Knee cartilage surgery and knee cartilage non-surgical repair
In this article we will present the non-surgical stem cell – comprehensive Prolotherapy alternative to various surgical techniques that are designed to repair or regrow the articular cartilage of the knee.
- Before continuing on with this article, do you have a question about Knee articular cartilage surgery or becoming a patient? Get help and information from our Caring Medical staff
Knee articular cartilage surgery and non-surgical repair
In researching such surgical options as:
- Microfracture knee surgery or Arthroscopic microfracture drilling:
- If you have cartilage breakdown behind the knee cap or in the knee joint itself, this procedure may be recommended to stimulate healing by drilling into the bones of the knee underneath the cartilage. The hope is that the drilling will cause bleeding, the blood will clot and the clotted blood with serve as a scaffold for ew cartilage cells to develop and patch the holes in your existing cartilage.
- Arthroscopic abrasion arthroplasty
- This surgery is best recommended to a younger athlete who has a simple cartilage tear or hole. It will usually not be successful for a patient who is older or a patient who has a significantly damaged knee. In this procedure as oppossed to drilling holes in the bone, burrs are used to scrape away damaged cartilage and “scrape” the bone. As with the microfracture procedure the hope is to cause the blood to clot and turn into a scaffold from which cartilage cells can develop.
- Autologous Chondrocyte Implantation (ACI)
- Osteochondral Autograft Transplantation (Donor cartilage from you)
- Osteochondral Allograft Transplantation (Donor cartilage from cadaver)
We often find one of the successes of the surgery outcome is that the patient did not need multiple surgeries. Let’s look at new research on these procedures.
Microfracture surgery for articular cartilage repair
Currently, there is no effective non-surgical treatment for articular cartilage injury
In November 2017 doctors from the Institute of Orthopaedics in China wrote in the medical journal Trials, “Spontaneous recovery from articular cartilage injury is difficult, and the ongoing progression of disease can eventually lead to osteoarthritis. Currently, there is no effective non-surgical treatment for articular cartilage injury.
Arthroscopic debridement and microfracture surgery are performed for fibrocartilage repair. But fibrocartilage is different from normal articular cartilage, and functional recovery is not satisfactory.”(1)
This research was not as enthusiastic as earlier 2017 studies where surgical researchers were happy to announce that cartilage repair or regeneration procedures (e.g., microfracture, Autologous Chondrocyte Implantation – ACI) typically result in a satisfactory outcome in selected patients.
This was detailed by doctors at the University of New Mexico who published research in which they suggest success in selective patients undergoing knee procedures including: chondroplasty, debridement, drilling, microfracture autologous chondrocyte implantation, osteochondral autograft, and osteochondral allograft, and that while these techniques may improve patient outcomes, NONE can reproduce normal hyaline cartilage.(2)
This is the problem, the cartilage repair is not as durable as the native cartilage. It is not a long-term solution.
- A team of international researchers writing in the medical journal Tissue engineering agreed in their research stating that the vast majority of patients with chronic symptoms and, in general, a more diseased joint, do not benefit from these surgical techniques.(3)
In March 2017, Rush University Medical Center researchers suggested in the journal Sports medicine and arthroscopy review:
- “For the vast majority of patients, marrow stimulation results in reduced pain and improved function, providing overall satisfactory outcomes. In some cases, however, marrow stimulation fails, resulting in symptom recurrence and often, the need for repeat surgery.”(4)
And in January 2017 research from Rush and Duke Universities about youth athletes:
- “Autologous Chondrocyte Implantation is an effective treatment for adolescent patients with symptomatic, large chondral lesions, resulting in significant improvements in knee-specific functional outcome scores and health-related quality of life scores.
