Spokane Journal of Business

Procedure uses patient’s cells

Doctor here implants into knee cells replicated by East Coast lab from ones extracted in a biopsy

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A Spokane orthopedic surgeon has begun performing an emerging procedure that involves extracting healthy cells from a patients knee, growing 10 million to 15 million new ones in a lab, then implanting the replicated cells back into the patient to regenerate healthy tissue in damaged knee cartilage.

The surgeon, Dr. Robert Brewster, of Northwest Orthopaedic & Fracture Clinic, performed his first such procedure in February on a 33-year-old former day-care operator who suffered from chronic knee pain. He says he expects to perform his second within the next month or so on a 24-year-old professional snowboarder.

Its pretty limited in what it can be used for, Brewster says. The procedure thus far has been licensed by the U.S. Food and Drug Administration only for the repair of acute or repetitive stress-related cartilage damage at the bottom of the femur, or thigh bone part of the knee.

However, Massachusetts-based Genzyme Tissue Repair, which developed the procedure and the proprietary cell-growing process that is a crucial part of it, has commercialized a related therapy for the regeneration of skin on severe burn victims.

More recently Genzyme has been working to apply its cell-regeneration therapy to the treatment of neurological tissue damage, such as that caused by Parkinsons and Huntingtons disease.

The company, a publicly traded division of biotechnology giant Genzyme Corp., claims to have pioneered the field of autologous cell therapy, in which a patients own cells are used to replace those that have been lost to injury or disease. Such therapies are part of an emerging medical field known as tissue engineering.

Brewster traveled to Boston a couple of years ago to be trained by Genzyme on how to do the knee cartilage repair procedure, and the company says he is the only Spokane surgeon to have gone through that program.

The procedure he performed in February at Sacred Heart Medical Center is believed to be the first of its type done in Spokane and one of only about 15 done so far in Washington state. Nationally, the procedure has been performed about 2,000 times, all over about the last three years, although it has been done in Sweden for about 10 years, a Genzyme spokeswoman says.

Genzyme refers to the procedure by the trademark name Carticel, but generically its called autologous cultured chondrocyte implantation. Autologous means tissue that originates from ones own body, and chondrocytes are the cells responsible for generating and maintaining healthy cartilage. Culturing is the tissue-engineering process in which the chondrocytes are grown in a laboratory over a period of four or five weeks.

The articular cartilage that the process is designed to repair is a thin layer of tough tissue covering the ends of the bones where they meet at the joint. It provides a smooth gliding surface that is essential for the knee to function normally, butunlike most tissuesit has limited ability to heal itself. People with damage to the cartilage generally display symptoms that include joint locking, catching, localized pain, and swelling. In addition to those symptoms and restricted mobility, chronic injuries to the cartilage over time may lead to debilitating osteoarthritis, which can severely affect a persons normal daily activities. More severe forms of knee cartilage damage can contribute to an eventual need for knee-joint replacement, about 250,000 of which are performed annually at a cost of about $25,000 each.

Genzyme describes its procedure as a longer-lasting alternative to certain other corrective surgical procedures that involve smoothing the surface of the damaged area of the cartilage or drilling holes into the underlying bone to cause scar tissue to form.

Brewster says the Genzyme procedure is most suitable for younger people who have suffered trauma to their cartilage, such as through sports injuries, he says. Its not intended for patients, often older, who have infections, osteoarthritis, or inflammatory diseases of the knees, he says. He expects that most of the patients who undergo the procedure will be under 40 years old, although he has heard of at least one patient who underwent the process elsewhere who was reported to be 56.

The first step in the process is an arthroscopic procedure in which a Genzyme-trained orthopedic surgeon examines the patients knee and, if cartilage damage is evident, extracts a biopsy of healthy cartilage. That biopsy is sent to Genzyme, which then uses its proprietary methods to culture, or grow, millions of new cells for the patient. Genzyme technicians then place the replicated cells in a small vial, which is sent back to the surgeon. That portion of the process costs $10,000.

The surgeon then performs surgery on the patients knee by cutting an opening into the knee, cutting out the damaged area of cartilage, suturing a patch over the opening using bone skin taken from another area of the leg, and injecting the cultured cells underneath the patch. There, the cells may continue to multiply, integrating with surrounding cartilage until the formerly damaged area is filled in with new, healthy tissue.

They migrate to the surface and start attaching themselves to it right away, Brewster says.

He says patients must be willing to endure a lengthy recovery process. They typically have to use crutches or a walker for 10 to 12 weeks or longer, must go through considerable physical therapy, and cant engage in any strenuous activities for a year.

For people who suffer from cartilage-related knee problems, thats a worthwhile sacrifice.

Kathryn York, the Spokane Valley woman on whom Brewster performed his first such cultured-cell implantation procedure, says, I was in constant pain. I couldnt go up stairs without problems, or squat down. My leg would go numb. It would throb when it was cold. I finally couldnt take it any more.

It took about two years and three appeals to get her health-care insurance provider to agree to pay for the expensive procedure, which studies done thus far have shown to have a typical cost of about $26,000.

Despite the long wait, the trauma of enduring major surgery, and the huge physical inconvenience, York is recovering rapidly, and she says, The pain is basically eliminated. I would do it again in a heartbeat.

Now that the FDA has approved the process, health-care insurance approvals of the procedure are coming more easily, Brewster says. It took the patient on whom he is scheduled to perform the second procedure only about three weeks to get approval for it, he says.

Brewster is one of 14 orthopedic surgeons at the Northwest Orthopaedic & Fracture Clinic and has been practicing there for about 24 years. He is the father of Rob Brewster Jr., the real estate investor and developer who currently is rehabilitating the historic Holley Mason Building in downtown Spokane. The younger Brewster also is leading a group of investors who are seeking tenants for a proposed 25-story, $35-million-to-$40-million office tower at the corner of Riverside Avenue and Howard Street downtown that, if built, would become Spokanes tallest office tower.

Kim Crompton
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