Joint Preservation Blog

April 18, 2009

Can stem cells fix a knee?

pix-knee1

Cartilage is funny stuff.  It’s a shock absorber and filled with cells, so it’s alive.  For a long time, we doctors believed is was so much inert filler so we developed a surgical culture of trimming it and cutting it out.  This was called debridement.  The problem is that arthoscopic surgery for knee pain doesn’t work.  The reason, cutting out living cells turns out to be a bad idea.  So the next step is actually trying to fix cartilage.  We have demonstrated on MRI that using the patient’s own stem cells can help the appearance of knee cartilage (as seen on high resolution MRI) as well as the pain reported by patients.  The secret appears to be taking the patient’s own stem cells and growing them to bigger numbers.  The FDA has taken a strange position on all of this, but doctors and patients have other ideas.  In the meantime, fixing cartilage with stem cells seems like a better idea than cutting it out.

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January 22, 2009

ACL Laxity and Knee Braces

acl laxity and knee braces

A doctor discusses ACL Laxity and Knee Braces. The ACL is the duct tape in the knee that holds the big thigh bone (femur) to the leg bone (tibia). It stabilizes (along with the PCL) the knee in a front-back direction. A knee brace can be used to help the ACL. An ACL knee brace allows the knee to flex and extend while holding the thigh and leg bones in alignment. However,is there a better way than wearing a knee brace all the time? Knee surgeries to replace or reconstruct the ACL should only be performed (in my opinion) if the ACL is completely gone. if the ACL is just lax, an older method of treatment is prolotherapy. This is the injection of a substance to tighten the ligament. Reeves has shown that the ligament can be tightened in this way using monthly shots for about 6 months. Newer options already being performed in the US include seeding the patient’s own adult stem cells onto the ACL ligament to repair the damage. This only works if there are ACL fibers left to seed. Eventually, this same technique may be used to inject an ACL scaffold material into the knee with adult stem cells that can create a ligament. So if you have a stretched ACL and you’re using a knee brace for ACL laxity, investigate some of the injections that can help you loose the brace!

January 3, 2009

Knee Replacement Surgery Recovery

Knee replacement surgery recovery is hard. As a doctor, I’ve seen everything from patients who can get back on their feet in weeks, to patients with months of severe pain requiring narcotics and ultimately poor outcomes (the knee area still hurts). Why? How can you tell who will do well and who will have a prolonged Knee replacement surgery recovery? After many years of seeing these patients, I think it comes down to why the knee hurts in the first place. Too often, the knee is diagnosed as the main pain generator, but much of the pain is really coming from somewhere else. For example, recent research has shown that while we see meniscus tears on MRI, they are often not the cause of knee pain. In addition, there is a mean serious complication rate from knee replacement surgery of 20%. This gets worse as the patient gets older, with severe consequences and complications (with protracted recovery) occurring in many more patients when they are over age 80. Even if the knee is the cause of the pain, you might consider trying non-surgical options before you pull the trigger on knee replacement. Many patients can get good results from SynVisc or other artificial joint lubricants. Some of my patients try prolotherapy. Even newer techniques are now available where the patient’s own stem cells are used to heal the problems in the knee. So one way to avoid a long Knee replacement surgery recovery watching re-runs of Oprah is to avoid the knee replacement altogether.

December 15, 2008

mri knee anterior and posterior ligament tears

MRI knee anterior and posterior ligament tears. The knee has ligaments in the font and back (ACL and PCL) that keep the knee stable in a front-back direction. These ligaments can be seen on MRI and will usually have bright areas in them under certain special MRI sequences if they are partially torn or stretched. These areas are called “high signal intensity” in medical radiology jargon. If the ligament tears are complete (broken in half), then surgery is needed to reconnect those ligaments. However, if the ligaments are only partially torn or stretched, newer techniques to treat these ligaments without surgery are available. Surgery to treat an ACL/PCL partial ligament tear may cause more problems than it’s worth, in that sewing these ligaments may result in ligaments that are too tight. Ligaments that are too tight can rapidly increase the wear and tear forces on the knee. This can lead to further degeneration of the cartilage and arthritis. However, leaving the ligaments stretched out and too loose may result in the same fate, as the extra motion of the knee joint will lead to extra wear and tear as well.

While surgical repair may well lead to more arthritis down the line, non-surgical repair has advanced greatly in the past few years. The ability to inject the patent’s own stem cells into the partially torn ligaments without surgery may be able to heal these tears without over tightening the ligaments. Research in the arena of using adult stem cells (not from embryos, but from the patient) has blossomed. This technique (see the first link in the above paragraph) allows for much less downtime than surgery and also allows the patient to remain active while the ligaments are healing. In addition, it’s believed that this more physiologic repair reduces the risk of over tightening the ligament.

For more information on these ligaments, see below:

The anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) are the primary restraints to front and back motion of the tibia on the femur. The femur (thigh bone) sits on top of the tibia (shin bone), and the knee joint allows movement of the mid leg. Without ligaments to stabilize the knee joint, the joint would be unstable and prone to excessive wear and tear and loose much of it’s bio mechanical advantage. The ACL and PCL prevents the tibia from sliding too far in the font-back direction. The ACL and PCL also contribute stability to other movements at the joint including rotation at the knee joint. The other major ligaments of the knee are the medial and lateral collateral ligaments (MCL and LCL, respectively).

What happens when there is an ACL or PCL injury?
When an ACL injury occurs, the knee becomes unstable. The ACL injury is a concern because this instability can make pivoting movements difficult, and it may make the knee more likely to developing arthritis and cartilage injury.

Why are ACL and PCL tears a big problem with daily activities?

When the knee is unstable, patients complain of a feeling that the knee will ‘give out’ from under them. When this “giving way” is because of an ACL injury, the knee joint is sliding around too much. This can be a problem because each occurrence of instability (the ‘giving way’ feeling) can lead to damage to the knee cartilage. Therefore an ACL or PCL injury can make a patient more likely to develop knee arthritis and meniscus tears.

December 14, 2008

Patella Tendon Repair and Rehab

The patellar tendon is the duct tape that holds the quadriceps muscle to the knee cap and attaches that bone to the tibia.  Patella tendon repair and rehab is all about how agressively you need to treat the tendon.  A complete tendon rupture needs surgery to reconnect the tendon.  However, a partial tear is a different story.  While this could be treated with surgery, newer treatments allow for more activity.  For example, to treat a partial patella tendon tear, an injection of stem cells (see link above) can allow for much less down time, no immobilization, and less needed rehab.

Rehab for this problem should focus on strengthening the quadriceps and hip girdle musculature.  However, we have seen many patients who have significant trigger points in the quadriceps.  These often prevent effective strengthening of the muscle.  An easy way to clear these trigger points is with IMS

August 21, 2008

What is joint preservation?

Joint preservation is both an unknown and new medical science.  It literally means what it sounds like, preserving a joint via a number of tools rather than replacing all or part of that joint.  So instead of a total knee replacement, fixing as many issues as possible to make sure the joint still functions.  Why do this?  Joint replacement is big surgery with big risks, so many of us would like to avoid these risks.  In addition, from a psychological perspective, one knows they are truly “old” when a surgeon cuts out what used to a perfectly good joint and replaces that with metal and plastic.  So this blog is dedicated to my clinical experience and the tools I use to save joints, hence joint preservation.

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