by Steve A. Mora, MD
Orange County Orthopedic Surgeon
I have personally used both Platelet Rich Plasma (PRP) as well as adult mesenchymal stem cell injection for knee pain and a few other diagnoses but I am very selective in its use. There is a lot of information regarding prp injections and Stem cells on-line. However most of this information focuses on the biology behind the treatment and not so much on the indication or the number of injections required to see a result. Patients also discover rather quickly that PRP and Stem cell injections are not covered by insurance. The cost of these injections can range from 800-1500 for PRP and $1000 to $3000 or more for adult stem cell injections. Most physicians will agree that these novel treatments are not magic bullets nor should they be used for everything. Some physicians do not recommend it at all while some PRP clinics tend to use it more liberally. The recommendations for the use of these novel injections are all over the board. Patients with unresolved arthritic knee pain find themselves in a quandary because they do not know if PRP and stem cell treatment is right for them, they find the cost an issue, they don’t know how many injections they will require and they do not know if it’s really going to work.
So when should you try PRP and or stem cell injections for your knee arthritis? I recommend that first the reason for your knee pain be well defined and fully understood.
Take home message #1-Has the correct diagnosis been made? Has traditional treatment been optimized?
Take home message #2- Many patients do not know that arthritis, a.k.a. Degenerative joint disease and OA, causes numerous pathological changes within the knee joint and leg. Cartilage degeneration and thinning is at the heart of the problem, however, there is associated inflammation of the lining and fluid, tightness of the surrounding soft tissue, deformity of the leg (bowing), weakness of muscles secondary to disuse, stiffness of the joint, degenerative meniscus tears, loose bodies and bone edema due to joint overload. In order to treat your knee pain all these problems must be looked at and addressed.
Before I consider offering PRP treatment I first do a comprehensive evaluation of the knee. This includes a detailed history, exam, quality X-rays and often times a good MRI. The Xrays are very important. I cannot do a proper evaluation with poor copies or wrong views. The best view for looking at arthritis is the Bilateral Standing Weight Bearing PA view, lateral and sunrise. The MRI is also very important. It is used not only to look for meniscus tears but also for bone edema and loose chondral flaps.
Specific problems I see in patients with knee arthritis and how they are addressed:
-If I discover subtle loss of motion, especially loss of knee extension, tightness of the IT Band or loss of patella mobility, I address these issues with a home exercise program or better yet focused physical therapy. The therapist is always given directions so that the patient’s time is not wasted.
-If there are mechanical problems such as chondral flaps, meniscus tear fragments or loose bodies they are addressed with arthroscopy.
-Some patients have severe inflammation of the joint which requires a Celestone steroid injection and/or a holistic anti inflammatory such as Traumeel (http://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?id=36010). I will also recommend injecting Hyauluronate which is a gelatinous substance which helps to reduce inflammation and improve the characteristics of the joint fluid and remaining cartilage.
-Patients with narrowing of the joint and significant bowing of the leg are recommended an unloading knee brace for walking.
-Overweight patients are recommended to seek help with nutrition and exercise. Hiking poles, a brace, and good shoes are highly recommended.
-Knee arthroscopy is recommended for patients with loose meniscus fragments and chondral flaps who have catching and weight bearing related pain. At the time of surgery I shave loose and or inflamed tissue, release tight structures, and sometimes do abrasion chondroplasty. Abrasion chondroplasty is done to promote coverage of the bare bone with a lining called repair cartilage. In these cases I make sure the patient uses crutches for 6-8 weeks after surgery.
-In many cases the bone under the arthritic surface becomes swollen. This finding is called a “bone marrow lesion”. This is often seen on MRI and on exam. Bone has nerve endings therefore bone that is stressed due to overload causes pain. Bone marrow edema is often times associated with extruded degenerative meniscus tears seen on MRI. Patients will complain of severe pain and tenderness on the inner side of the shin bone. If these patients end up requiring arthroscopy I will also do a simple procedure called Subchondroplasty which essentially reinforces the bone under the arthritis with bone cement (http://www.subchondroplasty.com/about_subchondroplasty/what_is_subchondroplasty).
The last take home message: Once all of the pathological problems associated with arthritis are addressed and corrected and if a patient continues to have arthritis related knee pain, PRP and/or stem cell injections can be considered.
I hope this information was helpful.
Dr. Mora is native of Orange County. He graduated from Anaheim High School in Orange County CA. He completed his training at the UC Irvine where he earned top of his class honors with his induction into the Alpha Omega Alapha Medical Society honors. He completed his Orthopedic Surgery training USC. He then completed a Sports Medicine, Cartilage, Shoulder, and Knee Fellowship at Santa Monica Orthopaedic and Sports Medical Group. He is currently practicing Orthopedic Surgery in Orange County at Restore Orthopedics and Spine Center. Dr. Mora’s practice focuses on sports related trauma, knee ligament and cartilage repair, shoulder rotator cuff and instability, hip arthroscopy, partial knee replacement and ACL reconstruction. He sees athletes of all levels including professional soccer and UFC/MMA. He is team doctor for the Anaheim Bolts pro indoor soccer team and Foothill High School. Some of the procedures he performs include Cartilage transplantation (Genzyme), partial custom knee replacement, OATS, tibial osteotomies, meniscus transplant, knee ligament reconstruction, shoulder reconstruction, elbow arthroscopy, hip arthroscopy, joint preservation surgery for knee arthritis. Dr. Mora’s family heritage is Peruvian. He speaks fluent Spanish.