How Stem Cell Therapy Can Make Knee Replacement Obsolete

Hello, Dr. Mok, I'd like you to introduce your new book to us, how to avoid knee replacement Surgery. And answer the question, Discover how stem cell therapy can make a knee replacement obsolete.

The title is kind of to be catchy because, you know, we write about in the book, but obsolete, who knows if that's going to happen or not. But in my career, I've seen many old therapies become obsolete. A good example is a big part of our business is treating what's called venous insufficiency, where people varicose veins or sores on their legs and the treatment had been putting them into wound care, where they go for the rest of their Life and spend $20,000 a year in wound care. And sometimes they get an amputation. We do a procedure called an ablation that makes that obsolete. It reverses the disease. It makes it. You don't need surgery. So that does happen, but sometimes it happens over time. And my prediction is knee replacement surgery will be optional in the future, might never be obsolete because there are people that did not intervene and do anything and let it get bad enough so the knee becomes crooked or bent things, we call it genu, valgus or varus, and they would potentially still need a knee replacement surgery. But I think now we have the option of doing things to intervene at earlier stage before there's significant deformity to reduce or completely replace the need for knee replacement surgery. And of course, that goes in contradiction with living longer. We might, you know, things might continue, but we do have an abundant amount of stem cells in our body. We can always get them from other sources. And the mechanics that cause the knee injury in the first place might still be going on, but we can mitigate that a lot with stem cell therapy. So let's talk about the kind of the normal course of arthritis and replacement. And I talk about knee replacement surgery. This could be for any major joint arthritis. Less studies and investigation evidence on the spinal cord, the spinal column, than there is in joints like the wrists and the knees and the hips and the elbows and the ankles and shoulders. But all joints potentially will respond to some kind of regenerative therapy. So regenerative therapy as a whole is the idea of regenerating your tissue either with your own tissues, some drug or some, you know, investigational drug in the future. And that's where part of the arms race is right now, is finding a drug that will sort of act like a stem cell into the joints. It doesn't exist yet. So what have we done? Well, in the past we would use pain pills and steroid injections. And the steroid injections have, are fraught with problems because even though they improve pain for a period of time, appear to increase the acceleration of disease of thinning out of the cartilage. So doctors used to do injections regularly until you needed a knee replacement. Now they're knowing not to do it so often because it does hasten, hasten that replacement surgery that's been around for decades, longer than I've been alive. And that has been an effective solution where you actually put a mechanical device into the knee. And I'd say a problem with that is that the biggest growth in knee replacement surgery, people in their 40s and these joints are only good for so long. The other thing with these joint replacements is you're doing this to stay active. But once your joints replaced, your activity is really restricted because if you do jumping basketball, running, play tennis, you're going to loosen those joints up and you're going to fail at a sooner point. So it's kind of like you're prescribing yourself to a life of less activity if you do a joint replacement. Now, the person that can't move without the joint replacement, they would have them definitely have improvement. But some in their 40s, that's having knee pain. This does not seem to me like a prudent move. And know that we're seeing that a lot in our society is a growth of knee replacements in young people. So what are our alternatives? Well, these. What's called hyaluronic acid. It's really not an acid, it's more like a sugar, but it's hyaluronic acid is the name of it. And it's a lubricant that you inject in the joint. And they find that does give people some improvement, not significant, but some improvement. So it might put it off for some time. Advances in that have been using something called a crosslink hyaluronic acid that is not FDA approved in the United States, although it's available for another condition that can improve it even better. And then adding different things to the hyaluronic acid so it doesn't break down as fast. This has been done in Europe. So there's new things on the way. There's platelets, which is the first form of regenerative therapy. So platelets are cell like structures in your blood that along with red blood cells and white blood cells make up the structure of your blood. And the rest of it is a juice. And in that juice there's different Things like there's things that are being carried, your kidneys and liver to get rid of, and there's things to move to different tissues. There's growth factors, antibodies, there's all kinds of things in your plasma. And we take the blood out, we can separate out the platelets and