Friday April 5, 2013
Welcome back to our blog! Today we are interviewing one of our long time users to get their insight about using stem cells. Dr. Brent Hague, DVM, Diplomate ACVS, ABVP has graciously agreed to be subject to my questions. Dr. Hague works at Oakridge Equine Hospital, located in Edmond, Oklahoma. Oakridge Equine Hospital is a referral practice, and is proud to be home to four board certified equine surgeons. They house state of the art technology, including a dedicated equine MRI (1.5T), orthopedic and soft tissue surgery suites, and a range of other specialty equipment for diagnosing and treating all of your equine needs. Go check them out at www.oakridgevet.com. Today Dr. Hague and I will be discussing how to select a good candidate for stem cell therapy. Without further ado…
Me: Tell us a bit about yourself, professionally…any special interests or accreditations?
Dr. Hague (DH): Our practice is a referral practice, with the main focus in sports medicine and orthopedics, although we do everything. My interest, in particular, is treatment of the athletic horse. I like to do arthroscopy and laser surgery; they are probably my two biggest areas of interest. I completed a surgery residency at Texas A&M, and I became board certified in surgery. I also became board certified in equine practice. I have been in an equine practice for 20 years now. I’ve gained a lot of experience from working with some of the better equine practitioners in the state, and around the country.
Me: How did you get started using ART?
DH: The reason I became interested in ART and investing in the technology is due to the positive results we saw. We were part of the pilot study done at CSU using bone marrow derived stem cells to treat traumatic conditions of the joint that we otherwise felt had a poor prognosis without stem cells. In that trial with CSU, we did a large number of cases and we definitely saw a positive effect, both in tendon/ligament injuries, and also joint injuries, using stem cells. As our control we used cases we have treated over the last twenty years, seeing how those horses responded without stem cells post-operatively. After the study we lost the ability to obtain the cells through CSU. Since the same people who spearheaded that research formed ART, we thought it was a no-brainer to go with someone we trusted to grow our cells.
Me: What type of injuries do you commonly treat with stem cells?
DH: We, as a practice, or me? I don’t know how our practice ended up in a bit of a split. I treat a lot more joint injuries as a total, but our practice as a whole also treats ligament/tendon strains that we think without regenerative therapy would carry a poor prognosis for athletic soundness. Those are the type of horses we think are good candidates for the stem cells. For instance, a SDFT that has a core lesion that involves greater than 50% of the cross sectional area of the tendon, in my mind would be a good candidate for stem cell therapy. As far as joint treatment, I think the stifle responds well to stem cell therapy; especially if there is a soft tissue component to the injury such as meniscus, collateral ligament, or mild to moderate cartilage damage. Those horses are good candidates for the stem cells.
Me: To branch off of that a bit: you said you see a split between what you mainly treat and what the other doctors do. Is there a specific reason why you are more prone to do the joint injuries; is that due to the case load?
DH: I think it is just how the case load has fallen out. I do a lot of western performance stifle surgeries. I think just numbers, not that they don’t do them, it just fell out that I have had more cases that fit the selection criteria for stem cell treatment.
Me: Do you find that any one type of injury responds better to stem cells?
DH: The horses that respond better, when talking about a joint, are the ones that have a soft tissue component to the injury causing cartilage damage. I have not had really good luck in horses that have widespread cartilage loss, where you have exposed bone everywhere in the joint. Those are end stage joints. I think it has helped a lot of those horses become comfortable, and become breeding sound-which they weren’t before surgery. But I haven’t had very good luck in returning those to being an athlete.
Me: Can you tell us a little about the diagnostic work needed to determine when to use stem cell therapy?
DH: Probably the biggest thing, when we are talking about a joint, would be MRI or diagnostic arthroscopy to actually make a visual and tactical assessment of what the cartilage is like and/or soft tissue structure.
My personal impression… A lot of these therapies, and especially stem cell therapy, get misused because they get put in everything. It kind of becomes a buzz to the clients, “I want to use stem cells”, and there are some people who will put them in anything. I don’t think that is beneficial to anybody. Say for instance, a horse that we would able to treat with arthroscopy, to take a chip out of a knee, that horse is going to do well anyway, you don’t have to use stem cells too. You still need to be selective what you use them in, to draw a correlation that definitely it is the stem cells positive effect that is making the horse sound.
Me: we have already touched on this a couple of times, so unless there is anything else you would like to add… Are there certain horses better suited for stem cell therapy?
