Knee problems are one of the most common problems I deal with in my practice. In the case of arthritis, patients often arrive saying that their x-rays revealed bone-on-bone and they were given the options of a cortisone shot, anti-inflammatories and, when they couldn’t stand the pain anymore, knee replacement.
With Regenerative Orthopedics we have a totally different approach. First of all it is important to appreciate that there is much more to the knee than just the bones and cartilage. There is a ligamentous capsule that holds it all together and this includes the medial collateral and lateral collateral ligaments. When evaluating a knee it is most important to check all these support structures and find out which of them might need to be regenerated with injections. Incidentally, it is important to realize that the capsule that encases the knee not only holds the knee together but it also holds the knee apart. In other words the stiff fibrous ligaments suspend the femur on the tibial plateau and are largely responsible for the joint space. As you regenerate the ligamentous support the joint space is reestablished. Many people don’t realize that the joint space comes from the ligamentous support as much, if not more, than the cartilage.
The next point of importance is whether we use PRP alone or if we need stem cells with the PRP. PRP might be OK if the main problem is sprained ligaments but the more severe the degeneration or injury the more we should we should consider using stem cells as a first line regenerative strategy. Also, If there is a lot of cartilage missing, stem cells are generally indicated.
If the knee is locking then MRI is indicated to confirm meniscal tears. If this is the case and the locking persists, arthroscopic surgery is indicated. I consider this particular procedure as quite elegant and have no problem referring my patients for it.
I don’t feel the same way about knee replacement. For me the latter should be the very last resort. I think the vast majority of patients with chronic knee pain can do very well with a regenerative approach although many cases might end up needing stem cells to get the results they are after. Since surgery always has its’ risks we recommend that people should thoroughly explore nonsurgical regenerative approaches before resorting to knee replacement.
As an additional note I think it is important for many patients with knee, hip and/or low back problems to get proper orthotics (arch supports). As we age the foot arches weakens and we start to pronate as we put weight on the foot. This in turn causes extra stress on the knee, hip and pelvic/low back. By supporting the feet with orthotics we maintain the foot in anatomic position at impact and optimize the biomechanics so there isn’t undue stress on specific structures.