the plasma from the red blood cells, even potentially from the white blood cells. And when we separate those out, we've got these platelets that are designed to fix things. So when you cut yourself, your platelets rush in and they make you cl. Stop bleeding. That's good. And then they make your skin grow, they bring stem cells in and they bring fibroblasts in. And the wound closes up and it heals and you get a little scar there and it's, it's done, you resolved, you might have a bad scar or a good scar based on the type of trauma in the first place. Platelets have very little control over that. So what's going on with the platelets? So they have three growth factors that we're well aware of. One's called vegf, vgf, Vascular endothelial growth factor. This brings, this promotes blood vessels and circulation to the region to help healing. The second one is pdgf, platelet derived growth factor. This helps migrate cells into the area, cells that are needed to repair. Instance where you cut your skin, you need certain things that make collagen and to make epidermis, you need some stem cells to make your basement membrane, eventually make your keratin. And then we have another one called transformative growth factor, which causes, in this case, the platelets for healing and causes these stem cells to turn into mature cells. And when we inject this into the knee, which started over a decade ago, or into the arthritic joint, people get clinical improvement over time. Most people, about 80% get some clinical improvement. And at first we didn't know exactly what was going on. And I was our first patient allure to get prp, platelet rich plasma. And I'll tell you, we have platelet rich plasma and platelet rich fibrin. For the sake of this discussion, they're the same thing. We've always used platelet rich fibrin. Platelet rich plasmus means the platelets are inactivated. Platelet fiber means they are activated. So we always use activated platelets. I had a rotator cuff, a 70% torn subscapularis tendon, and I had a shoulder injury, which was just a stupid injury. I was trying to get a safe out of a wall in our car wash. I owned and then that weekend I went and I launched my kids in the air, in the pool a few times. It tore and it really disabled me to where I couldn't do surgery anymore very well, really cause some problems. So I scheduled for a repair. So an orthopedic doctor, really, he's a shoulder guy and he was going to shorten the biceps tendon and actually my right shoulder, he shortened the biceps tendon and use a piece of that to repair the subscapularis tendon and I was going to have a scar. We have six weeks in a certain type of splint and some limited mobility, maybe arthritis down the road. And platelet rich plasma back then, this was 2011, was just coming on for some of these athletes, were getting it done for different injuries. And so I learned how to make platelet rich plasma. I bought the equipment I had my ultrasound tech was really doing vessels, learned how to do shoulders. And then I friend of mine, another different friend of mine is orthopedic doctor, we did it together and he injected my shoulder with the platelet rich plasma two times. The first time he did it wasn't painful and we could see the platelets going right into the torn tendon. And within a week or so I was feeling better. And two months later I was scheduled to do it again. It felt perfectly normal. We looked at the ultrasound, we couldn't even see the tear. The protocol was due to twice back then. So we did it a second time. The second time it did hurt. We were sticking platelets into a healed tendon. It's been fine since that time. No, no, no issues like nothing whatsoever. It grew back entirely. And that was my first experience. So then we started, you know, getting familiarity with uses, with other, with other things. Right about that time, stem cells were becoming something that people were starting to consider for other conditions than their original indication in the 60s, which are certain types of cancers. And stem cell therapy was being thought about as something to use for things like spinal cord injuries, heart disease, arthritis, various conditions of degeneration. So what happens over time? You have a stroke, let's say in your brain, and there's lack of blood flow to a certain area and the cells die off. And ideally they would start growing back, but they really don't. For a spinal cord injury, same thing, some trauma, some dead cells, and they don't tend to grow back in the spinal cord, in the knees or hips or shoulders, there's continuous wear, wear, wear, which causes inflammation and the stem cells just stop replacing the chondrocytes. Or the cartilage and stem cells were promising for that. My first patient was my brother. He had a spinal cord injury, couldn't walk without assistance. He had a spinal cord tumor they took out. And he was my first patient. Back then we do things a little bit differently. I did what's called intrathecal. I put him right into his spinal cord. Fat derived stem cells. We had our own lab. He gets stem cells out and he did recover. He was able to walk again. Unfortunately it recurred and he had a recurrence to it. Now he's too big of a defect, but he got a few years out of it. Led us to the ability to start looking at stem cells for