Biologic Orthopedic Update from Las Vegas

The TOBI biologic orthopedic meeting this past weekend in Las Vegas was simply outstanding.  Dr. Steve Sampson put together an excellent collection of lectures and then followed by an impressive ultrasound anatomy session by Dr. Jay Smith from the Mayo Clinic.   Hands on injections and bone marrow aspiration in a cadaver lab completed the stellar conference held at the Red Rock Resort.

Las Vegas Red Rock Area

Some highlights of the sessions.  We heard about the use of PRP in soccer players from Dr. Imtiaz Ahmad from London, England, the use of PRP for osteoarthritis from Dr. Brian Cole from Chicago, the use of adipose-derived stem cells for the treatment of knee osteoarthritis from Dr. Yun Choi from South Korea, minimally invasive techniques for articular cartilage damage from Dr. Neil Ghodadra from Los Angeles and the Andrews Institute Experience using Biologics to Accelerate Healing from Dr. Adam Anz.   Lectures about hydrodissection using ultrasound (Dr. Lam, Hong Kong), the current landscape of disc regeneration challenges and promises (Dr. Bae, Los Angeles) and the value of mesenchymal stem cells (Dr. Caplan, Cleveland) were also given.  That was just part of day one of the conference.  Day two included several more interesting and important lectures.  I think there were over 300 attendees and many more following the streaming video (including myself on day one).  In between the lectures, discussions were carried out in the hallways and exhibit area.  Overall, it was a fantastic international event.

The field of biologic orthopedics is exploding.  Worldwide interest in minimally invasive techniques to treat challenging musculoskeletal problems is rising rapidly.  It will still take time, effort and some luck to discover and develop clinically meaningful treatments.  The good news is, progress is definitely being made toward these lofty goals.

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Biologic Orthopedic Conference in Las Vegas (TOBI)

Today in Las Vegas a group of elite clinicians and researchers from around the world have gathered in Las Vegas for the 5th annual TOBI biologic orthopedic conference.  Discussions about platelet rich plasma, stem cells and a variety of other approaches for difficult problems such as arthritis, tendonitis and degenerative disc disease of the back.

Specific data has been presented suggesting various formulations of PRP and stem cells have value in the treatment of knee arthritis.  Clinical trials ongoing.

I'll be speaking at the conference on Saturday morning and will continue to report breaking news from the conference over the next two days.  Follow me on Twitter for real time updates (@BloodCure)

Dr. Steve Sampson has done a great job organizing the event.  Congrats!

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Can Curry Cure Knee Arthritis?

It sounds like a plot for a silly Bollywood movie, but published data actually supports the idea that one of the key components of curry powder can help alleviate pain for patients with knee arthritis.

Curcumin, a bright yellow spice found in curry powder, recently was found to have the same efficacy as ibuprofen (the active ingredient in Motrin and Advil) for patients with knee arthritis.  In a recently published study of 367 knee arthritis patients, researchers found 1500 mg of Curcuma domestica extract had the same effectiveness in terms of pain reduction as 1200 mg of ibuprofen at four weeks (Kuptnirataikul et al). Importantly, the curcumin treated patients had less episodes of abdominal pain or discomfort compared to the ibuprofen patients.  Importantly, another published study of of the same dosage of curcumin (1500 mg) was found to have significant improvements in terms of pain and physical function when compared to placebo at six weeks (Panahi et al).   Curcumin has been noted to block several substances involved in the inflammatory pathway and also inhibits activation of free radicals.  This could help explain why the spice works to reduce pain in arthritis patients.  

So next time your knee starts to hurt, put down the ibuprofen and hobble over to your favorite Indian or Thai restaurant for a tasty curry meal.  It may just help your knees feel better.

On a more serious note, the published data supports trying a curcumin supplement 1500 mg per day divided in three doses for 4-6 weeks for patients with knee arthritis.  (See chart below)

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Pain Reduction in Patients with Knee ArthritisKuptnirataikul et al

Can Stem Cells Cure Knee Arthritis?

Can Stem Cells Cure Knee Arthritis?

Unfortunately, the answer to that question is not known today.  It is clear, however, that many novel regenerative therapies are emerging to help the tens of millions of patients worldwide that are suffering from knee arthritis.

