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 14, 2009

Thumb Surgery

As a doctor, I see a lot of hand arthritis. With all of the Blackberry thumb and painful, and often disabling thumb joints out there, why don’t we see more thumb surgery? The reason is likely that the artificial joints in the hand seem to involve a long and often painful recovery with a lot of occupational therapy. Unlike a knee replacement, where you can still work with your hands, type, text, etc… a thumb joint replacement in your dominant hand means you’re totally out of commission in today’s modern hand-centered work force. As a result, we do see the occasional patients getting thumb surgery with a tendon (see Thumb Surgery Alternative post), but still the same issues above apply. Is there a way to avoid thumb surgery? Yes, we’ve had good experience with injecting the patent’s own adult stem cells into the joint. I’ve posted a patient testimonial below:

January 13, 2009

Steroid Shots

Steroid shots have become a mainstay of modern orthopedic medicine.  Relief from a cortisone shotis due to powerful anti-inflammatory effects of the corticosteroid medication.  You body uses this same chemical daily to modulate inflammation and help control tissue repair (generally to put the brakes on an inflammatory injury response).  In very low doses (about 1,000,000 times less than is used by most doctors) these natural steroids help to reduce swelling and help the joint produce growth factors like TGF-beta which can help heal local tissues.  However, in the high doses commonly used in orthopedics (milligrams or bout 1,000,000 times more than the nano-grams used naturally), steroids can be a big sledge hammer to the system, stamping out bad inflammation and good tissue repair with equal force.  A steroid shot for sciatica is common these days, as doctors often use these to decrease swelling around swollen nerve roots that lead to back and leg pain.  however, the same issues as above apply, the dose if often too high.  Our own experience with out own patients shows that relief from a cortison shot can be obtained with a low nono-gram dose approximately 1,000,000 times less than the commonly used milligram dose.  This also prevents many of the body wide side effects that can seen from high dose milligram cortisone shots, such as weight gain, changes in blood sugar, and moodiness.  Cortisone shots before surgery (the higher milligram dose) will generally reduce the effectivness of healing, as they tend to supress the healing immune system response including knocking down critical repair responses and adult stem cells.  Concerned about high milligram dose cortisone shots?  Alternatives treatments include prolotherapy and using your own stem cells to help heal a joint rather than just reducing the inflammation short term.

What is a hip labrum?

hip labrum

hip labrum

Yesterday I posted on how to fix labral tears with stem cells, today I think it’s important again to show what the labrum is and what it does.  The picture above shows the hip socket where the hip bone (femur) would insert (ball of the femur would fit here in that socket, but the ball is removed here).  The labrum is represented by the red circle and the x’s.  This is the “lip” of the socket where the ball fits.  What does it do?  It helps to keep the ball in the socket .  The labrum becomes very important in doing this in activities with allot of travel for the hip joint like figure skating, bump skiing, horse back riding, hockey, etc…  If the labrum gets torn, movements where the hip is brought to extremes may allow the ball of the femur to move slightly out of the joint which can place extra stress on the other ligaments that help hold the joint together.  So in summary, the labrum is the lip around the socket that holds the ball in the socket

January 10, 2009

Surgery for a Torn Labrum in Hip?

surgery for hip labrum

surgery for hip labrum

As a doctor who sees patients with labral tears, there’s allot of confusion among patients about what’s injured when they hear the word “labrum”. Think about the labrum as the lip around the socket where the ball of the femur bone (hip bone) inserts. I’ve seen a number of patients get surgery for a torn labrum in the hip, some with good results, some not so good. Why? One of the issues appears to be the very large amounts of traction that need to be pulled on the hip to get the arthroscope into the hip. This can cause the major nerve of the leg to loose the ability to transmit signals as well as extreme stretching of critical hip ligaments. The second reason likely has more to do with the same reason meniscus surgeries have recently come under fire, removing parts and pieces of a joint as part of what we medical types call “debridement” may sometimes cause more problems than it solves. For example, this removeal of important structural tissue from the hip may cause a retear of the hip labrum. How can a torn hip labrum cause problems in the first place? Realize that the labrum is one of the things that helps the hip bone (femur) stay in it’s socket. So a tear may cause small amounts of extrra motion, especially with movement out to the side (as in figure skaters, horse back riding, and gymnastics). So if the repair of the torn labrum in the hip can actually help the lip of the hip socket (labrum) mend without adding additional trauma, then the surgery will be sucessful. However, if it’s just a “cut out the bad part” type surgery, then it may make the problem worse. Is there a better way without surgery and pulling 80-100 pounds of traction? Yes, we’ve had good success with injecting the patient’s own stem cells into the tear in the labrum, which helps provide new tissue and heal the tear. This procedure can be done through an injection, without the need for surgery and as a result, with much quicker recovery and less down time.