other indications. And at that time we were doing a process where we would take the fat, we had our own lab, we'd add an enzyme to the fat, sort of incubate it, separate the stem cells out and use and wash them and inject the stem cells. Right around 20, 18, 19, 20. The government said, hey, we think that you're making a drug. Not to me, but to other doctors. I was big group and they said, well we think, you know, this is a drug. It probably, you know, we don't want you doing that anymore. So we've changed our processes. Now we use something that's using an FDA approved kit like Lipogens or we use a FDA inspected lab to get the stem cells out. And again, they're not FDA approved for anything. They said these devices or labs are FDA approved and inspected and it's no longer that makes it not drug part. Stem cells then started going into the. We were treating some people with ms, various neurologic conditions, but the real low hanging fruit was arthritis because there's so many people that have it and it can be devastating to your lifespan. We know if somebody has single joint arthritis which limits their mobility, they're not overweight, they lose about 1.8 years of healthy lifespan. And if they have one joint arthritis, limiting ability and they are obese, they lose about three and a half years of lifespan. So really mechanically, if you could fix that, you can expand their lifespan if we return mobility. So we turn towards mostly treating joints but still treating these other conditions. And I talked about the platelet rich plasma and the stem cells. Now we're kind of in the 2025 with these. Both seem to work. And so what is the difference? What are we using? So stem cells, again, not FDA approved for anything. There's three forms of stem cells are commonly used. One is bone marrow derived stem cells that's where they harvest out of the hip bone. We don't do that in our clinic. I have friends that do get it out of fat. That's a rich supply of stem cells or they come from donated placentas and umbilical cords. Those are the three types of stem cells commonly used in the United States. And then we have platelets, which come from your own blood. You have an endless supply of that. And these things all have some benefit. So let's talk about kind of what they do and what's the difference and what we know, which there's a lot of maybe unknown, maybe more unknowns than knowns. And just to be clear, this is not covered by insurance. This is not considered a standard treatment. There's no FDA approved products, even though there's FDA approved kits and devices and manufacturing techniques. But stem cells and platelets are not FDA approved of treating the condition. The FDA doesn't really approve stem cells, I'm sorry, platelet rich plasma. They're considered a same surgical procedure. So they don't have any, I guess, jurisdiction over that. But they can improve the equipment. So we think somebody's got arthritis and it's mild to severe and they're, and they have normal, they're not deformed, they've got normal, reasonably normal range of motion and just having pain. We want to reduce pain. So one thing might be using platelet rich plasma or platelet rich fibrin, which again are basically the same thing and we might add something to it like the hyaluronic material with a claw cross linking. And we do a series of three treatments and we expect about 80% of people will get more than half reduction in pain for about nine months to a year and a half. So that's a good first step for somebody looking for alternative to taking pain pills, steroid injections or you know, knee replacement. And it doesn't seem to matter how bad the arthritis is if it's bone on bone or just mild. It seems to work in all cases, perhaps more in mild arthritis. But in all cases we expect that 80% of people get 50% improvement for some period of time. And how is this working? Not crystal clear. We talked before about the three different growth factors in platelets. They appear to be that these appear to be the growth factors accounting for some degree of healing, decrease inflammation. But also studies are showing some cartilage grow back. So this idea of platelet derived growth factor and transformative growth factor bringing stem cells into the region and getting to mature appears to be what's happening. So again, we don't know positively, but studies have shown there's an improvement on MRIs or X ray of the cartilage having regrowth, ceasing the devastation and the advancement of arthritis and reversing it to some degree. And it's something that can be repeated. The technique of platelet rich plasma is fairly simple. You draw the blood in a specialized tube. In our case, we use a pure PRF that has no additives to it. That's not the only way to do it. I do not have any positive or negative opinions on different methods. We've used several over the time. The one we're using now is very practical, it's very safe. It is FDA approved equipment, these special tubes. And the tubes are designed to reduce clotting. So the platelets are. We can manage them. And we have a special device that separates the platelets from the blood. And then we have a way to store the platelets for 40 minutes or so so we can use them before they clot up, because platelets want to clot in 10 minutes or so. And then