Musculoskeletal Care of the Mature Patient

Probably the most important change in Osteoarthritis I have witnessed during my orthopedic career has been in attitudes rather than knowledge. The Boomers look toward continued well-being and extended athleticism and are unwilling to accept impairment and limited function associated with their osteoarthritis. Perception is everything; and new technologies lead to new concepts.  Osteoarthritis is common and not necessarily a progressive disorder, with the condition stabilizing in most cases. This is obvious if we compare the number of people in the population with radiographic evidence of OA and the number who come to joint replacement.  Recent research has indicated that physical activity optimizes cartilage health and is important in preventing the symptoms even in the presence of radiologic evidence of osteoarthritis. What about these new technologies and their increasing popularity owing to celebrity athletes?

What caused me to focus the blog again on Platelet Rich Plasma and Stem Cell management of osteoarthritis is an article appearing in the September 4, 2011 issue of the New York Times: As Sports Medicine Surges, Hope and Hype Outpace Proven Treatments by Gina Kolata. It is a well-written article and worth a Google. The introduction to the article describes the costly failure of physical therapy, strength training, Platelet Rich Plasma and cortisone injections in the care and treatment of a female marathoner’s hamstring tear. “ Medical experts say her tale of multiple futile treatments is all too familiar and points to growing problems in sports medicine” “Celebrity athletes, desperate to get back to playing after an injury, have been trying unproven treatments, giving the procedures a sort of star appeal.” You know what, I believe the author is right but does that make it wrong? I believe we must start with patients before we focus on populations. Researchers are indeed questioning the new procedures such as PRP and stem cells because there are no rigorous scientific studies to back them up. Yet there is a large group of patients eager for treatment, ranging from competitive athletes to casual exercisers to retirees spending their time on the golf course or tennis court who want to keep going.

So how do you protect yourself from the triad of famous athlete, famous doctor, untested treatment when there is so much marketing by sports medicine “experts”? First of all, make sure your sports medicine physician is a member of the American Academy of Orthopedic Surgeons because these experts are trained in offering care based on credible evidence. The continuing education initiative of the AAOS is the most advanced of any medical specialty. Second, when a procedure is new and unsupported as of yet by a large clinical experience/ data base, seek out a clinical trial and not simply a clinical encounter. In 1979, I was involved in the clinical trial of a cement-less design hip prosthesis which ultimately changed the surgical approach to joint reconstruction in the world. Management of osteoarthritis is complex and needs individualizing; so too, new isn’t always better but sometimes it just may be.

 Meanwhile back to that “hamstring tear”. Any supposed chronic hamstring tear is more likely referred pain from a degenerated or herniated lumbar disc but referred pain and missed diagnoses are for another blog

Mitchell B. Sheinkop, M.D.

847-390—7666

1565 N. LaSalle Street

Chicago, Illinois 60610

For the skeptic and naysayer, Stem Cell Therapy is coming of age. What further validation is needed than the recently announced symposium?

First Annual Symposium on Regenerative Rehabilitation

November 3 – 4, 2011

Sponsored by:

University of Pittsburgh School of Medicine Center for Continuing Education in the Health Sciences

UPMC Rehabilitation Institute

The McGowan Institute for Regenerative Medicine

University of Pittsburgh School of Health and Rehabilitation Sciences

University of Pittsburgh Department of Physical Medicine & Rehabilitation

Intent

Medical advances in the field of Regenerative Medicine are accelerating at an unprecedented rate. Re-growing a lost limb, restoring function to a diseased organ, or harnessing the body’s natural ability to heal itself are becoming part of our reality instead of a distant promise. Technologies, such as cellular therapies, bio-scaffolds, and artificial devices, are now in use or are being tested in clinical trials throughout the country.

••How do we as clinicians and rehabilitation professionals follow up on a patient who had undergone a cellular therapy or a tissue engineering procedure?

••How do we as investigators in the field of Regenerative Medicine make the most of these revolutionary results?

