05 May Knee Pain Solutions in a Post Pandemic World
Treatment for Knee Pain:
1. Knee Pain Solutions in a Post Pandemic World
2. PRP or Stem Cells? Which to choose before considering a total knee replacement in a Post Pandemic World.
By Paul Eliot Hughes, M.D., Founder and CEO of Hughes Orthopedics in San Mateo, CA
Knee pain can be caused by arthritis, degenerative disease, or other conditions including injury for which there are many medical intervention treatments available. It is common for medical doctors to suggest treatment with medications for knee arthritis. Oral medication including Tylenol, non-steroidal anti-inflammatories (NSAIDS) or other oral pain medications (even hydroxycholoquine has been used for severe knee joint inflammation) are commonly used to control the pain but do not change the direction and progression of the disease. When treated by a medical doctor certain medicines can be injected into the painful knee. These injections include corticosteroids or hyaluronic acid (i.e. Synvisc or Hyalgan). But it has been shown that multiple cortisone injections into the knee joints can worsen degeneration and progression of the arthritis. All of these medications are well known and have been effective in many medical practices to treat knee pain for decades. However, these medicines can only treat the symptoms of pain and do not change the underlining pathology of the erosion and degeneration of the cartilage of the knee.
Having accelerated or severe osteoarthritis of the knee is not benign, as advanced arthritis patients were approximately 25 times more likely to have a knee replacement within 9 years than those with mild arthritis. Since the decision to have surgery for an injured knee joint is one that most patients want to avoid, there is a movement in medicine and orthopedic surgery to look for alternative biologic treatments. A new generation of biologic therapies and injections have emerged in recent years to treat knee pain. These treatments are platelet-rich plasma (PRP) and stem cells. And both these biologic injection therapies not only help relieve people of pain but also can stop the degeneration of the knee joint by restoring, regenerating and repairing the damaged cartilage.
How PRP Works
After conventional treatments for joint pain have failed many patients are now looking into PRP or stem cells as a more modern and technologically progressive choice of therapy. PRP is obtained by drawing a small sample of the patient’s own blood (usually just like a normal lab draw) and processing it through a centrifuge that separates the plasma and removes the red blood cells. PRP is an autologous biologic fluid concentrated with activated platelets, which release mediators, growth factors and other cellular agents (cytokines) after being injected into the knee joint. PRP injections reduce inflammation and provide a local healing of the knee cartilage. Thus, PRP can reduce knee pain and increase activity level of the patient. PRP has been praised by professional athletes like Tiger Woods, who have gone through PRP injection therapy to help him recover from an injured knee.
How Stem Cells Work
Stem cells are a certain cell that can evolve and change to become different tissues in our bodies. Not all stem cells are the same and can come from different sources. In the USA, allergenic stem cells from placentas of live births are harvested to provide fetal cells from the umbilical cord and amniotic tissue. Many medical doctors and orthopedic surgeons treating knee pain prefer to use one’s own autologous stem cells to avoid potential infections of the joint and rejections of the graft as has occurred with fetal cell treatments. These adult stem cells can come from a bone marrow aspirate concentrate or adipose (fat) tissue concentrate. An aspiration from the bone or fat (liposuction) is done to get marrow or adipose cells which are prepared for injection by a centrifugation process. These stem cells, unlike PRP which has little or no cells in it, can become cartilage and can heal the injured knee joint. Since PRP and autologous stem cells come from the patient themselves, there is no risk of a transmissible infection and a very low risk of allergic reaction and is a very safe procedure when performed by a well-trained experienced orthopedic surgeon.