we deploy them into the knee, potentially with other things. And the injecting of the knee is an ultrasound. Our providers are trained on how to use ultrasound to get into the joints with accuracy, avoid structures we want to avoid. And that's a fairly straightforward, simple procedure. And it might be the first step for somebody once. I just want to see if this is going to work or not. Second step might be looking at a stem cell product. So a common stem cell product that's being used in America would be umbilical stem cells of some sort. Which is which, you know, we probably don't even call them stem cells. We call them Wharton's jelly. It's got stem cells plus tissue in it. And this is something that you would buy from a lab and inject into your knee in the same fashion. Again, we see good response with that. Most people respond, but it lasts a little longer, more in the order of years. So that would be another step, another consideration. You only need one treatment typically versus three with the platelets to get moderate improvement of pain or clinically meaningful improvement of pain. Maybe not gone, some people will be gone, but 50% or more improvement. And then there's fat derived stem cells, which in the case of fat derived stem cells, there's the ability for you to have your fat in extracted, send it to a laboratory, outside laboratory and they extract the stem cells out and bank them. So you can bank your stem cells for the rest of your life. It's very inexpensive to keep them there. And then they send them back to us at like 5 or 10 million stem cells at a time, which is typically for, you know, 5 million stells for a joint. It would be maybe would be used to inject in the joint. And there might be other reasons you want to bank as well, using it for other other areas. Those are really the three stem cell options and of trying to play this first easy to do stem cells certainly have controversy. A lot of consumers are thinking stem cells are embryonic stem cells from aborted babies. That's not. Those are legal in the United States. That's not the case. You can get stem cells out of your own body. They are interesting. Even though embryonic stem cells are not legal in the United States to be harvested from aborted fetuses. So that that can't happen. There's plenty of umbilical, I'm sorry, embryonic stem cells in labs that got them Pre before the 1980s law. But they can actually make embryonic stem cells from your skin. So the first human surgeries have been done taking skin cells from a baby. That is, I believe they did it in utero. The FDA did approve it and they took the fibroblasts out of the skin and they reverse engineered the fibroblasts into a cardiocyte. Cardiomyocyte and injected it into the baby's heart to repair heart defects. That has been. That's actually has happened already. And so the first really engineered stem cell, that's an embryonic stem cell has occurred. And there's companies now, they're actually growing hearts. And this sounds crazy, but they take skin cells and they turn them into embryonic cells. And they take a lattice of a pig heart, let's say the pig heart, kill all the cells and just have the connective tissue and they lay the cells on the membrane and it grows into a new heart that beats. So this is not ready for prime time yet, but we will have replace more organs in the future. It's not that far off. The real breakthrough was the ability to create an embryonic stem cell from your own skin. And this has already happened. It's already happened. It's already been done. When I say fda, they proved a surgery to be done. I don't know. There's been more surgeries done. But I meant the surgeon who did this heart surgery. Quite remarkable. There's an interesting situation where there was a family that was very wealthy. They lost a child to heart disease, a baby. And there was a surgeon that needed money to research operating a baby's hearts. And they got together and funded him with, you know, a bunch of money to be able to do the research and create embryonic stem cells and then actually do a surgery to save a child's life. Now whether that child would live long term, it's unknown, but would have died otherwise. So that's kind of more these things are occurring, the stem cells for the knees or for the hips or the joints. The idea of reducing or eliminating joint surgery would be really the idea for the betterment of humanity. Now one of the questions is why doesn't, why don't insurance pay for it? Insurance typically lags substantially behind new breakthroughs and treatments. Not because they're evil or anything like that, but it's just like that. It's lag. The other thing you got to consider, the threshold for a knee replacement surgery is pretty high. It is an expensive surgery all in. It's about 70 to 100 grand. In terms of the entire cost related to a knee replacement surgery. It's got a significant major morbidity mortality rate that's, you know, clinically significant. There's maybe a 2% and then there's a certain percentage of people who still have pain afterwards because of nerve injury, et cetera. So it's not the perfect surgery, but it's the best one right now. So most people don't go through knee replacement that are eligible. However, if we had an FDA approved stem cell that your insurance pays