Few opportunities are available to bring together scientists and clinicians working in these two currently quite disparate fields: rehabilitation science and regenerative medicine. However rehabilitation science and regenerative therapies have to work closely in order to achieve a successful outcome for the patient. This situation created the need for open cross-disciplinary work and collaborative communication.

This symposium provides the opportunity for researchers and clinicians from around the world to gather and learn about the latest developments, share ideas and concepts and create sustainable collaborations. The First Annual Scientific Symposium on Regenerative Rehabilitation will bring together world-renowned experts in the fields of regenerative medicine and rehabilitation.

Meanwhile, back in Chicago, we are ready to move forward with our Musculoskeletal Rejuvenation program using Bone Aspirate Stem Cells. We have two protocols, one in the knee and one for the plantar fascia.

Our research team is Mitchell Sheinkop, MD, (Orthopedic Surgeon, Emeritus Professor, Rush University Medical School) Lowell Scott Weil, Sr., DPM; Director Weil Foot-Ankle & Orthopedic Institute, Lowell Weil, Jr, DPM, MBA (Fellowship Director, Weil Foot & Ankle Institute; Co-Editor, Foot & Ankle Specialist.

We will have further communications and a prompt launch of our initiative. Our group in Cabo, Mexico, eagerly awaits our report as well concerning the launching of the Weil Foot, Ankle and Orthopedic Institute “Destination  Rejuvenation Program”.

Musculoskeletal Care of the Mature Patient

On January 9, 2009 I wrote my first Blog. The emphasis at the start up was joint replacement of the hip and the knee for arthritis. All are archived at www.sheinkopmd.com. In mid-March, 2010, my emphasis shifted to Musculoskeletal Care of the Mature Athlete or how to avoid joint replacement, somewhat influenced by personal motivation. Today is my 100^th blog and I will focus on the future of orthopedics: Bone and Joint Rejuvenation.

Treatment of Pre-collapse Osteonecrosis Using Stem Cells and Growth factors. Avascular Necrosis or (ON) of the femoral head is a devastating disease, a form of arthritis, affecting young patients at their most productive age, causing major socioeconomic burdens. ON is associated with various etiologic factors, and the pathogenesis of the disease is unknown. Most investigators believe the disease is the result of secondary microvascular compromise with subsequent bone and marrow cell death and defective bone repair. Could local delivery of vascular endothelial growth factor (VEGF) and bone morphogenetic protein-6 (BMP-6), which induces angiogenesis and osteogenesis respectively, reverse the disease process and provide a treatment for precollapse ON?

Use of genetically engineered bone marrow stem cells, carrying VEGF and BMP-6 genes, to enhance angiogenesis and osteogenesis in the necrotic bone by local delivery of growth factor in addition to the bone-forming property of the stem cells, tissue repair of the femoral head may be possible.

Imagine an injectable bone graft substitute containing engineered stem cells and therapeutic growth factors rather than hip replacement for a young person in need of treatment for ON.

Non Surgical Orthopedic Therapy: A Growing Trend and increasingly viable option.  Pittsburgh Steelers ‘s Hines Ward and Troy Palomalu underwent Platelet Rich Plasma injections in 2009. Tiger Woods went to Canada in 2010 for PRP to the knee. Superbowl Champion Jarvis Green underwent stem cell therapy in 2010 and subsequently signed with the Houston Texans when it was thought his career was finished. Yankees” Roberto Colon underwent stem cell management of his shoulder in 2011.When it looked as if this 35-year-old pitcher had reached the end of his career; he now is in the Yankee starting rotation. Kobe Bryant traveled to Germany for non-surgical management of his arthritic knee earlier this summer.

Elimination of surgical risks, the extensive rehabilitation following joint replacement and the inherent restrictions of a total hip or total knee is my motivation with this 100^th Blog. To do everything I can to make the future available in a clinical setting in the here and now. Last night, we came very much closer to making stem cell care of bone and joint pain a reality.

