 2
bull Femoral internal rotation knee valgus foot
pronation with navicular drop during single leg
squat with contralateral hip drop
bull Weak hip abduction 45
bull Pain to palpation at the Greater trochanter
Diagnosis
Treatment
bull Palpation guided corticosteroid injection
ndash 6 weeks of relief
ndash Pain came back worse
ndash Repeat injection
ndash Pain came back
ndash Repeat for a total of 5 steroid injections
ndash Referred to Sports Medicine
Sports Medicine Clinic
bull Continued lateral hip pain
bull Pain to palpation over the GT
bull Trendelenberg gait ndash worsening
bull Hip Abduction 25
bull We obtained an MRI
MRI
MRI
MRI
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Case 2
bull Femoral internal rotation knee valgus foot
pronation with navicular drop during single leg
squat with contralateral hip drop
bull Weak hip abduction 45
bull Pain to palpation at the Greater trochanter
Diagnosis
Treatment
bull Palpation guided corticosteroid injection
ndash 6 weeks of relief
ndash Pain came back worse
ndash Repeat injection
ndash Pain came back
ndash Repeat for a total of 5 steroid injections
ndash Referred to Sports Medicine
Sports Medicine Clinic
bull Continued lateral hip pain
bull Pain to palpation over the GT
bull Trendelenberg gait ndash worsening
bull Hip Abduction 25
bull We obtained an MRI
MRI
MRI
MRI
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Diagnosis
Treatment
bull Palpation guided corticosteroid injection
ndash 6 weeks of relief
ndash Pain came back worse
ndash Repeat injection
ndash Pain came back
ndash Repeat for a total of 5 steroid injections
ndash Referred to Sports Medicine
Sports Medicine Clinic
bull Continued lateral hip pain
bull Pain to palpation over the GT
bull Trendelenberg gait ndash worsening
bull Hip Abduction 25
bull We obtained an MRI
MRI
MRI
MRI
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Treatment
bull Palpation guided corticosteroid injection
ndash 6 weeks of relief
ndash Pain came back worse
ndash Repeat injection
ndash Pain came back
ndash Repeat for a total of 5 steroid injections
ndash Referred to Sports Medicine
Sports Medicine Clinic
bull Continued lateral hip pain
bull Pain to palpation over the GT
bull Trendelenberg gait ndash worsening
bull Hip Abduction 25
bull We obtained an MRI
MRI
MRI
MRI
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Sports Medicine Clinic
bull Continued lateral hip pain
bull Pain to palpation over the GT
bull Trendelenberg gait ndash worsening
bull Hip Abduction 25
bull We obtained an MRI
MRI
MRI
MRI
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
MRI
MRI
MRI
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
MRI
MRI
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
MRI
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
GTPS
bull Schapira et al
ndash observational study
bull 72 patients followed for 2 years
bull 916 of patients diagnosed with symptomatic
trochanteric bursitis had other associated pathology
ndash osteoarthritis of the ipsilateral hip or lumbar spine
Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
GT MRI
bull Bird et al
ndash Retrospective review of MRI findings in 24 women
with greater trochanteric pain syndrome presenting
with lateral hip pain and point tenderness at the
greater trochanter reported
bull 625 had evidence of gluteus medius tendonitis
bull 458 had gluteus medius tears
bull only 2 patients (83) had objective evidence of
trochanteric bursitis
Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
GTPS
bull GTPS
ndash Gluteus medius dysfunction
ndash Gluteus medius or gluteus minimus tendinopathy
ndash Piriformis tendinopathy
ndash Iliotibial tract friction syndrome
ndash Trochanteric bursitis
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
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Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Lateral Hip - GT
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
GTPS
bull Steroid ndash 75 success at 1 month
ndash The effect subsided with timebull 51 at 4 months
bull 48 at 15 months
bull Shockwave Therapyndash No benefit to early pain
ndash 68 at 4 months
ndash 74 at 15 months
bull Home PTndash Ineffective initially
ndash 41 at 4 months
ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Why consider orthobiologics
bull $30 billion spent on MSK injuries in the US1
ndash 45 tendon ligament injuries1
ndash Surgical repairs are often unsuccessful2
bull Majority become chronic2
bull Examples
ndash Rotator Cuff Tendonopathy
bull 16 of general population from PCP data 3
bull 21 when including elderly hospital data 4
ndash 30-50 of all sporting injury involves tendons
1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Why consider orthobiologics
bull Regenerative Medicine Orthobiologics Targets
Muscle
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Why consider orthobiologics
bull Tendonopathy1 Tendonitis
bull Inflammation and pain
2 Tendonosisbull Degeneration
bull Multifactorial process ndash Intrinsic factors
bull Age gender anatomy BMI disease
ndash Extrinsic factorsbull Sports occupation environmental
Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Why consider orthobiologics
bull ldquoTraditionally tendinitis was treated by
controlling inflammation through conventional
methods including corticosteroid and NSAIDs
with no scientific evidence to support these
treatment modalitiesrdquo
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Why consider orthobiologics
bull ldquoCorticosteroid injections may actually have
deleterious effects after their short term pain
relief rdquo
ndash Beneficial short term 6 weeks
ndash No evidence of improved patient outcomes beyond
6 weeks
ndash Those having injections have INFERIOR long term
results compared to placebo wait and see
N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
What has been the
evolution convergence
Image guided regenerative treatment
New treatments veterinary
and surgical
MSK US
Science
Tendon
Joint
Slide Courtesy of Joanne Borg Stein MD
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Tendon Healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Tendon healing
Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Tendon healing
Tissue Normal Injured
Type III Collagen 1 20-30 Superior elasticityinferior strength
Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
PRP
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Platelet Rich Plasma
