1. NANOFACTOR FLOW Stem Cell Therapy
An Alternative in Managing Knee Arthritis
Phil Davidson, MD
Park City, UT

2. Non-Operative Management of Knee OA
NSAIDS PT
Weight loss
Bracing
Injection Therapy
Corticosteroids
Viscosupplementation
PRP
Autologous MSC’s (BMA derived)
Amniotic Tissue Graft-Allogeneic MSC

3. Legacy Injection Therapies
Corticosteroids-good and bad….
Viscosupplementation: unpredictable, often ineffective, only potential to address aching, no reparative capacity, many insurances are not authorizing

4. CORTICOSTEROID BENEFITS
Rapidly reduce pain due to inflammation
Last for several weeks to months
Joints, Spine radiculopathy, Bursitis, Tendonitis, Neural inflammation (CTS)

5. CORTICOSTEROID SIDE EFFECTS SHORT TERM USE
Atrophy
Depigmentation
Hyperglycemia
Infection
Post injection flare
Tissue structure weakening, tendon ruptures

6. PRP in Cartilage Repair
Chondrocytes and MSCs exposed to PRP show increased cell proliferation and cartilage extra- cellular matrix synthesis of PG and Type II collagen
Synoviocytes cultured in PRP produce more HA- better lubrication and chondroprotective?
Better pain scale outcomes with PRP injections versus HA injections for management of knee OA
PRP preps highly variable
Over 6000 articles on PRP/only 50% of them show an effect-platelets, leucocytes?

7. BIOLOGICS Knee OA Biologic treatment is interactive
KEY ELEMENTS ALL REQUIRED:
Growth factors, cells, scaffold
Mechanically favorable environment
A “Nutrient Rich Soup” includes-
Cells (RBC, white cells, MSC)
Growth factors (from platelets or plasma)
Scaffolds
Potential sources of this “Soup”:
Bone Marrow Aspirate, Amniotic Fluid

8. MSC’s in Sports Medicine
MSC’s are undifferentiated cells:
Capacity for prolonged self-renewal
Ability to differentiate into specialized cell types
Have shown enhanced cartilage, tendon and meniscus healing
These results have increased patient awareness and demand
High-profile professional athletes are signing up for relatively untested cell-based therapies

9. Mesenchymal Stem Cells in Sports Medicine
Attractive to patients-they want regeneration technology rather than replacement
Harness your own body’s ability to heal
Not taking exogenous drugs
You are using your cells to heal your tissues
Perception that stem cells are reversing the trend not just treating it

10. Mesenchymal Stem Cells in Sports Medicine
MSCs do not recreate tissue
Modify the environment to enhance healing
Patients feel better-anti-inflammatory effect
May have role for Osteoarthritis
May be a role for augmenting surgical procedures-ACLR, RCR, cartilage restoration
We don’t know the ideal type or number of stem cells in specific indications

11. Mesenchymal Stem Cells Reparative Promise in Knee OA
Increased meniscal volume in post- menisectomy patients who received adult MSC injections into the knee
MSC implanted for knee OA showed improved activity levels and cartilage regeneration
One-step MSC treatment for large full thickness chondral defects showed improvement and significant cartilage fill

12. Mesenchymal Stem Cells Reparative Promise in Knee OA
Current MSC treatments for OA include BMA derived autogenous stem cells that are immediately injected into the knee
Jim Andrews MD at the Andrews Institute believes it controls swelling and inflammation and eases pain in knee OA
Results in a pilot study of 31 NFL players, at 10 months, showed efficacy
Reported decreased pain up to 45% with scores & improved by 50% from baseline at 6 months

13. Amniotic Membrane and Fluid Allograft
So why use nanofactor FLOW if BMA works?
Growth factors, scaffolding, and MSCs
First used in 1910
Preservation techniques in 1940
Has been proven in ophthalmology, burns, plastic surgery, foot and ankle, diabetic ulcers
Amniotic fluid stem cells have a delayed/more robust differentiation compared to bonemarrow derived MSC in recent studies

14. Journal Transplantation, April 2015
Prospective Randomized Trial for Knee OA
Allograft MSC vs Hyaluronic Acid injected in knee
One year follow up
MSC patients improved clinical outcomes, including pain vs. HA
MSC patients showed actual IMPROVEMENT in cartilage quality and quantity on MRI vs. HA

