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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 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.
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.
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.
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.
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.
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.
PurePRP II is an autologous cellular biologic that has become standard of care for many treatment modalities. In today’s world of regenerative medicine, clinicians are requiring products that are not only clinically eﬀective but, also have the versatility to provide for speciﬁc treatment requirements. This may include therapeutic strength PRP with low neutrophils and no red blood cells. Or it may include therapeutic strength PRP with high neutrophils and nominal red blood cells. Some physicians may require a bioregenerative ﬁbrinogen matrix scaﬀold to support PRP retention and sustain growth factor release. Others may require protein compositions to help mitigate cellular degradation. Whatever the need, PurePRP® II has the biologic versatility to be an integral part of the treatment modality.
Deliverable platelets are the actual volume of viable platelets contained in a PRP sample. PurePRP® II provide upwards of 9.5 billion platelets in a 7mL treatment sample (approximately 1.4 million platelets per microliter). High volumes of deliverable platelets enhances the volumetric activity of platelet growth factors and cytokines in active tissue repair. Platelet alpha granules contain various platelet growth factors that promote tissue repair through cell proliferation, chemotaxis, diﬀerentiation, and angiogenesis. Platelet cytokines provide the chemical stimulus needed to mediate cell signaling and migration. The amount of deliverable platelets are clinically signiﬁcant if you are to attain active tissue repair. It is imperative that your deliverable platelet count be more than 1 million platelets per microliter.
Neutrophils are the most abundant leukocyte and one of the ﬁrst-responders to migrate towards a site of injury or infection (chemotaxis). Neutrophils are also the hallmark of acute inﬂammation. This is an aggressive response of chemical signals from cytokines such as interleukins (IL-1, IL-8) and tumor necrosis factor alpha (TNF-α) along with many others. The primary function of the neutrophil is to engulf and destroy foreign material through phagocytosis. Under normal circumstances, neutrophils are short lived (1-2 days) and are cleared by tissue macrophages. In conditions where the neutrophils cannot be cleared, for a lack of macrophages, they undergo a process called necrosis resulting in the release of all of the intracellular contents. This causes the ampliﬁcation and prolonging of the inﬂammatory response. This prolonged ampliﬁed inﬂammatory response potential, is a concern of many physicians. This is why physicians are not encouraged by a PRP product containing high concentrations of neutrophils.
Monocytes are the largest of all leukocytes and are characteristically non-inﬂammatory phagocytic cells. Monocytes migrate to sites of injury and infection and diﬀerentiate into macrophages and dendritic cells to elicit an immune response which last for longer periods of time (months rather than days when compared to neutrophils). Monocytes illicit the immune response through phagocytosis, antigen presentation, and cytokine production each of which has a speciﬁc and deliberate function in enhancing the immune response through both protective prophylaxis and active phagocytosis.
PurePRP® II is unique in that it greatly enhances monocyte concentrations, while giving the end user control over the amount of neutrophils they would like to add to their PRP preparation. PurePRP® II takes advantage of the long term phagocytic and protective properties of the monocytes while avoiding the potential harmful inﬂammation incurred by large concentrations of neutrophils that go through cellular necrosis. This is another diﬀerentiating factor that help to explain the natural success of PurePRP® II in patient outcomes.
Protocol A processes PurePRP® without red blood cells or neutrophil granulocytes. This protocol is used when powerful healing without inﬂammatory activity is required at the application site. This protocol is also the low viscosity solution to a viable PRP product, providing very high concentrations of platelets in a bath of non-viscous plasma. This protocol has also been reported to reduce the potential for pain at the application site. It is the most frequently used protocol.
Protocol B processes PurePRP® with low red blood cell counts and very high cytokine activity and neutrophil cell recoveries. This protocol is used when the phagocytic powers of neutrophils are needed to help ﬁght infectious processes at the application site. This protocol produces the highest chemoattractant activity and signiﬁcantly increases regeneration potential. Once the neutrophils have completed phagocytosis, they become apoptic cells and are subsequently removed, thereby also eliminating the inﬂammatory activity.
The AbsolutePRP™ Concentrating System has been re branded from the former 544e. AbsolutePRP™ provides the complete PRP composition. Therapeutically high concentrations of platelets and growth factors along with very high concentrations of neutrophils, monocytes and other cell mediating cytokines. AbsolutePRP™ is the fastest and most eﬃcient single spin 60mL concentrating systems available. Prepare 7mL of PRP, with high concentrations of regenerative cells, in a SINGLE 5 MINUTE SPIN. These systems were designed to accommodate physicians that run a busy practice and mandate superior performance outcomes that is consistent and reliable.