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
PRP
bull Conversion of a chronic non healing injury into an acute injury with increased healing potential
bull Contains Growth factors
bull Platelet alpha granules
bull Small peptides that bind to membrane receptors
bull promote downstream biologic pathways
bull Influence chemotaxis and cell migration
bull Induce Mitosis
bull Extracellular matrix production
bull Angiogenesis
bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Case 2
bull 50 year old male with medial right knee pain
He has completed 2 prior marathons Currently
competing in triathlons No trauma Pain and
stiffness is present in the AM improves as the
day goes on worse at night Described as an
dull achy sensation
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Case 2
bull Exam
ndash Normal lumbar exam
ndash Intact Myotomes Dermatomes Reflexes
ndash Pain to palpation along the medial joint line
ndash Crepitus
ndash Negative ligamentous testing
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Baby Boomers and
ldquotweenersrdquo
bull ldquoIn betweenrdquo normal
joint and arthroplasty
Slide courtesy of Dr Joanne Borg-Stein
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Orthobiologics
bull Prolotherapy
bull PRP
bull BMAC
bull Adipose derived
bull Amniotic products
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Mesenchymal stem cells
bull MSC cells that have the ability to
proliferate and differentiate into
progenitors of different mesenchymal
tissue
bull They have unique cell surface
markers adhesion molecules
cytokines growth factors and
receptors
bull Anti-inflammatory and
immunomodulatory
Obaid et al Cell therapy in tendon disorders
What is the Current evidence
Am J Sports Med 2010 38 (10)
bioscienceorg
Slide Courtesy of Dr Joanne Borg Stein
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Mesenchymal stem cells
bull Mesenchymal Stem Cells
1 Bone Marrow Derived MSCs
2 Adipose Tissue Derived MSCs
3 Synovium Derived MSCs
bull De Bari et al 2001
4 Muscle Derived MSCs
bull Williams et al 1999
5 Dermal Fibroblast
1 Connell et al N=12
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
BMAC
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
BMAC
bull Hemopoietic stem cells
bull Nonhemopoietic cells Mesenchymal Stem Cells
ndash 0001-001 of total cell population
ndash 100k - 2M MSCs
bull Diminishes with age
Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
BMAC
bull General Set up
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
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Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
BMAC
bull Rate is not greater than that observed with other types of intra-articular injections
bull Annual neoplasm 078 in adults 50 ndash 64 yo
ndash This study showed 014
bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure
bull Only 3 were possibly related to stem cells
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
BMAC
bull Eight studies focused on focal chondral defects
bull Three studies evaluated for treatment of
osteoarthritis
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
BMAC
bull Six trials with high risk of bias showed
level-3 or level-4 evidence in favour of stem
cell injections in KOA
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
BMAC
Author BMAC Pathology NCenteno et al 2008
BMAC meniscus 1 ndash case study MRI showed increased volume
bmac prp x2 and dex with hyalgan
Giannini et al2009
BMAC Talus 48 6121824 mo Second look arthroscopy
New tissue on MRI
Kennedy and Murawski 2011
BMAC Talus 72
Pascual-Garridoet al 2012
BMAC Patellar tendinopathy
8 2-5 year follow up
Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri
Giannini et al 2013
BMAC Talus 20 48mo MRI new tissue
Singh et al 2014 BMAC Lateral epicondyle
30 2612 weeks Sig decrease in PRTEE scores
Centeno et al 2015
BMAC GH OA 115 2 year pain improvement
Prolo bmac and prp
Centeno et al 2015
BMAC ACL 10 cases grade 1-III
Improved MRI findings
Prolo BMAC + prp
Hannon et al 2016
BMAC Talus 34
Shapiro SA et al 2016
BMAC vs saline OA knee N = 25 VASWomackoos
Contralateral knee with saline
Safe well tolerated placebo
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
ADIPOSE TISSUE
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Adipose Tissue
bull Human ADSCs
ndash localize in the stromal vascular fraction
(SVF)
ndash The SVF consists of a heterogeneous
mesenchymal population of cells
bull Adipose stromal stem and progenitor cells
bull Hematopoietic stem and progenitor cells
bull endothelial cells erythrocytes fibroblasts
lymphocytes monocyte macrophages
and pericytes
NIH
-PA
Auth
or M
an
uscrip
tN
IH-P
A A
uth
or M
an
uscrip
tN
IH-P
A A
uth
or M
anu
scrip
t
BOURIN et al Page 13
Table II
Cell populations resident in SVF
Hematopoietic-lineage cells
Stem and progenitor cells lt01
Granulocytes 10ndash15
Monocytes 5ndash15
Lymphocytes 10ndash15
Endothelial cells 10ndash20
Pericytes 3ndash5
Stromal cells 15ndash30
Cytotherapy Author manuscript available in PMC 2014 April 08
Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Adipose Tissue
bull The stromal vascular fraction (SVF) is a
heterogeneous cell population derived from
manipulation of adipose tissue
ndash homogenization
ndash enzymatic digestion
ndash differential centrifugation
ndash red blood cells lysis and washing
Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Mesenchymal stem cells
bull Mulitpotent
bull More prone to differentiate
into muscle cells or even
into cardiomyocytes
compared with bone
marrow MSCs
bull Less efficient at osteogenic
and chondrogenic
differentiation
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Adipose Tissue
bull When treated with growth factors
ndash Upregulate expression of tendon related markers
ndash They are found comparable scaffold adherence and
proliferation potential
bull Suggesting AD-MSCs as alternative cell type for tendon
tissue repair
D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Adipose Tissue
bull Easier to obtain
bull Bioscaffold
Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Adipose Tissue
bull General Set up
FDA CLEARANCE AND PRODUCT INFORMATION
TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose
tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure
Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints
middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture
middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents
middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue
middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)
IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha
legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat
isonlytobeusedwithoutanyadditionalmanipulation
Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister
middot LG60cc
middot LG240cc
1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm
120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes
260mlpolycarbonatesyringe2FemaleLuertransferconnectors
LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria
middot TheHCTPisminimallymanipulated
middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)
middot TheHCTPisnotcombinedwithanotherarticleand
middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction
DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Adipose Tissue HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer
5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe
6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Local Anesthetic
bull Connect the vacuum syringe to the
blunt 13-gauge Lipoaspiration
cannula
bull Advance and withdraw cannula in a
ldquospokes-of-a-wheelrdquo pattern
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto
createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly
3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand
holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe
canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe
canisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanister
approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Adipose Tissue
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid
beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe
desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock
valveattachmentremainstightenedontothecanister
bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds
in a vertical motion
ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals
ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent
bull Collection ndash Pull down on the syringe
ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister
ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device
HarvestingandProcessingGuide
ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile
field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)
3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite
4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor
thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe
subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-
wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue
7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration
NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea
AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula
andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect
tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer
Lockconnectordecantthelipoaspirate
4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)
LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely
attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened
2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)
3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward
4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles
5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister
PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand
openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly
coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full
NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister
HarvestingandProcessingGuide
WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand
rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities
2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion
3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals
4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps
CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach
10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe
clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith
salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull
syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe
Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor
Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Adipose Tissue
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Adipose Tissue
bull 2002 national survey of 66000 tumescent
liposuction cases
ndash No deaths were reported
ndash Complication rate was 0068 per 1000 cases
Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Stem Cell summary
BMAC
bull 100k - 2M MSCs
bull Chondrocyte
bull Osteogenic
bull More painful
bull Volume limit
Adipose
bull 250k - 125M MSCs
bull Bioscaffold
bull Tendon defect filling
bull Less painfull
bull Larger volumes
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
AMNIOTIC TISSUE
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Amniotic Tissue
bull Human Amniotic suspension allografts ndash Human amniotic membrane
ndash Human amniotic fluid-derived cells
bull Contain anti-inflammatory factorsndash IL-10 IL-1
ndash Metrix metalloproteinases 123 and 4
ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen
G5
ndash Hyaluranic Acid and small amount so proteoglycans
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Amniotic Tissue
bull Human amniotic membrane
ndash Growth factors including EGF TGF-β and FGF
bull Stimulate epithelial cell migration and proliferation
bull PDGF A and B
ndash Stimulate many metabolic processes
raquo General protein and collagen synthesis collagenase activity
and chemotaxis of fibroblasts and of smooth muscle cells
raquo TGF-β has been shown to significantly increase type I
collagen production by tendon sheath fibroblasts
Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Amniotic Tissue
bull N = 6 KL grade 34
bull 12 weeks 3512 months
bull Primary goal feasibility of injection for treatment of OA
bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Amniotic Tissue
bull Pain and functional measures
ndash P ADL QOL S SR of the KOOS
ndash Overall KOOS IKDC SANE
bull All scores demonstrated improvement at 1 year
ndash Labs
bull No concerning changes in renal function blood cell
counts or lymphocyte subsets
bull Statistically significant increase in IgG and IgE relative to
baseline but not abnormal level
