Sunday, May 1, 2016

Steph Curry, MCL, PRP and Stem Cells

Below is an excerpt from a Wired online article discussing PRP and stem cells and what the role is for regenerative treatments when treating knee injuries.

PRP (platelet rich plasma) has been scientifically studied for several years.  The fascination with this regenerative technique is based on science that shows PRP may act as a stimulator of healthy cells by releasing chemical signals that switch these cells “on”.  This may tissue to repair itself.  These signals regulate growth and development of cells including growth factors that are present in platelets termed PDGF, TGF-ß, and VEGF (to name a few).  Alpha granules from PRP are a source of cytokines that stimulate cell migration, proliferation and maturation.  However, PRP has never been shown in a high quality scientific study to improve an athlete's recovery after an MCL or ACL sprain/tear/injury.  There is some data supporting the use of PRP in articular cartilage injury and tennis elbow injury.  

Stem Cell biology is an entirely different type of regenerative medicine therapy.  Stem Cell therapy is "not ready for prime time" use knee injuries in 2016.  The science is still being worked out to discover what (if any) is the best application for this technology.

A low grade MCL sprain typically heals in 1-6 weeks with traditional modalities.  Steph will have access to the best professionals, facilities, medications and modalities to rapidly diminish the pain, inflammation and swelling of his knee while guiding him through an aggressive rehabilitation program.  One would predict Steph Curry to return to competitive play within this time frame without the need for "heroic measures".

Quoting from Luke Whelan of Wired:
"After diagnosis, they’ll try to decrease swelling with ice, compression, and anti-inflammatory drugs, and protect the injured area with tape and braces. That might be enough to get the player back on the court if the pain is manageable. But, like in the case of Curry, the physician might call for testing to see if more treatment is necessary. MRIs can estimate the water content in different tissues to create a 3-D image of the body part. For a knee, it provides a picture of a ligament sprain, soft tissue bruise, or cartilage damage.
Extreme Measures
That’s all pretty standard—the kind of treatment you might get as an active recreational athlete, just with quicker test turnarounds. But with intense pressure to get back to play as fast as possible, many professionals go a step further, turning to new, rarer therapies. “We may do things with professional athletes that are maybe not proven,” says Cole, “like regenerative medicine.”
The most popular of these therapies is platelet-rich plasma (PRP) injections, which are concentrated with growth factors that might help to speed healing. Doctors also use more invasive stem cell injections, sticking a needle into the hip bone to suck up bone marrow cells and then inserting them into the injured tissue. Cole maintains these injections have shown some benefits for healing and, at the very least, haven’t shown evidence of being harmful.  
But others are skeptical. “There are some situations where it’s not utilized in a biologically sound way,” says Luke. “Everyone is always looking for the newest cutting-edge technique that might save a few days or a magic bullet that might fix this.” He cautions athletes from using therapies like PRP injections in the place of giving the body enough time to heal."

Friday, April 29, 2016

What is New in Total Knee Replacement

A summary appeared in the January, 2016 JBJS and here are the highlights.

Risk stratification is predictable and accurate for Knee Replacement patients.  Patients at higher risk for complications should postpone (if risk factors are modified) or avoid knee replacement surgery.  These risks are uncontrolled diabetes (higher risk of deep infection, blood clot, periprosthetic fracture, aseptic loosening, and poorer Knee Society function score.  Morbid obesity (BMI > 40)  is a patient factor associated with increased medical costs and complications including medical complication (heart attack, pneumonia, etc), postop knee infection, return to the operating room for a second procedure and longer hospitalization.  Morbidly obese patients have a higher risk of in hospital death after knee replacement surgery.

There is no evidence to support a particular design, brand, or material impact range of motion, clinical scores or quality of life.

The value of computer assisted TKR surgery remains undefined.  One study showed an insignificant improvement of leg alignment but no better rotation of tibial or femoral components compared to standard non navigated surgery.

Patient specific custom cutting blocks showed no improved clinical, operative or radiographic results.

Friday, April 22, 2016

Unicompartmental Knee Replacement Has Advantages Over Total Knee Replacement

Unicompartmental knee replacement (e.g. Makoplasty partial knee replacement) offers a number of advantages over TKR including reduced risk of complications, bone and ligament preservation, and a more naturally feeling knee.  One study looking at 14,000 knee joint replacement patients found the partial knee patients (compared to TKR patients) were more likely to achieve an excellent result and more likley to be highly satisfied and were less likely to have had a complication or hospital readmission.

Friday, April 15, 2016

Female Soccer Players ACL Retear Risk is High

Female soccer players that returned to play soccer have a higher retear rate of both the surgically reconstructed ACL graft or the previously healthy ACL in the opposite knee compared to non soccer female athletes.  The study compared 180 female atheletes (90 in each group).

One third of soccer players that returned to soccer sustained a second ACL tear in one of their knees.

Soccer athletes vs. non soccer athletes had: a)11% vs. 1 % ACL graft retear and b) 17% vs 4% other knee ACL tear.

These female athletes were studied on average for 6 years after their first ACL tear.

The lead author is Aaron Krych, MD of Mayo Rochester.

Friday, April 8, 2016

Minimalist Running - An Orthopedic Viewpoint

The potential benefits of barefoot and minimalist running are hypothesized to be lower collision force (with ground), increased muscle strength, improved running performance and lower injury rates.  If the strike pattern is forefoot/midfoot loading rather than heel loading the improved kinetics will result in a lower force at the knee.

It has been hypothesized that minimalist running will decrease anterior knee pain or runner's knee.   Standard running shoes, which 90 % of distance runner use,  result in more heel loading which is transmitted to the knee and hip.  Modern running shoes cushion the heel for comfort during RFS (rear foot strike).  The decrease in load to the knee from a cushioned RFS shoes is at a lesser degree than the decrease load to the knee with FFS pattern.  RFS is intolerable if barefoot.

So while all this seems to suggest running injuries may be mitigated by changing running style from RFS to FFS, conclusive scientific proof is lacking.  The most common injuries associated with RFS running include patellofemoral pain syndrome (runner's knee), IT band syndrome, plantar fasciitis, achilles and patellar tendonitis, and stress fracture.  FFS running is linked to metatarsal stress fractures, plantar fasciitis and puncture wounds.

Minimalist running is an emerging style of exercise running that seems to mimic a "more natural way" of running.  This running style warrants continued interest from orthopedic surgeons and the public.