for, pretty much everybody that has knee pain is going to get it done. Your doctor would be really have a low threshold for doing it that's going to cost a lot of money. So they got to look at it from actuarial standpoint. Are they really willing to put this much money into it? A good similar example right now is most insurance carriers do not pay for weight loss medications that are working really well because most people are eligible. And it would cost, you know, 15, 20,000 a year, but theoretically would save health care costs, but they would still be paying more in the front loading. It's one of those things that, you know, who knows if they'll be covering it soon. There is some companies trying to make an FDA approved stem cell product that can be shipped to the doctor that way. It is a drug. That's the first step towards getting insurance covered. But the FDA, I've been hearing from this, this company Cellularity for 10 years that they're going to get an FDA approval and it hasn't happened yet. So I'M not sure it's holding that up, but it'll probably happen in my lifetime, I hope. In the meantime, from personal history, I had PRP in my shoulder, completely healed my subscapularis tendon. And I did that genetic testing a few times over my life. And of course your genes don't test, but I'm doing it again to see what new stuff they have. And I'm at genetic risk for knee arthritis, so. Genetic risk for knee arthritis. My mom had her knees replaced at 67, both of them. And I did X ray in 2017 and my joint space was just mildly narrow. So no, no, I have no knee pain. Maybe my knees get a little hot when I walk too much or something, but I want to not get arthritis. So I did several things over the last eight years to make them actually get the joint space get a little bigger. Number one is I did something called extracorporeal shockwave therapies to my knee joints back in 2017 for one year, once a week. I did photobiomodulation with a high powered ND AG laser about once a month, month for a year. And then I did platelet rich plasma with this cross linked HA mannitol two times in the past four years. And my knees now, eight years later are look the same on X ray or a little better than they did eight years ago. And I don't have any arthritis. Which natural history was it would have gotten worse. So, you know, case report doesn't mean anything but. And why did I do all these crazy things? Well, in trying to find solutions, you go through different iterations of things that may or may not work extra. Corporate shockwave therapy definitely helps improve knee pain. Does it grow cartilage back? Don't know. Photobiomodulation definitely helps knee pain. Does it grow back cartilage? I don't know. Platelet rich plasma definitely helps knee pain. Most cases. Does it grow back cartilage? Now we know it looks to be doing that, so I'm doing those things in a stepwise fashion based on, you know, when the evidence becomes available. I've not done stem cell therapy. My knees are not that bad. But if they got that at that point I would, I would definitely, I would definitely be doing that. So back to the original question is, will stem cell therapy make knee surgery obsolete? I think I'll make it optional. There'll be some point of obsolescence once therapies are probably when insurance starts covering other things. We're getting people at a younger age that have less Advanced disease before they have deformities or their joints. And that five years out or 20 years out, don't really know. It's definitely coming. We're seeing a tremendous interest in the community about doing stem cell therapy. I'd say 10 years ago, people were. It was kind of taboo to even talk about it because of this issue regarding the embryonic stem cells. Well, that's been handled because we make embryonic stem cells. Not that we are in our clinic, but this has happened in America and elsewhere. And we can use platelets, which are not controversial FDA approved machinery. Platelet or stem cells are still a little controversial because there's a lot of misunderstanding. It's not super clear if the FDA will get involved with these again, but for right now, there was actually a lawsuit by a group I used to belong to, Cell Surgical Network, where the government had tried to make stem cells into a drug. That case I talked about earlier with using the enzyme. And Dr. Berman, you know, sued the FDA and won, and then he passed away. So the FDA went and appealed it, and they got it appealed. So once he's dead, they, you know, I guess that's lawfare. FDA's gonna win. So can't be done in the lab, legally in your own office. But there's other methods potentially for stem cell therapy. People want it, and I think when the public wants things, the government will try to shut it down, protect the status quo. But that really probably won't go on forever. You know, I'm not a conspiracy theorist, but I know that the FDA does need Big Pharma to stay in business. They can't make payroll without Big Pharma creating new drugs. That's their preferred client versus the patient who they're worried about safety, clearly, but that's not their client. So I'm a negative view on them at all. But that's. I just know that that slows down innovation, and probably rightly so, make sure things are safe and consistent. So thank. You.