15. Attributes of Amniotic Tissue
Immunoprivileged (no class 1 or 2 HLA antigens)
No rejection reaction
Anti Inflammatory
Transforming growth factor beta-1 (TGF-1)
Insulin-like growth factor I (IGF-I)
Anti Microbial- defensing/peptides/ enzymes
Cells: MSC’s, Fibroblasts and Keratinocytes +++
Chen EH, et al. J Implant Adv Clin Dent. 2009;2(3):67-75.
(2)Bongiovanni cd133+ cell as advanced medicinal product for Myocardial and limb ischemia
Stem cells and development vol23, 20, 2014
(3)Karantalis, MSc w CABG circulation research Feb 2014

16. NANOFACTOR™ FLOW 900,000 cells/mL
44% MSC’s; remainder-kerintinocytes, fibroblasts, epidermal
Collagen Types III, IV, V, VII
Amino acid precursors – taurine, glutamine
Growth factors: Epidermal growth factor, Transforming growth factor alpha & beta-1, Insulin-like growth factor 1, Granulocyte colony stimulating factor
(AmnioTechnology LLC, with permission)

17. Nanofactor Flow: Nanofactor Membrane: MSCs + Growth Factors + Scaffold
NanoFx (MSCs) + Growth Factors + Scaffold

18. PRP
1 Element Tx
BMA
2 Element Tx
Nanofactor
All Elements

19. Amniotic Membrane

20. Amniotic Scaffolding Cryofractured Amnion Membrane particle
Micronized amnion contained within the allograft was imaged by scanning electron microscopy. Here you can see at a magnification of x the membrane particles. The membrane particles are approximately 0.5 to 1 um in size.
Scanning Electron Microscopic image of cryofractured amniotic membrane particles.

21. Nanofactor Minimally Manipulated Extracellular Matrix
Morcelized Tissue
Disrupted 3D Structure
CryoFractured Tissue
Intact 3D Structure

22. What makes Nanofactor Flow different?
Growth factors
Scaffolding
Cells and lots of them and immature-pluri- potential-900,000 viable cells/ml, 44% are MSCs in one ml
BMA has 1,500 CFU-f/ml, another article stating 2,300 CFU-f/ml (donors<1 yo) to 500 CFU-f/ml (donors>60)
BMA cells are senile

23. Amnio vs BMA: MSC Volume Comparison
Amniotic
440,000 MSC’s/1ml
Bone Marrow Aspirate
1,600 MSC’s/1ml
Jing Li et al: Chin J Cancer Res 23(1): 43-48, 2011

24. Human MSCs Decline with Age
_______
1,000 1
Estimates obtained by CFU- f assay
MSCs per Marrow Cells 1
Bone marrow MSCs decline with age. Bone marrow was obtained, dispersed, placed in a Percoll gradient and the light cell fraction seeded onto culture, After 7-10 days colonies can be visualized. The CFU-F assay is an incomplete and crude estimate of MSCs in marrow samples, but clearly we can see that the number of MSCs in marrow decreases with age.
_______
100,000
_______
250,000 1 1
_______
400,000 1
_______
2,000,000
Newborn
Teen 30 50 80
Age (Years)
Adopted from: Al Caplan. J Pathol 2009; 217: , 2008

25. Relative Number of MSC’s by Age
Adopted from: Al Caplan. J Pathol 2009; 217: , 2008
MSCs per Marrow Cells
2000
400
250
100 1
Bone marrow MSCs decline with age. Bone marrow was obtained, dispersed, placed in a Percoll gradient and the light cell fraction seeded onto culture, After 7-10 days colonies can be visualized. The CFU-F assay is an incomplete and crude estimate of MSCs in marrow samples, but clearly we can see that the number of MSCs in marrow decreases with age.
Newborn
Teen 30 50 80
Age (Years)

26. Amniotic Tissue Allograft
Nanofactor FLOW
Growth
Factors/Peptides
Cellular Components
Extracellular Matrix
So to summarize, the amniotic tissue allograft (Nanofactor flow) contains the same 3 elements present in amniotic tissue and that have been demonstrated to have anti-inflammatory, anti-scarring, anti-microbial, and regenerative capabilities which are the growth factors, the cellular components, and the extracellular matrix/scaffold + +

