Advanced Knee Care

Knee Surgeon and Specialist Stefan D. Tarlow, M.D.

Evidence Based Treatments for Knee Osteoarthritis

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What works:

Strengthening Exercises with neuromuscular education*

NSAID (pills such as ibuprofen and naproxen)

Appropriate weight loss if BMI > 25

Total or partial Knee Replacement

Cannot Recommend for or against:

IA steroid injection

Acetaminophen

Manual therapy, electrotherapeutics

Knee arthroscopy for meniscus

Cannot Recommend:

IA Hyaluronic Acid (viscosupplementation)

Braces

Arthroscopy – clean out

Glucosamine and Chondroitin

Acupuncture

Insoles

*The Alexander Technique (AT) is a method of neuromuscular re-education which aims to teach individuals how to improve postural support, reduce potentially harmful patterns of muscle tension and improve control of response. AT lessons provide an individualised approach to developing skills that help people recognise, understand, and avoid poor habits adversely affecting postural tone and neuromuscular coordination.

Knee Osteoarthritis Treatment Ranked for Pain and Function

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Non surgical treatment for osteoarthritis of the knee is most successful for mild to moderate disease.  Usually the pain and function from severe knee OA requires partial or total knee replacement surgery.

Patients need to know how likely a particular treatment is.  This study ranked the effectiveness of oral pill treatment and intra articular injections categorized based on pain symptom relief and knee function improvement.

The 3 most effective treatments for knee OA pain are Intra Articular steroid injection, oral ibuprofen and knee injection with Platelet Rich Plasma.

The 3 most effective treatments for knee OA functional limitations (limp, diminished walking ability) are non steroidal anti inflammatory medications – Naproxen, Diclofenac and Celecoxib.

The 3 most effective treatments for both knee pain and  knee OA functional limitations are oral Naproxen pills, Intra Articular steroid injection and knee injection with Platelet Rich Plasma.

Of note, hyaluronic acid (also known as viscosupplementation) injections is at best in the lower half of the effectiveness scale.  Similarly, Tylenol (acetaminophen) is not therapeutic.

This study can be found in the JAAOS, May, 2018.

Vitamin D, Knee Surgery and Sports

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Vitamin D has hypothetical and proven benefits for orthopedic surgery patients and athletes.

I advise my joint replacement patients to begin 800 IU of VitaminD3 one week prior to continuing for 3 weeks total due to theoretical benefits for reduced infection risk.

Vitamin D has been shown to increase muscle strength, reduced injury rates and improve sports performance.

Vitamin D is also known to be importance for  bone metabolism.

 

Mortality Following TKA is Declining

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Research on outcomes for joint replacement surgery has led to targeted patient selection for Total Knee Replacement surgery.  Risk factors for poor outcomes include obesity, uncontrolled diabetes, smoking and cardiovascular disease.  Great emphasis has been placed on modifying risk factors PRIOR to knee replacement surgery. Many patients are willing undergo an intervention which lowers their chance for an adverse outcome.  It appears that this approach is benefitting our patients.

There is an ongoing worldwide temporal decline in mortality following total knee arthroplasty. Improved patient selection and perioperative care and a healthy-population effect may account for this observation. Efforts to further reduce mortality  following total knee arthroplasty should continue.  Patients that are unable to be “optimized” should be offered alternative, non surgical treatments.

An article published in JBJS June, 2018 explored this topic.

Mortality data from 15 different countries following over 1.75 million total knee replacements formed the basis of this review. 30 and 90-day mortality were 0.20% and 0.39%. Both estimates have fallen over the 10-year study period.

Weight Loss Slowed Rate of Knee Degeneration

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A 4 year study using MRI to look at knees showed the rate of knee degeneration/wear.  The more weight loss, the slower the rate of knee destruction.  Another study showed that combining weight loss with exercise with dietary modification improved exercise tolerance (walking) and improved weight loss.  Finally, the proportion of obese patients with artificial knees requiring repeat replacement surgery  has increased dramatically over the last 10 years.  Obese is a modifiable risk factor for failure of Total Knee Replacement  that should be addressed prior to knee replacement surgery.

Unicondylar (Partial) Knee Replacement Comparable to Total Knee Replacement

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In properly selected patients with isolated, single compartment arthritis of the knee success at 2 years post op is similar.  Young age, BMI > 30, and low surgeon volume are associated with decreased implant survivorship and higher failure rate.

Makoplasty Robotic Partial knee replacement is an great alternative to full knee replacement.  Read this link and learn more.