Replacing the Achilles Tendon with a Cadaver Tendon?

 

As a doctor, replacing the Achilles tendon with a cadaver tendonwould be the absolute last resort for patients with complete and retracted tears of the Achilles tendon.  This means that the two pieces of the tendon aren’t connected.  For patients with partial tears of the Achilles tendon where the tendon is still intact and not completely torn and retracted, this should not be considered.  This is due to the significant complications that can accompany this type of very big surgery.  Newer methods of tissue bioengineering look to replace this Achilles tendon replacement surgery.  This involves injecting the patient’s own mesnechymal stem cells into the Achilles tendon tears.  We have some experience with injecting adult mesenchymal stem cells into torn tendons with very good results.  This procedure is much less invasive and involves much less recovery and downtime for the patient. 

January 6, 2009

recooperation from shoulder surgery

Typical shoulder surgery recovery.

Typical shoulder surgery recovery.

As a doctor, recooperation from shoulder surgery can be tough. The problem is that the severe degree of immobilization that’s needed (that big blue pillow) makes that arm/hand useless. Is there a better way? Well, if you have a rotator cuff tear, newer and much less invasive methods of treatment may be the answer, as with less trauma from the procedure comes quicker recovery times (read no blue pillow). How can this be possible? Trade the scapel for a needle. Rather than trying to sew ligaments back together or sewing a torn rotator cuff tendon, get stem cells to repair the damge. The doctor simply places the cells in the damaged area with an injection. Little trauma, little recovery. Sounds like science fiction? Not really, as this procedure using your own stem cells to repair the damage is now being used reduce recooperation times. No surgery, less recovery. To learn more, click the video below:

January 3, 2009

video’s of low back surgery

Video’s of low back surgery. Low back surgery for a bulging disc cuts off the back part of the disc, making it weaker and more prone to failure. Below is a video showing a new method of treating a disc bulge, whereby the tear in the low back disc is repaired with an injection of the patient’s own stem cells

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

Torn Achilles Tendon Physical Therapy

A tear in the Achilles tendon can be either partial or complete.  Torn Achilles tendon physical therapy depends greatly on how the tendon is treated.  Surgical repair usually means significant immobilization.  This is a two edged sword.  On the one hand, immobilization can help the tendon mend, on the other, it also dramatically weakens the strength of the natural repair.  For a complete tear of the tendon (when it’s disconnected), aggressive casting may be the only way to promote even weak repair.  However, when the ligament is partially torn, the rehabilitation and recovery plan can vary widely depending on treatment method.

The rehab plan depends on if surgery is needed or not.  If the tendon is sewn back together, rehab will have to be non-weight bearing (on crutches) so at least 4-8 weeks.  However, there is a better way that can allow for quicker return to activities.  Recent research has shown good results when implanting the patient’s own adult stem cells into the tear.  This treatment technique is available now to patients in the first link above.  This is an injection of stem cells to heal the partial tendon tear.  If the Achilles tendon is repaired by this method, activity can start immediately as it helps stem cells differentiate into fibroblasts to repair the tendon.

For our patients, it’s critical to get rid of myofascial trigger points in the gastrocnemius muscle.  This can be accomplished by IMS.  This allows the muscle to function normally and allows for quicker strengthening of this critical muscle.

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