First, we must explore what type of stem cells could be helpful in the treatment of arthritis.  Stem cells of various types can be obtained from your blood (peripheral derived stem cells), bone marrow (mesenchymal stem cells), fat (adipose derived stem cells), and even from umbilical cord blood.  Studies today are exploring various ways to extract, purify and concentrate many types of stem cells.  The cells can then be injected as a suspension into your knee, used as part of surgical procedure or even injected after an operation.

Microfracture of Damaged Knee Cartilage

One recent study (Vangsness et al 2014) showed how an injection of mesenchymal stem cells could lead to more meniscus tissue after a knee arthroscopy.  24% of the treated group were found to have at least 15% increased meniscal volume.  This is a small amount in only a a quarter of the patients but it does represent a start.  Another study published last year (Saw et al 2013), injected peripheral derived stem cells after a microfracture procedure and noted improvement in the cartilage quality.  Other approaches (Pak et al 2014) use adipose derived stem cells from liposuction in combination with platelet-rich plasma to treat meniscus tears.  Finally, a review (Anderson et al 2013) of potential stem cell therapies for knee cartilage outlines many potential and emerging options.

Also, a variety of procedures also use non-stem cells to treat arthritis of the knee.  One of the oldest is called autologous chondrocyte implantation.  This is where a biopsy of your own cartilage is taken and then grown in a lab.  The expanded cells and then reimplanted into an arthritic lesion of the knee.  Another procedure simply penetrates the bone under the defective cartilage.  This leads to leakage of some of the bone marrow along with your own the stem cells within the marrow into the defect.  This is called microfracture.  Yet another procedure uses juvenile cartilage that is minced and then glued into a arthritic zone of the knee.

It is clear that there are many competing approaches to the use of cells and stem cells to treat knee arthritis.  None have "cured" the problem.   There is, however, an earnest worldwide research effort that will produce clinically meaningful options for clinicians and patients.

Millions worldwide are waiting for that day.

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TotalTendon

References
Anderson et al 2013
Saw et al 2013
Vangsness et al 2014
Pak et al 2014

Platelet Rich Plasma, Stem Cells and Biologic Orthopedics on Dr. Radio

On Monday May 12th, I will be on Sirius-XM Doctor Radio (Channel 81, 7 pm EST, 4 pm PST) discussing platelet-rich plasma, stem cells and other biologic orthopedic treatments.  It is an exciting time for this topic because research in these areas has progressed significantly just in the last few months.  Also, patients and payers are demanding less invasive and more effective treatments for difficult problems such as knee osteoarthritis and degenerative disc disease.  So, tune in at 7 pm EST, 4 pm PST on Monday May 12th to learn more about the frontiers of musculoskeletal medicine and surgery.  

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Platelet Rich Plasma Helpful for Patellar Tendonitis in Athletes

A new study published in the American Journal of Sports Medicine that ultrasonic guided platelet rich plasma  (PRP) injections improved pain and function in athletes with chronic patellar tendinopathy.  (See abstract below)

Patellar tendinopathy typically affects running and jumping athletes such as tennis, volleyball and basketball players.  It manifests itself with pain in the front of the knee and typically is worse with repeated jumping activities.  Most often, it will resolve with appropriate non-invasive treatment such as rest, icing and physical therapy.  It can be difficult to treat.  When the symptoms persists, published data supports the use of PRP injections.

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1. Christophe Charousset, MD*,†, 
2. Amine Zaoui, MD‡, 
3. Laurence Bellaiche, MD§ and 
4. Benjamin Bouyer, MD∥

+Author Affiliations

1. ^†Institut Osteo Articulaire Paris Courcelles, Paris, France
2. ^‡Laboratory of Bioengineering and Biomechanics for Bone Articulation, University of Paris, Paris, France
3. ^§Centre D’image Médicale Bachaumont, Paris, France
4. ^∥Biostatistics and Epidemiology Department, Hotel Dieu Hospital 1, Paris, France
5. Investigation performed at the Institut Ostéo Articulaire Paris Courcelles, Paris, France

1. ↵* Christophe Charousset, MD, Institut Osteo Articulaire Paris Courcelles–60 Rue de Courcelles, 75008 Paris, France (e-mail: dr.charousset@ioapc.fr).