Running Does Not Lead to Knee Arthritis

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A 2018 report in the JBJS found a lower incidence of knee and hip damage (osteoarthritis) in active marathon runners.  675 Marathoners were questioned.   These runners on average had run for 19 years logging an average of 36 miles per week.  Arthritis prevalence was only 9 % for runners vs. 18 % for the US population.  Seven of the marathoners were able to keep running after hip or knee replacement surgery.  So the question is why ?  Is it lower BMI, better muscle mass, better bone density, or is impact loading exercise actually protective to our weight bearing joints.  At this time, the answer is not known.  What is known is that running is good for knees and hips.

Robotic Knee Replacement Trends

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A recent analysis of Utilization Trends show Robotic /Computer assisted Knee Replacement surgery is increasing in the US.  Approximately 12 % of Knee replacement cases in 2015 up from 4 % in 2008.   29 % of Facilities (hospitals, ASC) and 17 % of Orthopedics Surgeons use robots/computers for hip or knee replacement surgery.  This is the most recent data available and is from 2015.

PRP for Knee Chondral Defects

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PRP for Chondral Defects): Partial Thickness Knee Lesions

PRP (platelet rich plasma) is an injection treatment performed in the office. PRP for the knee is a biologic regenerative medicine treatment that does not require a surgical procedure.  Knee chondral defects have a limited capacity for self repair due to the low biologic activity of chondrocytes and its lack of blood supply. Articular cartilage defects often fail to heal spontaneously and may result in progressive deterioration and eventually osteoarthritis.

PRP is used to treat the symptoms from partial thickness chondral defects of the knee. Platelet-rich plasma (PRP), with a rich source of autologous growth factors, can promote healing of partial thickness chondral defects in otherwise healthy knees.   PRP owes its therapeutic use to scientific evidence that growth factors released by the platelets possess multiple regenerative properties. Platelets are involved the complex process of tissue repair by the release of these growth factors. Studies have suggested that PRP stimulate either cell proliferation or matrix metabolism by articular chondrocytes

Symptoms of Knee Chondral Defect:

Patients with a knee chondral defect may have pain and swelling with activities, or a “noisy knee” .  The diagnosis is made with a 3T MRI.

PRP is an In Office Procedure:

PRP comes from your blood.  A nurse draws the needed amount of blood from your arm.  Your blood is processed in the office and the PRP that is produced is then injected into your knee.  The process takes 1 hour.  The preparation used at Advanced Knee Care is Emcyte PurePRP (https://www.emcyte.com/pureprp-sp/. For knee OA, leucocyte-poor PRP appears to be better than leucocyte-rich PRP.

How does it work in Chondral Defect knees?

In the knee, the release of growth factors from PRP occurs immediately and lasts for around three weeks and the clinical effect tends to wane down by the end of the year. Prolonged and sustained release of growth factors from platelets could possibly help in biological healing and anti inflammatory effects.

More specifically (and a bit technical):

PRP acts at various levels to alter and improve the joint homeostasis.

Within the knee: Platelet alpha-granules contain and release numerous growth factors, including hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF) and transforming growth factor-b (TGF-b) , which are good proteins in may promote healing.

The cells lining the knee, synoviocytes are influenced by increased hyaluronic acid (HA) secretion, creating a more favourable and balanced state of blood flow, and a decreased of “bad proteins” like interleukin-1 (IL-1) and  matrix metalloproteinases (MMPs).

The death of knee cartilage cells (chondrocytes) is probably diminished through a complex interaction of PRP in the knee joint as insulin-like growth factor 1 (IGF-1) in PRP may slow the expression of programmed cell death 5 (PDCD5). 

An overall suppression of the joint inflammation can explain the pain reduction effect, which is the most prominent and disabling symptom of knee OA.  PRP counteracted the inflammatory cascade by inhibiting these “bad proteins” with names like IL-1ß,TNF-α, COX-2 and MMP-2 gene expression.

Researchers have noticed increase in mRNA levels of cannabinoid receptors CB1 and CB2 (receptors involved in analgesic and anti-inflammatory effects) and this could explain the analgesic effect of PRP.

PRP is safe.

PRP is a fascinating biological possibility as a therapeutic approach for cartilage pathology.

The present state of knowledge holds promise for PRP in certain applications to promote healing of  Knee Chondral defects. Nevertheless, a lot of grey areas remain in our understanding of PRP and articular cartilage healing, and many more focused clinical and in vitro studies are required. 

PRP is definitely there to stay for knee cartilage therapy treatment in future.

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