|Must be good to be number 1|
I've addressed knee pain before but since it's such a common problem that takes people to their medical care giver, let's go over where we are in 2014. Like the e-mail from this athlete we'll call Tina.
I recently had an MRI that indicated "full thickness chondral loss along the apex and medial facet measuring 0.8cm in dimension -focal severe patellar chondrosis. The initial injury occurred in a hockey game, and I made it substantially worse over a year attempting to cycle and elliptical. Currently simply walking 500 feet causes discomfort.
My OS gave me orthovisc injections, and sent me to physio to try to strengthen my VMO. There has been no improvement whatsoever.
I'd like to attempt some type of surgical fix. Would microfracture be a reasonable first step?
This is a request from an active athlete who wishes to remain so. Tina is describing a problem with the articular or joint lining cartilage. The phrase "full thickness chondral loss" refers to the cartilage on the back of her knee cap. Although we as humans seem to tolerate arthritis in this part of the joint better than the weight bearing areas, Tina has an area where the cartilage has been worn completely through down to the underlying bone. Although this sounds like something old people - watch it there, Post - have, it's really quite common in the athlete.
When the joint lining cartilage begins to break down, arthritis if you will, the owner has a problem. It doesn't happen overnight and very frequently the owner of the knee is hard pressed to remember a specific accident or incident that lead to the current complaints. Initially of course, conservative (read non-operative) options are tried including activity modification, NSAIDs, injections of various substances, maybe even physical therapy or bracing depending on the situation. If these prove unsuccessful, the talk may turn to arthroscopy of the knee, usually performed in the outpatient setting under either general or regional (not local) anesthesia. Two or three, one quarter inch incisions, so small that suture closure is rarely necessary, is all it takes.
One of the tools available during arthroscopy is known as microfracture. The goal is to get the body to use it's own resources to "heal" this cartilage problem. Although not a cure for arthritis, it can produce a new type of cartilage where there was little to none, in selected patients, and upwards of 80% of patients exhibit a reduction in pain and swelling and improvement in function.
During microfracture surgery, if the surgeon feels the patient qualifies, a small awl is placed through the arthroscopic holes and a series of small "holes" or punctures are made in the arthritic area about 4mm apart to allow bleeding and the formation of a uniform clot. Slowly, over time the clot matures and patches the damage. Crutches are often used for the first 6 weeks or so but motion is encouraged. Rehab might include Physical Therapy, weights, stretch cords and occasionally a brace. My patients would not be permitted to return to sports for 4-6 months following the procedure, some even longer if they participated in a jumping sport. This would best be determined by one's Orthopedist who knew the exact size and location of the lesion. Most patients continue to slowly improve over the first year post-op, some even the first two years.
A small percentage will fail and they may become "ex-runners" knowing that some day they may need further knee surgery of a greater magnitude. Although there are a host of knee arthritis procedures, this one has given many mid term happiness and a return to athletics.
Surgeons have tried a number of different options over the years to try and make this a life long repair. OATS, Osteochondral Allograft Transfer is one attempt. It allows the operating surgeon to transplant normal articular cartilage from one part of the knee to another. But, the indications are pretty narrow.
In this months Journal of Arthroscopy and Related Research a study by Steadman, et. al. discusses the use of stem cells (See my blog from 10/25/2011) to augment microfracture. They note that "Arthroscopic and gross evaluation confirmed a significant increase in repair tissue firmness and a trend for better overall repair tissue quality..." Although this particular study was done in horses, I suspect that further studies using a human model are right around the corner. Physicians have been harvesting stem cells (frequently from an area of the low back) and re injecting them for a variety of conditions over the years. One such treatment is called Regenexx ( see www.regenexx.comm) where, for a host of conditions, the non-surgical use of stem cells seems promising in the short term.
A fascinating recent development in cartilage repair is called BioCartilage, "designed to provide a reproducible, simple and inexpensive method to augment traditional microfracture procedures. It is developed from allograft cartilage that has been dehydrated and micronized. BioCartilage contains the extracellular matrix that is native to articular cartilage" made by the Arthrex Corporation.
This is a relatively new product but the hope is that it produces a more permanent match to one's own articular cartilage. If it develops a successful track record over the long haul, it could be a real boon to the athletic community.
"Hold on to 16 as long as you can, changes come around real soon make us women and men*."
Tiny little creatures that live in your closet and sew your clothes a little bit tighter every night.
Images 2, 3 Arthrex Corp
* John Mellencamp