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Amniotic Tissue
bull N23
ndash 14 Corticosteroid
ndash 9 c-hAM
bull Safe and comparable to steroid
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Amniotic Tissue
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Amniotic Tissue
bull N=470 181
bull VAS WOMAC
bull KL 1-3 OA
bull 30 90 120 days
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Page 1 of 2
Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee
Douglas Beall MD and Sri Nalamachu MD
Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS
Summary
Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained
improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days
Study Design
Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study
efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days
Results
To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)
OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points
evaluated showed high statistical significance (p values lt
0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)
Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment
Figure 3 WOMAC Scores and Overall Patient Population Improvement
Figure 1 Mean VAS Score and Percent Improvement
Figure 2 Overall WOMAC Score and Percent Improvement
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Amniotic Tissue
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Amniotic Tissue
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Amniotic Tissue
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
FDA
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Slide Courtesy of Dr Joanne Borg Stein
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
FDA ndash NEJM Perspective
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Adipose Tissue
31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM
Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print
Access this article
Or purchase this article - $20
Print Subscriber Activate your online access now
Welcome Guest Renew Subscribe or Create Account Sign In
HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch
Share
Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS
Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by
ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety
of disorders We evaluated three patients in whom severe bilateral
visual loss developed after they received intravitreal injections of
autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in
the United States In these three patients the last documented visual
acuity on the Snellen eye chart before the injection ranged from 2030
to 20200 The patientsrsquo severe visual loss after the injection was
associated with ocular hypertension hemorrhagic retinopathy
vitreous hemorrhage combined traction and rhegmatogenous retinal
detachment or lens dislocation After 1 year the patientsrsquo visual
acuity ranged from 20200 to no light perception
Supported by grants from the National Institutes of Health (Center Core grant
P30EY014801) Research to Prevent Blindness the Department of Defense
(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders
named were not associated with the clinical trial described
Disclosure forms provided by the authors are available with the full text of this
article at NEJMorg
This article was updated on March 16 2017 at NEJMorg
We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics
This article is available to subscribersSign in now if youre a subscriber
ORIGINAL ARTICLE
Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang
K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry
W Flynn Jr MD and Jeffrey L Goldberg MD PhD
N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583
MEDIA IN THISARTICLE
FIGURE 1
Findings onOphthalmologicExamination in Patient1
FIGURE 2
Findings onOphthalmologicExamination inPatients 2 and 3
ARTICLE ACTIVITY
1 article has cited this
article
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
FDA
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
FDA
bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act
ndash 1942 ndash Public Health Service Act
bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change
bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap
ndash FDA approved as new medical device
bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic
ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway
ndash 2006 ndash Changed regulatory focus ndash expanding regulation
ndash 2016 ndash Meeting in september
Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
FDA
bull 21 CFR 1271
ndash Not all autologous cells are drugs
bull HCTP (human cells tissues and cellular and tissue
based products)
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
FDA
1 More than Minimally Manipulated
ndash Centrifugation crystalloids water cuttingshaping
2 Homologous use
ndash Same structure function
3 Processed in isolation
ndash Same surgical procedure no combinations
4 Limited systemic effect
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Summary
bull Indicationsndash Cartilage defects
ndash Osteoarthritis
ndash Tendonopathies
bull Patient selectionndash Completed standard of care
bull physical therapy program
bull Other injectables
bull NSAIDs
ndash Age and medical factors
ndash Continued disease impact on QoL
ndash Peri vs intra-articular
bull Severity and location
ndash Knee hip shoulder
ndash Not a surgical candidate
bull Ie Medical surgeon patient
ndash Patient preference
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Physical Therapy
ndash Phase 1 ndash Inflammation proliferation phase
bull Weeks 0-2 = rest low load
ndash Phase 2 ndash Proliferation phase
bull Weeks 2-4 = active exercise increase load
ndash Phase 3 ndash Remodeling phase
bull Weeks 5-6 = expanded active exercise (eccentrics)
ndash Phase 4 ndash Integration phase
bull Weeks 7-8 = exercise progression run walk rep max
ndash Phase 5 ndash Sport specific
bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Future
bull Vectors
bull Bioscaffolds
bull Gene Therapy
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Personalized Regenerative
Sports Medicine
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Conclusion
bull Let us not be governed today by what we did
yesterday nor tomorrow by what we do today for
day by day we must show progress
ndash AT Still
Thank you
bull Questions
Thank you
bull Questions