27. Amniotic Placental Tissue Collection
Scheduled c-section
Amniotic fluid (~ 650cc)
Amnion membrane (900 cm2)
Consent
Infectious Disease Testing
Shipping to Manufacturing Facility
Overnight at 1-10o C
Tissue Processing
Processed in Class ISO 5
Bioburden Testing USP <61>
Environmental Monitoring
Micronized Amnion
Growth Factors, Cytokines, ECM Proteins
Viable Cells
5% DMSO
Final Product Lot Release
Sterility Testing USP <71>
Mycoplasma Testing USP <63>
Endotoxin Testing USP < 85>
3-4 weeks
Nanofactor Flow is derived from placental tissue donation obtained from consenting donors who are screened in the prenatal unit and donors with a drug or alcohol history and those with communicable diseases such as HIV and hepatitis are excluded from donation. Tissue is procured during a scheduled c-section.
Product Packaging and Distribution
>65o C

28. How do the sources compare?
“A multipotent stem cell population that is still of fetal origin and may be superior in proliferation and differentiation to cells deriving from adult tissues”
Francesco Alviano et al, BMC Developmental Biology

29. Why do I offer my patients Nanofactor Flow?
Patients can benefit from this non surgical treatement modality
Many patients want/need to avoid surgery
Large demographic of patients wants to “try everything before considering surgery”
This is only modality that has the actual ability heal cartilage and tissues (vs steroid/HA)
Easier to administer than PRP/BMA
Cost is not out of line with PRP/BMA

30. How do I discuss Nanofactor Flow?
Attractive option to include “stem cells”
Safe, no rejection, no after-pain
New technology without specific indication parameters
I discuss the concept of orthobiologic treatment to include the 3 key elements: cells, growth factors and scaffolding
I explain that senescent MSC’s make very little sense to me
It is not a magic bullet but it does have promise
I explain that it is expensive and not covered by insurance

31. PHASE I Getting Started in the Office+
CryoFreezer:
If you plan to do any volume
Dilutants & Nanofactor

32. Acceptable Dilutants Flow (Pure) Lidocaine /Marcaine, (not in joints)
PRP (Platelet Rich Plasma):
PPP (Platelet Poor Plasma):
Hyaluronic acid (supartz, eufflexa):
Saline: Use Normal Saline:
Types of Saline:
Normal: Sterile Solution of Sodium chloride in water
Bacteriostatic: Sterile Solution with 0.9% benzyl alcohol with no sodium chloride

33. Unacceptable Dilutants
Flow
Unacceptable Dilutants
Do Not Use
Glycerol (eg. Grafton DBM)
Glucose Solutions (eg. D5NS)
Epinephrine (in or around treatment site)
Lidocaine/ Marcaine (with preservative) in joints
Do NOT Use Systemically – no IV or intra arterial injections
No literature to support this method of administration.

34. Preparation & Mixing Flow
Remove the package from freezer or dry ice container. Cut the package. *Outside of vial is not sterile
Defrost vial by holding still in hand for 3-5 minutes. *Do not shake vial
Fill syringe with dilutant. (typically 1:1 ratio)
Draw Nanofactor™ Flow into syringe with 18g needle.
Use a 22 or 23g needle for injection but nothing smaller than a 23g

35. Recommended Joint Dosing
Flow
Recommended Joint Dosing
Shoulder
1ml Flow Graft,
1:2 up to 1:4 dilution
Elbow
1:1 dilution
Wrist, Fingers & Facets
(per joint)
0.25ml Flow Graft,
Hip
2ml Flow Graft,
1:2 up to 1:3 dilution
Knee
(per compartment)
Stage 3: 0.5ml Flow Graft,
Stage 4: 1ml Flow Graft,
1:2 dilution
Ankle
1ml Flow Graft,
1:1 dilution
Subtalar &
Midfoot Joints
0.5ml Flow Graft,
1:1 dilution
MPJ’s & Toes
(per joint)
0.25ml Flow Graft,

36. PEARLS No anti-inflammatories or ASA (6 weeks pre & post)
Increased tissue vascularity improves cellular incorporation
Lidocaine 1% preservative free as carrier
Full activity (restrictions only if warranted by diagnosis)
No issues with icing or polar care machine
Not use – systemically, open growth plates, oncologic process, active infection

37. Summary
Nanofactor Flow is an alternative therapy to treat inflammatory and degenerative musculoskeletal conditions.
It makes sense given what we know about orthobiologic principles with MSCs, growth factors and scaffolds
Patients are asking for this type of treatment
The cost is not prohibitive
Early observations very encouragin
We need more prospective data at all levels
Dosing
Efficacy
Indications/Contraindications

38. Thank You phildavidsonmd@gmail.com