The AbsoluteBMC™ Concentrating System has been re branded from the former 544e. AbsoluteBMC™ provides signiﬁcant concentrations of CFU-F, CD34+, and total nucleated cell counts. CD34+ are cell markers for hematopoietic stem cells. These are the primary multipotent cells that replenishes all blood cell types. These cells are crucial for the regenerative processes needed for active tissue repair. In addition to these cells are CFU-F, which are representative of mesenchymal stem cells. Mesenchymal stem cells (MSC) are multipotent stromal cells that can diﬀerentiate into a variety of cell types, including cartilage, bone and adipose cells. AbsoluteBMC™ provides therapeutic concentrations of these cell types which is the key to desirable patient outcomes. AbsoluteBMC™ is the fastest and most eﬃcient single spin 60mL concentrating systems available. Prepare 7mL of BMC, in a SINGLE 5 MINUTE SPIN.
The QuickDRAW Delivery System is a state of the art delivery system that contain proprietary valve ports that permit simultaneous ﬁlling and delivery of the PRP plus activator. The system comes with a malleable spray tip or a dual spray tip. The dual spray tip permits activation at the delivery site and not in the device. This allows the delivery system to be used leisurely without clotting at the tip.
FDA cleared sterile resorbable granule bone graft composed of puriﬁed ﬁbrillar type I collagen, 60% hydroxyapatite and 40% tricalcium phosphate . The device is safe and has excellent biocompatibility. After implantation, the graft resorbs and is later replaced by natural bone. Comes in 5cc strip or 10cc strip
The Tabletop Device Holder accommodates four 60mL concentrating devices. The Device Holder permits hands free operation and help to maintain stability while operating the concentrating device.
The EmCyte Plasma Concentrator contains a 7mL concentrating chamber with microﬁber ﬁlaments that quickly and accurately concentrates the plasma proteins. This system eﬀectively concentrates ALL plasma proteins, including albumin, α2-macroglobulin, ﬁbrinogen, regulatory proteins and clotting factors. Approximately 60mL of plasma can be concentrated down to 13mL in less than ﬁve minutes without centrifugation.
PureBMC® is better than ever and remains the ﬂawless solution to Bone Marrow Cell Concentrate. PureBMC® processes BMC in a system that remains closed and sterile throughout all steps of processing. This is especially important when processing in a surgical suite. It is also proven to concentrate viable platelets, hematopoietic stem cells (HSC), total nucleated cells (TNC) and mesenchymal stem cells (MSC) in a bath of plasma with a low hematocrit. PureBMC® can be prepared with or without Heparin, either way it provides viable platelet concentrates that further add to the strength of the cell composition. PureBMC® delivers the excellence and reliability physicians can depend on.
Hematopoietic stem cells (HSCs) are the blood cells that has the ability to replenish all blood cell types (Multipotency) and the ability to self-renew. This include monocytes, macrophages, erythrocytes, megakaryocytes, platelets, neutrophils, basophils, eosinophils, dendritic cells and lymphoid lineage cells.
Mesenchymal stem cells (MSC) are multipotent stromal cells that can diﬀerentiate into a variety of cell types. These cell types primarily include cartilage, bone and adipose cells. Mesenchymal stem cells are found in very small quantities in bone marrow aspirate, making the concentrating capabilities of PureBMC® more vital to the physician.
Total nucleated cell count by any method is a count of cells with nuclei. In order to properly represent the TNC cell count a correction calculation that removes nucleated red blood cells (nRBCs) is performed. It is understood, as in other therapies, that more cells better outcomes. GenesisCS
PureBMC® has been designed to improve performance outcomes. The design details allows the end user to more accurately collect high therapeutic cell concentrates with low red blood cell content.
Same Great Outcomes Hematopoietic stem cells (CD34+), total nucleated cell (TNC), mesenchymal stem cell (CFU-F) and platelet isolation is perfected in the PureBMC® system. PureBMC® retains high concentrations of these cell types with the lowest concentrations of red blood cells in a bone marrow concentrate product. Using a specialized cell isolation technique, PureBMC® provide more than 9X cell concentration in 7mL of PureBMC® . Preparation times are less than 10 minutes at the point of care. With careful attention to the details of gradient cell isolation, PureBMC® is a viable choice for a low hematocrit and high yielding bone marrow cell concentrate product.
PureBMC® provide selectable sample volumes ranging from 3mL to 14mL. No matter what the sample size, PureBMC® provide therapeutic cell counts that exceed industry standards.
See the Ongoing Performance Analysis Report Campaign, for PureBMC® at https://www.emcyte.com for the “always current” and up-to-date analysis of the performance of the PureBMC® system. This system was developed to provide objectivity and transparency in the clinical performance of the EmCyte systems. To be a participant in sample submission, call 239-481-7725 or visit the website for more information.
The data provided in the Ongoing Performance Analysis Report Campaign is independently reviewed at a reputable laboratory.
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
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 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.
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 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.
Scottsdale Knee Specialist & Surgeon – Stefan D. Tarlow M.D
Stefan D. Tarlow, MD, is Arizona’s premier “knees only” orthopedic surgeon.
© 2019 | ALL RIGHTS RESERVED. ADVANCED KNEE CARE, STEFAN D. TARLOW, M.D.