DH: I think any of them; it is more of an injury dependant kind of thing, and not discipline or breed dependant. A thoroughbred is not going to respond more than a quarter horse. It depends a lot on the nature of the injury.
Me: Do you take any intermediary steps before deciding on stem cells? (i.e. HA, PRP, IRAP, other)
DH: Let’s take a stifle for instance, say a cutting horse. We have done the diagnostic work up, the pain blocks to the stifle, we are sure that’s where the pain is. Radiographically, the stifle is normal, but the horse continues to have inflammation in the stifle. I will try routine injections first. Say those injections make the horse clinically sound, but they only last maybe 2 months. I would like those injections to last 4-6 months. If they don’t last that long, and we still don’t see anything on ultrasound and/or changes on the radiographs, we would maybe try a series of IRAP injections first. For a good many horses, especially reiners and cutters, the IRAP will help whatever is going on in the stifle, they will get sound and we won’t need to do surgery. If you do the IRAP series and the horse still needs medication to be sound, then it’s time to get on the surgery table and explore the joint. The sooner you look, the better the prognosis is, because you don’t let the cartilage damage get to the point where there is too much damage to do anything, even with stem cells.
Me: Do you use other treatment types concurrent with stem cells? (i.e. HA, PRP, IRAP, other)
DH: Usually not. I usually put the stem cells in the joint with HA, since that is the protocol we have been using for a long time. But I am using the HA as a carrier and an anti-inflammatory while the stem cells are in there, not as an adjunct treatment.
Me: What kind of success rates do you see?
DH: I think out of that study, to give you some numbers without pulling them out of the air, the original study from CSU with Dr. Frisbie for the joint. I think that number was 60-some percent that returned to same or better level of use. That was from a group of horses who otherwise had a poor prognosis. I think that’s pretty impressive. ***
Me: Me too! Without making you guess any numbers, do you still see those same kinds of results? ****
DH: Yes. I think that overall, stem cell therapy percentages are probably better because those original horses had joints you put a scope in and you say “man, this thing is terrible”. Then you put stem cells in and we saw a positive result. Now, we are using stem cells also on some of those horses that are the borderline cases. Some that may have responded to surgery alone, but we think if we use stem cells it would be an opportunity to augment the healing process. Including these less severe cases in the overall treated group, improves the overall prognosis. I don’t think that is a bad thing, we don’t want the patient to get to the point where they have an end stage joint before we intervene.
Me: Is there a particular case that stands out in your mind as being the most remarkable?
DH: One horse in particular that did not return to athletic soundness, but the clients goal was to have the horse breeding sound comes to mind. A stallion that had a stifle with almost no cartilage left, a mensical tear, and no cartilage on the end of the femur. It was a grade 4/5 lame, losing weight, couldn’t get on a breeding dummy. We operated on the horse, cleaned up the joint, and put stem cells in it. 6 months later, he was sound enough they were light riding him—which I didn’t want them to! Still that’s two breeding seasons ago, last breeding season and this breeding season and he is still breeding sound. That’s pretty remarkable.
Me: Anything else you would like to add?
DH: I don’t think so. I do think you guys do a great job, so thanks!
Me: Thanks Dr. Hague!
*** The published results of the study Dr. Hague is referring to can be found by clicking below (link to ourwebsite)
Ferris DJ, Frisbie DD, Kisiday JD, McIlwraith CW, Hague BA, Major MD, Schneider RK, Zubrod CJ, Kawcak CE, Goodrich LR. Clinical follow-up of horses treated with bone marrow-derived mesenchymal stem cells for musculoskeletal lesions. In Proceedings, Am Assoc Equine Pract 2009; 55:59-60. Submitted Equine Vet J 2010.
**** Watch for new material:
Ferris DJ, Frisbie DD, Kisiday JD, McIlwraith CW, Hague BA, Major MD, Schneider RK, Zubrod CJ, Kawcak CE, Goodrich LR. Clinical follow-up of thirty three horses treated for stifle injury with bone marrow derived mesenchymal stem cells intra-articularly. Vet Surg 2013. In Press.
We would like to thank Dr. Hague for his time, and for agreeing to talk with us. If you have more questions about selecting a candidate for stem cell therapy, Advanced Regenerative Therapies offers peer-to-peer consultations with our veterinary specialists. Call us today for more information!
Disclaimer: Advanced Regenerative Therapies is a commercial veterinary stem cell expansion company. Information contained within this blog is solely for the general knowledge of the reader. We do not diagnose any health problems, nor is this information meant to diagnose any health problems or substitute the judgment of a licensed veterinarian.