Abstract

Background: Chronic patellar tendinopathy (PT) is one of the most common overuse knee disorders. Platelet-rich plasma (PRP) appears to be a reliable nonoperative therapy for chronic PT.

Purpose: To evaluate clinical and radiological outcomes of 3 consecutive ultrasound (US)–guided PRP injections for the treatment of chronic PT in athletes.

Study Design: Case series; Level of evidence, 4.

Methods: A total of 28 athletes (17 professional, 11 semiprofessional) with chronic PT refractory to nonoperative management were prospectively included for US-guided pure PRP injections into the site of the tendinopathy. The same treating physician at a single institution performed 3 consecutive injections 1 week apart, with the same PRP preparation used. All patients underwent clinical evaluation, including the Victorian Institute of Sport Assessment–Patella (VISA-P) score, visual analog scales (VAS) for pain, and Lysholm knee scale before surgery and after return to practice sports. Tendon healing was assessed with MRI at 1 and 3 months after the procedure.Results: The VISA-P, VAS, and Lysholm scores all significantly improved at the 2-year follow-up. The average preprocedure VISA-P, VAS, and Lysholm scores improved from 39 to 94 (P < .001), 7 to 0.8 (P < .0001), and 60 to 96 (P < .001), respectively, at the 2-year follow-up. Twenty-one of the 28 athletes returned to their presymptom sporting level at 3 months (range, 2-6 months) after the procedure. Follow-up MRI assessment showed improved structural integrity of the tendon at 3 months after the procedure and complete return to normal structural integrity of the tendon in 16 patients (57%). Seven patients did not recover their presymptom sporting level (among them, 6 were considered treatment failures): 3 patients returned to sport at a lesser level, 1 patient changed his sport activity (for other reasons), and 3 needed surgical intervention.

Conclusion: In this study, application of 3 consecutive US-guided PRP injections significantly improved symptoms and function in athletes with chronic PT and allowed fast recovery to their presymptom sporting level. The PRP treatment permitted a return to a normal architecture of the tendon as assessed by MRI.

http://ajs.sagepub.com/content/42/4/906.abstract

Best Overall Exercise: PowerKnee Bike Program (Knee OA Part 4)

The PowerKnee Bike Program uses an upright exercise bike to work out all of your leg muscles.  It is the best overall exercise for knee pain and arthritis because it can do so much for you without significant impact on the joint.   By simply riding the exercise bike for 30 minutes 3 times per week you can also improve your cardiovascular fitness and burn a bunch of calories.  See the video below for details.

Record the calories you can burn in 30 minutes and compare your results week by week for a month.  If you are consistent in applying the PowerKnee Bike Program you have an excellent chance of decreasing your pain and improving your knee function.

As always, check with your doc before beginning any exercise program.

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Best Initial Knee Stretch "The Hammy" (Knee OA, Part 3)

Your hamstring tendons start on your pelvis and insert behind and below your knee. In almost every person, these tendons tighten with time.  Stretching your hamstring tendons is one of the best exercises you can do for your knee and back.  One study found "individuals with and without osteoarthritis of the knee are able to demonstrate immediate beneficial adaptations to a stretching intervention."
Reference

I recommend do a set of 3 hamstrings stretches, 3 times PER DAY.  Stretching multiple times per day is better than stretching only once a day or not at all.  You may be surprised with your improved flexibility if you are consistent about stretching.  See the video below for a simple stretch that can done anywhere.  I call it the "Hammy Stretch".



Start by placing your leg on a step, or low table.  Keep your back straight and your toes pointed toward the ceiling.  Then, simply hinge forward at your waist.  You will likely feel the stretch in the back of your thigh, knee and calf.

Consistency is the key to improvement.  Try this simple exercise and it will help your overall knee health and improve your ability to straightening your knee.  Hamstring stretching is like sunscreen, it is best to start early and continue to stretch throughout your life.

As always, check with your own doctor before beginning any exercise program.

Next time, we reveal the simple yet highly effective way to strengthen all of the muscle of your legs.

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Best Initial Knee Exercise: The QuadCrunch (TM) (Knee OA Part 2)

There are dozens of knee exercises you can do to strengthen the muscles around your joint.  One crucial muscle to strengthen is the quadriceps or "Quad".  Too often, however, this muscle simply does not cooperate.  We need a simple way to get started.  We need an exercise than can be done anywhere, anytime without any equipment.  Now, we have one, the QuadCrunch (TM).  