- Although patients must be cautioned on the relatively high reoperation rate (37.8%) and limitations in knee function even after ACI“(5)
When microfracture is most successful and when it is not
In February 2018 published in the Orthopaedic journal of sports medicine, doctors at Keck School of Medicine, University of Southern California and the Department of Orthopedic Surgery, Rush University Medical Center offered these findings on which patients Microfracture would offer the most benefit stting that “Microfracture has become a common treatment option for relatively small, symptomatic cartilage defects in the knee.”(yyy)
yyy. Weber AE, Locker PH, Mayer EN, Cvetanovich GL, Tilton AK, Erickson BJ, Yanke AB, Cole BJ. Clinical Outcomes After Microfracture of the Knee: Midterm Follow-up. Orthopaedic journal of sports medicine. 2018 Feb 6;6(2):2325967117753572. [Google Scholar]
- Patients who underwent microfracture showed clinically meaningful and statistically significant improvements in patient report outcomes after an average of 5.7 years, regardless of whether it was performed at a single site tear, multiple site tear, or with concomitant procedures.
- Overall, male patients demonstrated better final postoperative patient report outcomes as well as a greater magnitude of improvement when compared with their female counterparts.
Patients who did not have a more desired response to surgery and were less tna good candidates.
- Older age,
- Higher BMI Body Mass Index (weight/obesity)
- Larger defect size in the cartilage
- If the knee had multiple defect locations
- If you had a larger lesion/tear size and prior surgery predicted the need for additional surgery after microfracture.
The researchers also noted that the surgery worked best when the cartilage tear was small and was the only tear. A wound in isolation. They note that this type of patient while ideal is more rare than the true to life patient who has many concomitant challenges such as meniscus damage, loose bodies in the knee, synovial inflammation of the knee requiring as Synovectomy or cleaning out of the inflamed synovial tissue. Additional some of the study subjects had the procedure done at the time of a Anterior cruciate ligament reconstruction or Medial patellofemoral ligament reconstruction.
At our clinics, we rearely see a patient that has a small cartilage tear in isolation. When we do we find very high success rates with our regeneartive medicine injections. Patients who have a more advanced knee injury or advanced levels of degeneration would obviously require a more comprehensive approach to healing.
Curious and troubling findings in patients who previous had Microfracture surgery and then went on to total knee replacement
Researchers writing in the medical journal Orthopedics found curious and troubling findings in patients who previous Microfracture surgery and then went on to total knee replacement. In comparing total knee replacement patients who had the Microfracture surgery and those who did not prior getting knee replacement, the doctors found that
- Patients who had Microfracture surgery prior to knee replacement demonstrated significantly less improvement in knee pain and function that the patients who did not have prior microfracture
- The knee replacement failure rate after five years was doubled: 4.8% to 2.4%.
- Older patients had less clinical improvement than hoped for
- Patients with less preoperative range of motion after Microfracture had less clinical improvement than hoped for
- Women with an increased body mass index also had less improvement.(6)
Surgery creates more bone damage
Doctors at Saarland University Medical Center in Homburg, Germany publishing in the journal Scientific reports tested the hypothesis that early osteochondral repair following microfracture surgery is enhanced if bone marrow stem cell aspirate is added as an adjunct to the microfracture procedure.
The problem they were trying to solve was that the surgery creates more bone damage.
- Their key finding is that microfracture treatment of chondral defects induced a substantial early loss of the subchondral bone that may be significantly counteracted if bone marrow aspirate is applied.
- Second, such bone marrow aspirate enhanced microfracture also significantly protected the subarticular spongiosa (the spongy) below the defects from osteoclast-mediated peri-hole bone resorption (over reabsorption of bone) compared with microfracture alone.
Interestingly, debridement down to the subchondral bone similarly led to a reduction of the bone volume both in the subchondral bone plate and subarticular spongiosa.(7)
Cartilage repair surgery an example of over complication with stem cells
Here in our opinion is another example of over complicating a simple procedure, the introduction of reparative stem cells into the knee.
- Here is the more complicated surgical process:
- Researchers wanted to know if they could regenerate articular cartilage in patients with severe cartilage deterioration by drilling the bone underneath the cartilage (to jump start healing) and then after the surgery if intra-articular injections of hyaluronic acid with and without peripheral blood stem cells (PBSC) repaired the tissue.
