Ankle Osteoarthritis and Stem Cell Therapy

By Staness Jonekos

My future was changed forever when I sprained my ankle in a college ballet class. This injury was 40 years ago yet a third degree sprain like mine was treated the same way as today: P-R-I-C-E (protect from further injury, restrict activity, apply ice, apply compression, and elevate the injured area).

Little did I know that the ligaments I injured had started physiological changes that would compromise my joint stability. The healing response that was initiated in an attempt to repair the damage actually increased my risk for degenerative changes that eventually led to osteoarthritis. It is the most common type of arthritis caused by the degradation of a joint’s cartilage. There are up to two million acute ankle sprains each year in just the USA alone.

Fifteen years after the initial ankle sprain I had severe pain and was forced to seek out medical attention in an attempt to walk normally again. Being in my mid-thirties and hearing that my only option was an ankle fusion, limiting motion for the rest of my life, was devastating news. My new mission was to find an ankle expert that was a pioneer.

NOTE reference photo of my left ankle X-ray 40 years after the injury, bone on bone, compared to a healthy normal ankle on the right side.

After five appointments with orthopedic surgeons in the Los Angeles area, I discovered Dr. Richard Ferkel at the Southern California Orthopedic Institute (SCOI). He became my lifetime ankle hero. He specializes in arthroscopic and reconstructive surgery of the ankle, as well as cartilage restoration, but it was his work with the U.S. Olympic teams, the NFL and NBA that really impressed me. If professional athletes entrusted their careers and joints to him, so would I.

Dr. Ferkel did a procedure to clean up the bone spurs, called arthroscopic debridement, and microfracture and drilling to help stimulate cartilage growth.

This procedure, along with lifestyle changes that included eliminating all high-impact activities, bought me over 20 years of good mobility with manageable pain. Once I hit my fifties with an injury over 30 years old, my quality of life was once again compromised with limited motion and bad pain.

Dr. Ferkel then suggested viscosupplementation, an ankle injection procedure with lubricating fluid. It is also called hyaluronic acid injections and commonly used to treat knee osteoarthritis. It was not FDA approved for ankles (and insurance would not cover it), but I wanted to proceed if it meant a decrease in pain and an increase in mobility. It worked, and I did the injection every year for five years. After each injection, it felt like a little cushion in my ankle; there was a spring in my walk again. Acupuncture also greatly helped manage the pain when I could find the time to do it.

Although it was not a cure, my quality of life improved. When I traveled and needed to do a lot of walking, I would take Celebrex, (also know as a COX-2 inhibitor) a nonsteroidal anti-inflammatory drug (NSAID) that works by reducing hormones that cause inflammation and pain in the body.

There were no real fixes, just management options. Total ankle replacements (TAR) only last about eight to ten years, so that was not an option either. Fortunately for knees and hips total joint replacement surgery is an excellent option with longer-term beneficial results.

Looking at the end of my fifth decade, I was still not interested in ankle fusion, ankle arthrodesis, which can relieve pain but it also limits motion. I still had decent ankle motion and an ankle fusion would reduce existing mobility. My other fear was it could compromise other functioning joints that would eventually become taxed when the injured ankle joint was no longer mobile.

After extensive research there was promise for adult stem cell therapy that is an intervention strategy that introduces new adult stem cells into damaged tissue in order to treat disease or injury.

Stem cells are unprogrammed cells in the human body that have the ability to change or “differentiate” into other types of cells. Since they are obtained from the patient, the risk of rejection is almost non-existent. Knees have shown good results with stem cell therapy.

A 2014 study revealed that mesenchymal stem cell (MSCs) therapy on knees with osteoarthritis had the potential for cartilage regeneration. Today this procedure is considered a reliable alternative treatment for chronic knee OA.

Ankles are still the last frontier in this area. After 40 years since the initial injury, the biomechanical changes across my ankle joint surface had produced severe osteoarthritis. Daily walking became so painful I started planning my day around managing how much walking was needed to accomplish basic life duties.

I had dreams about running, and being free to move without pain. Friends no longer called to go hiking or power walking. It was difficult to maintain a healthy weight without being able to just simply walk. I was envious of friends who counted steps to lose weight, I planned my day around how few steps were needed to survive daily tasks.

Something had to be done, and it wasn’t going to be ankle fusion. That said, I spoke with many people who opted for ankle fusion and it changed their lives. Many even returned to athletic hobbies.

Stem cell therapy was my next move and Dr. Ferkel felt it could be a good option to help reduce pain and increase mobility.

It was an “experimental” procedure because it is not yet FDA approved. Based on research using stem cells from the iliac crest (hip bone), it had promise.

Dr. Ferkel told me,

“The goal is to reduce pain and keep mobility.”

He knew I had a fantasy that those stem cells would grow new cartilage, which it would not in my case of almost total bone on bone. For many who have a smaller injury, stem cells are now an excellent option, even on ankles.

During the surgery they had to collect the stem cells from the hip joint and distract my ankle joint (separate it from my leg) for the injection of bone marrow aspirate.

Concentrated bone marrow aspirate contains healing and growth factors, as well as healing cells called pluripotent cells. Bone marrow is the tissue that is found in the hollow spaces in the interior of our bones.

A centrifugation machine called the Magellan® MAR0Max™ was used to concentrate the platelets and growth factors, as well as the pluripotent (or stem) cells, creating an injectable product that is delivered directly to the ankle. The processing time is about 12-17 minutes, and the entire surgery was less than an hour.

My personal ankle plan now is to wait for another ten years until I am a candidate for a total ankle replacement. I will continue to utilize hyaluronic acid injections, take Celebrex when needed and be open to new options until it is time for my total ankle replacement.

We are all different, and fortunately there are good options available for ankle osteoarthritis now.

My hope is that those with similar injuries catch it early so new treatments like stem cell therapy may stop the progression of osteoarthritis, and joint replacements become a thing of the past for everyone.

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References:

Wodicka R, Ferkel E, Ferkel R. Osteochondral Lesions of the Ankle. Foot Ankle Int. 2016 Sep;37(9):1023-34.

Ramponi L, Yasui Y, Murawski CD, Ferkel RD, DiGiovanni CW, Kerkhoffs GM, Calder JD, Takao M, Vannini F, Choi WJ, Lee JW, Stone J, Kennedy JG. Lesion Size Is a Predictor of Clinical Outcomes After Bone Marrow Stimulation for Osteochondral Lesions of the Talus: A Systematic Review. Am J Sports Med. 2016 Nov 16. pii: 0363546516668292.

Jo CH, Lee YG, Shin WH, Kim H, Chai JW, Jeong EC, Kim JE, Shim H, Shin JS, Shin IS, Ra JC, Oh S, Yoon KS. Intra-articular injection of mesenchymal stem cells for the treatment of osteoarthritis of the knee: a proof-of-concept clinical trial. Stem Cells. 2014 May;32(5):1254-66.

Mehrabani D, Mojtahed Jaberi F, Zakerinia M, Hadianfard MJ, Jalli R, Tanideh N, Zare S.
The Healing Effect of Bone Marrow-Derived Stem Cells in Knee Osteoarthritis: A Case Report. World J Plast Surg. 2016 May;5(2):168-74.

Burke J, Hunter M, Kolhe R, Isales C, Hamrick M, Fulzele S. Therapeutic potential of mesenchymal stem cell based therapy for osteoarthritis. Clin Transl Med. 2016 Dec;5(1):27.

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