The QuadCrunch (TM) helps initiate and reinforce the contraction of the most important component of the Quad---the Vastus Medialis Obliquus or VMO for short.  

QuadCrunch (TM) Video

Simply, straighten out your leg and place your fingers over the inside portion of your thigh just above your knee.  This is where the VMO lives.   With your leg fully straight and your heel on the ground, push your leg toward the ground and try to contract the muscle.  If you are successful, you will see your kneecap move.  The reason to put your fingers on your muscle is to help your brain know it is contracting the muscle.  This helps reinforce the contraction.  

I recommending doing a set of 5 contractions, holding each contraction for 5 seconds, 5 times per day.  

This elementary exercise is often ignored but serves as the foundation for more advanced strengthening programs.  It can be helpful for people who want to strengthening their legs for any reason.  It may also be useful for patients with knee arthritis, patellofemoral pain, knee tendonitis and even meniscus tears.  (Always check with your doctor before beginning any exercise program)

Good luck and get started today.  Remember, this exercise can be done in shorts, pants and almost anywhere.  Simply place your fingers on your quad muscle and straightening your knee with your heel on the ground.  It is best if your are sitting on the edge of a chair.  

It is best to record how many sets per day you do.  That will help you be compliant with the exercise.  We will discuss exercise compliance more in a later post.  

Post any questions, comments or suggestions below.

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The Best Initial Treatment for Knee Arthritis (Part 1)

What is the best initial treatment for knee arthritis?

The answer is diet and exercise.

It isn't easy but diet and exercise are highly effective at reducing pain and improving function.  In a recent study of about 400 patients the combination of diet and exercise decreased pain scores by 45%.  This is impressive because most injection therapies improve pain by 30-40% and often only last 6 months.  This study showed benefits up to 18 months.   Patients who also completed both a diet and exercise program were able to walk 136 feet more than patients who only dieted during a 6 minute walking test. (Messier et al JAMA 2013)  This is a simple and inexpensive way to treat a problem that affects 10 million Americans and millions more worldwide.

Too often patients and clinicians fail to select this strategy.  Patients often do not recognize how overweight they are and may even get angry if their physician points it out to them.  Physicians lack the time and tools to appropriate help patients begin an diet and exercise program.  With 69% of Americans either overweight or obese, it is very likely that weight reduction should be part of most knee arthritis treatment plans.

So, here are some suggestions to get started.
(Always check with your own physician before beginning any program.)

Give your knee a pain rating from 0-10 overall as a baseline measurement.

1.  Weight yourself and calculate your Body Mass Index.  (BMI Calculator)
     Be honest about the weight.  Record your weight daily.

2.  Set a goal to lose 5 pounds in two months and KEEP IT OFF.

3.  Lose weight by trying the One Less Diet (TM)
     One less dessert, one less sugary soda, one less beer, one less bagel, etc
     Use any other safe and effective means to lose weight.

Weekly, update your pain rating for your knee.  After two months, compare your baseline weight and pain to your new weight and pain.  You may find that if you simply lose weight your knee will begin to feel better.  The side effects of losing weight will also be good for your heart and your waistline.

In the next post, we will discuss a simple exercise plan.

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TIger Woods Back Surgery Video (Example)

Tiger Woods will miss the Masters for the first time in 20 years because of back surgery for a herniated disc.  He had the surgery on Monday in Park City, Utah and will soon begin rehabilitation.  There is no time table for his return.

Below is a video of my own back surgery for a discectomy that was done via small portal incisions about 5.5 years ago.  I was miserable prior to the surgery and am amazingly better.  Many thanks to my excellent surgeons and physical therapists.  View the video below to gain a better understanding of the mechanics of the surgery.

Video of Lumbar Disc Herniation Surgery


I wish Tiger the best of luck in his recovery.  I hope his surgery will allow him to return to the golf course soon but more importantly at a much higher functional level for a long time.

It is important to note that a variety of biologic treatments for this condition are presently in development.  Hundreds of professionals worldwide are working on these solutions.  For more information, visit:  BiologicOrtho.com

More info via a detailed story about Tiger Woods and his back.

AM
TotalTendon