Band-aid VS a Solution:
The decision whether to use PRP or stem cells can be a place of contention. So, the question can be which one to choose. Both of these sterile injections, when done by an expert, are placed with precision into the knee joint using ultrasound guidance. PRP has been shown in many studies to decreased knee pain caused by arthritis of the knee. The PRP solution itself cannot become cartilage after injection but signals a healing process using the cytokines and growth factors to stimulate the local tissue to heal. PRP and stem cells can decrease the local inflammatory response that causes the pain in the arthritic painful knees. In addition, stem cells from bone marrow aspirate concentrate (BMAC) or adipose tissue can heal our joints by differentiating to become cartilage or other local tissue. Stem cells have the ability to become bone, cartilage, muscle, tendon, fat or even synovial cells. These are live cells and can be present for long periods of time after the injection signaling local cartilage cells to heal, decrease inflammation and grow cartilage themselves. The presence of stem cells injected into problematic painful joints can help decrease pain from inflammation by cellular modulation and releasing exosomes. There are studies that have shown that bone marrow aspirate concentrate (BMAC) can decrease joint pain and can increase the volume of meniscus tissue and cartilage tissue in the knee as seen on MRI. Stem cells are a very powerful treatment for knee pain.
PRP injections costs less than stem cell treatments. There can be a progression of treatment options to try PRP treatment first and if it does not work or not enough relief is achieved than patients can move on to stem cell treatments. An advantage to BMAC therapy injections is that the by-product of the concentration of the bone marrow aspirate is a platelet pore plasma which is similar to PRP and is used in conjunction to BMAC at the time of injection to help nourish and stimulate the stem cells to produce a healing effect. The use of bone marrow stem cells (mesenchymal or adult stem cells) in orthopedic surgeries has been present for many years. These surgeries were microfracture treatments of knee joints by making small holes in the bone allowing bone marrow cells to leak inside the joint to heal the areas of lost cartilage to promote a healing response. Numerous studies have shown that microfracture in knee arthroscopy surgery can heal the cartilage. The ability to concentrate the bone marrow cells from an aspirate, thus increasing the number of adult stem cells present, gives a potentially higher healing effect in the knee joint compared to a microfracture surgical procedure. Because of the strong cellular effect stem cell therapy tends to have higher potential healing effect on the knee joint than PRP and should be considered as the first choice of treatment for the arthritic knee. The earlier a biologic treatment of stem cells or PRP is done the more likelihood of avoiding surgeries such as a total knee replacement because the loss of cartilage can be halted and the healing effect can begin. If all medical therapies including stem cells and PRP have failed for knee pain in the arthritic knee than one can proceed with a knee replacement or arthroscopic surgery knowing they have tried all reasonable non-operative solutions.
Simply put, the combination of the two of has the power to alleviate pain and inflammation, while simultaneously repair the knee – without evasive surgery. One of the drawbacks to only using PRP, is that a patient has to constantly go back for injections, which can start to add up financially and does not solve the underlining issue. If a patient is able to combine PRP with Stem Cells, it provides the patient with a quicker road to recovery, as well as saves money on a lifetime of PRP injections. At Hughes Orthopedics we routinely use stem cells with PRP booster injections to increase the healing and regeneration of the knee and typically see significant improvements by 6 months post injections.
In conclusion, choosing a treatment with stem cells and PRP can be a great way to decrease pain and to increase the healing potential of the knee joint. The process is done as an in-office procedure and takes about 1-2 hours with little pain and virtually no recovery time, a little soreness is all that is expected. How do we keep this a relatively pain free procedure? We for one have over 20 years of experience in giving joint injections (over 10,000 performed). Also, our skills in providing local anesthetic is second to none. We expect to keep our patients comfortable during all portions of the procedure from the aspiration of the bone marrow or fat to the injections into the knee joint. Our patients who have gone through the stem cell procedure always say they are surprised how easy and unexpectedly comfortable the process was. Significant pain relief can happen almost immediately and final improvement is expected by 6-12 months.
