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Subchondroplasty Revisited

Subchondroplasty Revisited

In the late summer of 2015, I was featured on a Fox cable news segment featuring a patient on whom I had performed a Bone Marrow Aspirate Concentrate –Stem Cell intervention coupled with a subchondroplasty procedure. The patient had experienced a poor result from a right Total Knee Replacement years earlier and was seeking a means of improving function and minimizing her left knee pain resulting from arthritis. Cartilage does not have a nerve supply so scientists and clinicians have long sought a clear understanding of the pain generator in osteoarthritis. While there still is not a clear-cut consensus, many clinicians are looking at the bone marrow lesions seen on an MRI when taken of an arthritic joint as the possible cause of pain associated with arthritis.

In the case of my patient, the combined BMAC-Stem Cell procedure coupled with the subchondroplasty had resulted in a very satisfactory outcome and such maintains at this time to the best of my knowledge. What was unique about my patient was the use of Bone Marrow Concentrate-Stem Cells to serve as the catalyst to effect healing of the bone marrow lesions. Up until that time, surgeons were using a synthetic calcium phosphate material to fill the defects above and below a joint surface with a mandatory three months of protected weight bearing and six months of altered physical activity. The introduction of Bone Marrow Concentrate with Stem cells required 48 hours of crutch support and six weeks of restricted physical activity.

My patient who received media attention served to foster a debate in the medical device industry as to the superior methodology serving as an adjunct to a subchondroplasty. First came the initial trial using a subchondroplasty procedure and synthetic filler with the inherent need for prolonged altered function and assisted ambulation. Now there are several clinical trials in development pertaining to an arthritic joint and the minimally invasive, percutaneous subchondroplasty comparing the synthetic filler to the Bone Marrow Aspirate Concentrate-stem cell adjunct; with the latter used both inside the joint and in the adjacent subchondral bone.

Are your arthritic joint changes affecting both the cartilage and the supporting bone? Is the actual source of your joint pain, the supporting bone or bone marrow lesions adjacent to the hip, knee, ankle or shoulder? It would require a complete examination and review of X-rays and an MRI for me to answer the question and advance the most appropriate therapeutic recommendation. Could it be that the failure of a regenerative intervention wasn’t a failure of the stem cells but rather a failure to address the real pain generator, subchondral bone?

Call for an assessment 312 475 1893 and I will try to answer that question.

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Subchondroplasty Revisited

“Exercise linked to reduced risk of several cancers”

From the AMA Morning Rounds May 16, 2016
Today’s Medical News Prepared Exclusively for You

Leading News
“Exercise linked to reduced risk of several cancers”

ABC World News Tonight (5/16, story 11, 0:25, Muir) reported, “The
National Cancer Institute confirms that moderate exercise, all the way
up to intense exercise, lowers the risk of” cancer “in many forms.”
The Los Angeles Times (5/16, Healy) reports that the research,
published in JAMA Internal Medicine, suggests, “exercise is a powerful
cancer-preventive.” Investigators found that “physical activity worked
to drive down rates of a broad array of cancers even among smokers,
former smokers, and the overweight and obese.”

US News & World Report (5/16, Esposito) reports that
investigators “analyzed data from participants in 12 US and European
study groups who self-reported their physical activity between 1987
and 2004.” The researchers “looked at the incidence of 26 kinds of
cancer occurring in the study follow-up period, which lasted 11 years
on average.” The data indicated that “overall, a higher level of activity
was tied to a 7 percent lower risk of developing any type of cancer.”

TIME (5/16, Park) reports that “the reduced risk was especially
striking for 13 types of cancers.” Individuals “who were more active
had on average a 20% lower risk of cancers of the esophagus, lung,
kidney, stomach, endometrium and others compared with people who
were less active.” Meanwhile, “the reduction was slightly lower for
colon, bladder, and breast cancers.”

Historically, I have directed my Blog to fitness, improved activities of
daily living, and recreational endeavors. The Leading News report
quoted above introduces an additional goal. Considering the significant
progress in research and management of different cancer types, after
mesothelioma explained, I am not going to suggest
that you will prevent cancer by undergoing a cellular orthopedic
intervention to an arthritic hip or knee; but, I am introducing the
concept that by my improving your activity level and functional
potential with a cellular orthopedic intervention for the symptoms of an
arthritic hip or knee, I will improve your exercise capacity and your
exercise tolerance with the inferred inherent health care benefits be it
cancer prevention, heart health, etc.

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Subchondroplasty Revisited

Autologous Regenerative Therapies

You may have seen this subject matter before but research and everyday experience reminds me that one has  to hear the informed consent three times for the best retention.

Clinical translation of regenerative medicine technologies requires a source of stem and progenitor cells and growth factors. The most success in Cellular Orthopedics to date has come from Bone Marrow Aspirate Concentrate wherein concentrations of mesenchymal and hematopoietic stem cells and soluble growth factors are recovered, concentrated and the joint intervention shortly follows. The procedures we use offer an FDA-compliant means of concentrating autologous stem and progenitor cells, platelets and growth factors to be used in the treatment of osteoarthritis of a joint. In a single event, we may introduce a means of pain relief, increase joint motion, improve activity and quality of life, reverse osteoarthritic changes on a bio-immune basis and possibly affect joint regeneration.