- The doctors took 50 patients (young patients age 18 to 50) with cartilage loss and began to drill the bones. One week after the drilling, 25 of the patients received a weekly injection of hyaluronic acid (HA) with peripheral blood stem cells, 25 without. Then 6 months later the injections were repeated.
- The researchers found that arthroscopic subchondral drilling (drilling underneath the cartilage) into grade 3 and 4 chondral lesions, postoperative intra-articular injections of (stem cells) in combination with hyaluronic acid resulted in an improvement of the quality of articular cartilage repair over the same treatment without (stem cells). In other words when the stem cells were added, everything worked better.(8)
So here is the understanding of it all:
1. Arthroscopic drilling
2. hyaluronic acid injections
3, stem cells therapy
and more injections six months later.
The study focused on the surgery and what made the surgery work better, and it wasn’t hyaluronic acid. It was the stem cells.
Why not try the repair with bone marrow aspirate stem cells without the surgery first?
In another study doctors writing in the medical journal Arthroscopy found that in 55 knees that underwent High Tibial Osteotomy (bone resurfacing or reshaping) and microfracture, those who received stem cells with hyaluronic acid had significantly better results than those who just received hyaluronic acid.(9)
- Research in the medical journal Cartilage showed that a “one-step” surgery bone marrow aspirate stem cell treatment showed good results in helping stage IV knee osteoarthritis patients Back to the original question, why not try the repair without the surgery FIRST when research suggests stem cells have the ability to repair and reshape bone.(10)
Other research including our published findings
- Other research, including our own, shows complete relief of symptoms in arthritic joints with bone marrow stem cell treatments.(11) Below we will discuss three case studies from this research.
Here is a recent study that can suggest that trying the stem cell injections first may be a more realistic option for patients especially those concerned with microfracture knee surgery recovery time and rehab.
Abrasion Arthroplasty is a procedure that sounds exactly what is is – abrasions are created on the cartilage to create an injury with the hope that the body will repair not only the new injury but the deterioration of the joint as well. This is a surgical procedure. Studies have pointed out that this procedure may help alleviate symptoms of knee pain but it is not curative.(12)
Not only non-curative – may not work at all.
Doctors at RWTH Aachen University in Germany had a problem with Arthroscopic abrasion arthroplasty. They are not sure it worked at all. To test the theory that the surgery was helpful – they examined the effusion, the swelling fluids in the knee following the surgery.
What they found was the surgery indeed starting a healing process by stimulating STEM CELLS to repair the cartilage.
Now here is the amazing part. The doctors found that during the surgery, the doctors used constant suction to drain the surgical area. The researchers now “recommend not to use suction drainage as by this procedure a considerable amount of the regenerative potential of postoperative joint effusions might be extracted.”(13)
- In other words the stem cells were stimulated to repair spontaneously and mobiles to the wound site.
- The benefit to the surgery was to get stem cells to the wound
- The surgery’s benefit was being removed as soon as it started.
Treatment for articular cartilage is challenging because knee cartilage shows limited reparative and regeneration abilities following injury. Traditional non-operative (RICE therapy), various injection therapies and traditional arthroscopic techniques cannot restore the normal anatomy and function of cartilage in osteoarthritis.
Stem cell therapy for cartilage repair need not be a complicated procedure. In many instances bone marrow stem cells are drawn from a patient and injected into the patient’s knee with the hope of repairing cartilage and bone damage typical of a knee with severe osteoarthritis or damage from injury. The procedure is simple in concept: inject stem cells, heal knee. Please watch the video below.
Caring Medical and Rehabilitation Services Research
Please see our discussions in the medical journal Clinical medicine insights. Arthritis and musculoskeletal disorders where our team presented three difficult knee pain case histories treated with Bone Marrow Stem Cell Aspirate.
In this article we will present clinical research and case studies to support the use of Bone Marrow Aspirate for Knee Pain. Bone Marrow Aspirate therapy is often called bone marrow stem cell therapy or simply stem cell therapy.
