The Approach to Knee Restoration and Orthobiologics

The Knee Restoration and Orthobiologics Center has earned an international reputation for excellence in patient care and offers the latest in strategies for conservative and operative management of various knee conditions. Our nationally recognized research efforts document outcomes to provide patients with realistic information on clinical outcomes and patient expectations regarding treating knee symptoms and improving function. The Center provided the healthcare community with some of the first clinical publications on operations for osteoarthritis, including meniscus repair, meniscus transplantation, and tibial osteotomy to restore joint function and limit or slow the need for joint replacement.

The Approach to Knee Restoration

Articular Cartilage Injuries of the Knee

Articular cartilage is a complex, highly organized structure that serves as the outer covering of bones within a joint and functions to decrease force while allowing for low-friction motion. Injuries to articular cartilage of the knee are becoming increasingly common and can cause significant pain and dysfunction. These injuries are often referred to as “chondral defects” or “chondral lesions”. Studies have demonstrated chondral lesions in as high as 61%-66% of patients undergoing knee arthroscopy (Curl 1997, Aroen 2004, Hjelle 2002).  The overall prevalence of chondral defects of the knee in athletes has been estimated to be 36% (Flanigan 2010). However, the true incidence and prevalence is difficult to determine since a large percentage of defects are asymptomatic. Chondral lesions that do cause pain and dysfunction have the potential to progress to osteoarthritis (wearing out of the knee) in some cases. Unfortunately, cartilage lacks a blood supply and exhibits poor healing potential but there are non-surgical and surgical treatment options available for these injuries. Surgical intervention may delay or prevent wearing out of the knee in select symptomatic patients who could be at risk for developing osteoarthritis.

Symptoms and Diagnosis

Patients with symptomatic chondral defects typically present with knee pain and swelling. Mechanical symptoms such as catching and locking may be present as well as instability (giving out of the knee).  Traumatic etiologies are often associated with a specific event such as a fall or twisting injury while playing sports. On the contrary, idiopathic lesions (lesions of unknown etiology) and those associated with repetitive microtrauma may have more of an insidious onset without an event the patient can recall.  The first step toward a diagnosis is a visit to a physician, who will obtain a detailed history regarding the onset of symptoms. After obtaining a detailed history, a comprehensive physical examination will be performed by the physician. The exam begins with a gait analysis followed by assessing for swelling, deformity, motion, and stability of the knee. X-rays will be ordered to look for fractures, loose fragments, bone spurs and joint space narrowing. MRI may also be ordered to evaluate the articular cartilage and the bone beneath it. Results of this imaging will help the physician determine how serious the injury is and establish a treatment plan.

Care Management

The Approach to Orthobiologics

Orthobiologics refers to the treatment of musculoskeletal disorders using different autologous and allogenic products.  This treatment modality has been incorrectly advertised as “Stem Cell Therapy” however importantly these products often do not contain any stem cells or in such a small amount to not have patient benefits. Furthermore, there is no scientific evidence of regenerative or direct reparative effects of any of these products despite the majority of advertising on the internet and clinics stating the opposite.  Recently Kingery et al (JBJS 2020) reported that 95.9% of practice websites contained at least one statement of misinformation and “failed to accurately represent the clinical efficacy” of “Stem Cell Therapy”.  It is in fact unethical and illegal to advertise or promote such deceptive claims and accordingly physicians and hospital systems are currently experiencing great difficulty in responding to patients requests for these types of treatment modalities that are not based on accurate scientific evidence.

For the benefit of our patients we wish to provide an overall summary of all the therapies that are involved in treating symptomatic knee arthritis. These therapies progress in a step wise manner from using simple modalities to progressing to the more sophisticated injectable products that involve platelet rich plasma from the patients’ blood as well as bone marrow or fat harvest from the patient. We present the realistic expectations from these later Orthobiologic products and again note that well controlled clinical trials are still forthcoming and the scientific evidence of efficacy is still unknown.  Many of these Orthobiologic products have been shown to be beneficial in certain clinical studies as the products contain growth factors and cells that reduce inflammation and pain symptoms (not reparative or regeneration effects as already discussed). On the other hand, there are clinical studies that show reduced or less beneficial patient effects with up to 30% to 50% of the patients experiencing little or no benefit.  Therefore, in using the Orthobiologic products it is often not possible to inform a patient if they will be in the responding beneficial group or have no beneficial effect.  This represents a major problem as these products are often expensive and paid for by the patient without insurance coverage.  As a result, it is important that the physician fully inform the patient on this issue with complete transparency.

Patient Guide for the Medical Non-Operative Treatment of Knee Arthritis

This guide is prepared by Frank R Noyes MD based on over three decades of treating knee arthritis in thousands of patients. This guide has many useful suggestions and guidelines for the safe and effective treatment of knee arthritis.  However, the guide is not meant to be the only approach and patients are advised to be well informed and ask guidance from their primary care physician, pharmacy and other specialists.

Remember, every medicine has beneficial effects, but every medicine has “a little bit of poison” meaning side effects that need to be avoided if possible.

The overall goal is to select the safest approach with the least amount of medicine and side effects.  Secondly to understand that the treatment of knee arthritis involves an entire program of rehabilitation, keeping active, weight control, possible knee braces and other treatments and it is not correct or beneficial to rely only on medicines.

For example, exercises are a major part of the treatment of arthritis and you should be under the care of an experienced physical therapist for a home program that is performed at least three times a week!  Weight control is so important and for every pound you weight you place 3 to 6 times that amount on your knee joint in just walking or climbing stairs!  With knee arthritis your activity decreases and your ability to burn calories taken in by your food also decreases so you need to adjust your diet and avoid high carbohydrate foods that put on weight.

Use of Oral Over the Counter Medicines

Use of Oral Anti-Inflammatory Prescription Medications

Use of Creams Applied to the Skin Over the Knee Joint

Steroid Injections for Knee Arthritis

Use of Hyaluronic Gel Inections for Knee Arthritis

Platlet Rich Plasma (PRP) Injection for Knee Arthritis

Umbilical Cord Blood and Placenta Knee Injections for Arthritis

Bone Marrow Injections (BMAC) for Knee Arthritis

Fat Cell Injections for Knee Arthrits

Final Comments on Stem Cell Injections (PRP, BMAC Fat cells)

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CSMOC is an award-winning center for orthoapedic treatment in Cincinnati.

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When you experience an injury or have pain, your goal is to seek health care that will return you to a quality lifestyle as soon as possible. You want a physician that is the absolute best in their field – one that can diagnose and treat you right the first time.