One of the drawbacks of the current post COVID-19 epidemic, is that people are stuck are in their homes, they decide to go for a jog and hurt, or reactivate their injury, and because all non-emergency appointments have been temporarily suspended, the patient needs to live with that knee pain until the medical world “reopens.” This can lead to a painful few weeks, or months, as well as depression without getting physical exercise. This is why Hughes Orthopedics is taking virtual appointments to learn about the patient’s knee pain, and in some cases, providing home calls, or visits to patients with severe knee pain that are ready for stem-cell therapy. We do this by listening to our patient’s issues and deciphering through the best modern treatments available to point our patients towards a course of recovery and a pain-free lifestyle without the need for surgery.
About Hughes Orthopedics and Addressing Pain During A Post Pandemic Crisis:
At Hughes Orthopedics we have a research study that shows with statistical significance that bone marrow aspirate concentrate (BMAC) injections in patients with knee pain has successfully shown an increase in the activity scores and a decrease in the pain scores of our patients. Over 85% of our patients have this significant improvement. Our PRP and stem cell process is in accordance with FDA and is a safe way to obtain treatment for your knee pain. The earlier the intervention with PRP or stem cell therapy is done, an alteration of the natural history of joint disease and degenerative progress can be expected. We are excited to continue providing stem cell therapies to the knee and other painful joints including treatments of the shoulder, hip, wrist, hand, elbow and ankle which also are showing pain relief with stem cell treatments. Multiple joints can be treated with one single visit at our office.
Please contact our office by phone, message or email about setting up a free 15 Minute Zoom or telemedicine consultation. Inquire about possible house calls or in-person appointments that can also take place in our clean and constantly disinfected office by appointment only – there will never be more than one patient coming through the office at a time. We want our patients to always feel safe and protected as we work to solve your painful joint problems.
Hughes P.E.: The Eﬀects of Autologous Stem Cells from Bone Marrow and Adipose Tissue on Patients with Knee Osteoarthritis, World Stem Cell Conference 2020, Barcelona, Spain (Abstract accepted)
Davis J.E., Liu S.H., Lapane K., Harkey M.S., Price L.L., Lu B., et al.
Adults with incident accelerated knee osteoarthritis are more likely to receive a knee replacement: data from the osteoarthritis initiative. Clin Rheumatol, 37 (2018), pp. 1115-1118
Collins J.E., Losina E., Nevitt M.C., Roemer F.W., Guermazi A., Lynch J.A., et al.
Semiquantitative imaging biomarkers of knee osteoarthritis progression: data from the foundation for the national institutes of health osteoarthritis biomarkers consortium
Arthritis Rheumatol, 68 (10) (2016), pp. 2422-2431
Lee W., Ruijgrok L., Boxma-de Klerk B., Kok M.R., Kloppenburg M., Gerards A., et al.
Efficacy of hydroxychloroquine in hand osteoarthritis: a randomized, double blind, placebo-controlled trial. Arthritis Care Res (Hoboken), 9 (2017), pp. 1320-1325
Julien Freitag, Dan Bates, James Wickham, Kiran Shah, Leesa Huguenin, Abi Tenen, Kade Paterson, Richard Boyd. Adipose-derived mesenchymal stem cell therapy in the treatment of knee osteoarthritis: a randomized controlled trial. Regenerative medicine 14 (3), 213-230, 2019
Yong Huang, Xiaolu Liu, Xinliang Xu, Junbin Liu. Intra-articular injections of platelet-rich plasma, hyaluronic acid or corticosteroids for knee osteoarthritis. Der Orthopäde 48 (3), 239-247, 2019
Patel S., Dhillon M.S., Aggarwal S., Marwaha N., Jain A.: Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: Prospective, double-blind, randomized trial. Am J sports Med 2013; 356-364
Chahala J., Edan C.S., Moatshe FG., Pascual-Garrido C. Serra Cruz R., LaPrade R.F.: Concentrated bone marrow aspirate for the treatment of chondral injuries and osteoarthritis of the knee: A systematic review of outcomes. Orthop J Sports Med 2016;2325967115625481