Do you have a question about Knee articular cartilage surgery or becoming a patient? Get help and information from our Caring Medical staff
References for this article
1 Ma N, Wang H, Xu X, Wan Y, Liu Y, Wang M, Yu W, Dai Y, Peng J, Guo Q, Yu C. Autologous-cell-derived, tissue-engineered cartilage for repairing articular cartilage lesions in the knee: study protocol for a randomized controlled trial. Trials. 2017 Dec;18(1):519. [Google Scholar]
2. Richter DL, Schenck RC Jr, Wascher DC, Treme G. Knee Articular Cartilage Repair and Restoration Techniques: A Review of the Literature. Sports Health. 2015 Oct 12. pii: 1941738115611350 [Google Scholar]
3. Scotti C, Gobbi A, Karnatzikos G Martin I, Shimomura K, Lane JG, Peretti GM, Nakamura N. Cartilage repair in the inflamed joint: considerations for biological augmentation towards tissue regeneration. Tissue Eng Part B Rev. 2015 Oct 15. [Google Scholar]
4. Frank RM, Cotter EJ, Nassar I, Cole B. Failure of Bone Marrow Stimulation Techniques. Sports Medicine and Arthroscopy Review. 2017 Mar 1;25(1):2-9. [Google Scholar]
5. Cvetanovich GL, Riboh JC, Tilton AK, Cole BJ. Autologous chondrocyte implantation improves knee-specific functional outcomes and health-related quality of life in adolescent patients. The American journal of sports medicine. 2017 Jan;45(1):70-6. [Google Scholar]
6 Ansari MH, Pareek A, Johnson NR, Abdel MP, Stuart MJ, Krych AJ. Clinical Outcome of Total Knee Arthroplasty After Prior Microfracture: A Matched Cohort Study. Orthopedics. 2017 May 1;40(3):e473-e478. [Google Scholar]
7 Gao L, Orth P, Müller-Brandt K, Goebel LKH, Cucchiarini M, Madry H. Early loss of subchondral bone following microfracture is counteracted by bone marrow aspirate in a translational model of osteochondral repair. Scientific Reports. 2017;7:45189. [Google Scholar]
8 Saw KY, Anz A, Siew-Yoke Jee C, Merican S, Ching-Soong Ng R, Ahmad RS, Ragavanaidu K. Articular Cartilage Regeneration With Autologous Peripheral Blood Stem Cells Versus Hyaluronic Acid: A Randomized Controlled Trial. Arthroscopy. 2013 Feb 4. [Google Scholar]
9 Wong KL, Lee KB, Tai BC, Law P, Lee EH, Hui JH. Injectable Cultured Bone Marrow-Derived Mesenchymal Stem Cells in Varus Knees With Cartilage Defects Undergoing High Tibial Osteotomy: A Prospective, Randomized Controlled Clinical Trial With 2 Years’ Follow-up. Arthroscopy. 2013 Dec;29(12):2020-8. [Google Scholar]
10 Gobbi A, Karnatzikos G, Scotti C, Mahajan V, Mazzucco L, Grigolo B. One-step cartilage repair with bone marrow aspirate concentrated cells and collagen matrix in full-thickness knee cartilage lesions: results at 2-year follow-up. Cartilage. 2011 Jul;2(3):286-99. [Google Scholar]
11 Hauser RA, Orlofsky A. Regenerative injection therapy with whole bone marrow aspirate for degenerative joint disease: a case series. Clin Med Insights Arthritis Musculoskelet Disord. 2013 Sep 4;6:65-72. [Google Scholar]
12 Johnson LL. Arthroscopic abrasion arthroplasty: a review. Clin Orthop Relat Res. 2001 Oct;(391 Suppl):S306-17. [Google Scholar]
13 Beckmann R, Lippross S, Hartz C, Tohidnezhad M, Ferreira MS, Neuss-Stein S, Seekamp A, Nebelung S, Kweider N, Rath B, Jahr H. Abrasion arthroplasty increases mesenchymal stem cell content of postoperative joint effusions. BMC Musculoskeletal Disorders. 2015;16. [Google Scholar]