The standard of Regenerative Medicine remains Bone Marrow Aspirate Concentrate; the most studied approach in clinical practice. I am aware of the option of Fat Graft Harvesting, Micro-fracture of the Fat Graft and injection of the emulsified adipose tissue into a joint; but to the best of my knowledge at this time, the clinical outcomes results are no longer than 90 days, so stay tuned or just keep reading my Blog to update.

Platelet Rich Plasma preparation process certainly has improved over the past several years and now allows for protein and growth factor concentrating but with the notable absence of the Progenitor Cells ( Mesenchymal Stem Cells, Hematopoietic Stem Cells, etc.)

Amniotic Fluid Concentrate has recently gained traction in the clinical practice setting as a replacement for Hyaluronic Acid derivatives or synthetic  alternatives but the clinical results are only now being studied. I have said it before and I will emphasize, there are no living Stem cells in Amniotic Fluid Concentrate after sterilization and processing. That is not to say, AFC is not a superior option with a longer lasting pain relieving anti-inflammatory benefit to Hyaluronic acid based offerings.

There is no test now that you have studied my Blog but hopefully you are more familiar with Regenerative Therapies. As part of my Clinical Practice, we have developed the Center for Clinical Investigation. To learn what might best suit your needs, call 847 390 7666 and schedule a consultation.

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Subchondroplasty Revisited

Regenerative Therapies: How We Might do Even Better

Bob Dylan released his third studio album The Times They Are A-Changin’ in 1964; but history was in a constant state of flux before and Regenerative Medicine continues to evolve. While I am concerned about devolution in our civility and world; that’s outside the scope of my medical Blog and I will leave Gulliver’s Travels to Jonathan Swift. Returning to the thrilling Interventional Orthopedic days of now and the future, how might we improve Cellular Orthopedic outcomes? Be reminded that Regenerative Therapies for now are and have been based on rapid concentration of your (autologous) progenitor cells, platelets, growth factors and proteins. Change in Regenerative Medicine is difficult and must meet stringent FDA criteria.  I am thrilled to announce that this past Friday, I received preliminary IRB approval for my protocol VQ-501-K wherein pulsed electrical stimulation will be added to the Bone Marrow Aspirate Concentrate/Stem Cell intervention process for osteoarthritis.

The safety and efficacy of pulsed electrical stimulation for treatment of osteoarthritis has been tested and confirmed. As well, the improvements in clinical measures for pain and function by Pulsed Electrical Stimulation have been documented. In a Regenerative Medicine conference I attended last year, challenge was put forth concerning modalities that might improve results of Bone Marrow Aspirate Concentrate/ Stem Cell intervention and act as a catalyst for post intervention cartilage regeneration. By chance, I was part of an investigational group on the treatment of osteoarthritis of the knee with pulsed electrical stimulation five years ago and I decided to review a potential role for post Stem Cell intervention with the pulsed brace. It took nine months but Friday came the preliminary approval and we will begin the trial in short order.

There are all kinds of unproven, anecdotal approaches in an attempt to restore cartilage in a degenerative arthritic setting but Pulsed Electrical Stimulation is the only methodology shown in the laboratory and in the clinical setting to have efficacy. At the same time in hundreds of patient studies, there have been no adverse effects.  As we review the effect of Pulsed Electrical Stimulation on cartilage under a microscope, the device is safe with no adverse effect on cells. It makes sense; the adjunct is cost effective and just may help us do even better.

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Subchondroplasty Revisited

When knee pain doesn’t come from the knee

Last week, a patient presented with intractable right sided knee pain of five days duration following a fall in his home. I evaluated him and found no swelling, no limitation in the range of motion, no tenderness, no instability and no bruising. I caused an X-ray to be taken and it was “negative”.  He sat in my office rubbing his painful knee. I remembered that when he first became my patient four years earlier, he had presented for a second opinion pertaining to his knee and had been scheduled at a major medical center for arthroscopy the following week. After my complete assessment at that time, my diagnosis was spinal stenosis and right lumbar radiculitis; that is nerve root irritation in the back at L3-L4 referring to his knee. I arranged for an epidural steroid injection at that time and he has lived without pain for four years until the aggravation of the preexisting spinal arthritic disorder by the fall last week.  He was experiencing referred pain to the knee from an arthritic back.

A second patient had presented two weeks ago with a very painful right knee limiting his work and interfering with his activities of daily living. His examination excluded swelling, warmth, tenderness, instability, limitation in the range of motion or a limp. The X-ray of the knee excluded any significant abnormal changes. I referred him for an MRI of his spine and the report came back Friday consistent with a herniated nucleus pulposis (slipped disc) at L3-L4. That latter patient is scheduled later this week for an epidural steroid injection.

The third scenario is equally informative as it involves a colleague at a major medical center in Chicago. He was experiencing calf cramps with severe night pain. Because he concluded the problem was from his leg and ankle, he sought attention from a foot and ankle surgeon who promptly sent him for imaging of his leg. Because of a long-term personal relationship, I recalled that ten years ago, he had had an epidural for radiculitis (referred pain down a leg) having to do with an arthritic low back. I asked him to share his recent MRI and there was the diagnosis “severe stenosis”. Both the physician patient and his foot and ankle specialist had discounted the MRI result because of the absence of back pain.

The lesson to be learned from this Blog is that all symptoms may not necessarily arise from the point of discomfort and you can have disabling extremity pain, no back pain and the source may still be the spine. If your doctor doesn’t know that, teach her or him.

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