Musculoskeletal Care of the Mature Patient

Stem Cells May Prevent Need for Joint Replacements, if FDA Allows It June 1, 2011 PRNewswire-USNewswire

“Preliminary studies show that many patients with osteoarthritis might be able to avoid total knee replacement with this therapy.”

The orthopedic surgeon has historically depended on comparative effectiveness research to provide the science for supporting results. Yet the explosive growth in the number of costly orthopedic procedures-including joint replacements, back surgeries, arthroscopic procedures and other treatments-has attracted the attention of legislators, payers, employers, and experts in both health care and economics. In many of these cases, there is no scientific evidence to support the effectiveness of these procedures. I am trying to understand how Platelet Rich Plasma affects the healing process and whether there is an appropriate type of PRP for a specific orthopedic condition. Minimally Invasive Needle Injection of stem cells and PRP have very little draw back and are certainly less costly treatment options than major surgical procedures with their inherent complications.

Platelets provide an autologous source of growth factors for healing and tissue regeneration. Studies involving the use of PRP for cartilage degeneration have shown consistently favorable results. PRP injections in the knee have resulted in less pain, improving function and enhancing quality of life. A comparison of Platelet Rich Plasma with hyaluronan injections (visco-supplementation) for osteoarthritis of the knee found improved scores with PRP.

Mesenchymal stem cells (MSCs) secrete large quantities of various cytokines and growth factors thereby modulating the local immune response. They can be harvested in large quantities, expanded and used to regenerate bone and cartilage.

The emerging field of regenerative medicine aims to provide the required elements to promote tissue regeneration; total joint resurfacing to manage conditions such as osteoarthritis. Development is being stalled by the Federal Food and Drug Administration regulation of cellular therapy. The potential for rebuilding tissue is similar to our embryonic development. What we know is that cartilage rebuilt from MSC influence is very functional; what is unknown is long-term remodeling behavior, which may compromise the biologic resurfacing. Before making any clinical decision regarding any and all forms of treatment be it surgery, Platelet Rich Plasma or Stem Cells, discuss your candidacy with an orthopedic surgeon as all medical procedures have a success and failure rates.

In continuing to assure my reader fairness and balance in the field of reconstructive surgery, I want to call your attention to the OA of the Knee Registry paper of which I am co-author that will be published as a supplement in the October, 2011 edition of Rheumatology News.

Musculoskeletal Care of the Mature Patient

How long will a joint replacement last?  Should you put off surgery as long as possible to minimize the risk of needing a revision surgery or two?  It is one thing to be in so much pain that you can’t go for a walk, work without major restriction or enjoy travel. The idea of being that miserable at age 50 and delaying surgery to age 70 doesn’t make sense even though that’s how we practiced in 1973.  On the other hand, the more active the patient after joint replacement, the faster that joint will wear out, loosen or otherwise require revision.

 I encourage my patients to walk, swim and cycle. While there is not an abundance of scientific study regarding sports and survivorship after total joint replacement, research I directed in the Rush Orthopedic Research Center indicated little force across the hip joint or knee joint while cycling.  Most of the forces were absorbed in muscle groups. In swimming, 95% of the stroke is generated by upper extremity forces unless you are a very competitive swimmer.  If your goal is a successful, long-term outcome, a joint replacement recipient needs to avoid high impact sports such as jogging, running, and jumping. Personal quality of life issues are important; and even though advances in wear-resistant materials may make implants being used today last 15 years or more, it is 85% of patients who still have a functional hip or knee. The other 15% have been revised. Metal-on-metal hips were to have lasted for a lifetime; but their use is declining because of metal ion release. Ceramic -on- ceramic hips squeak with time.  A new “30-year knee” received marketing approval from the FDA based on tests mimicking 30 years of wear; it will take long-term outcomes studies to see how they faire in actual patients.

 Assume if you will the following hypothetical patient; or it may be you. The diagnosis advanced as the explanation for your limited motion, pain, and altered functional capacity after examination and X-ray by your orthopedic surgeon is arthritis of the hip or knee and you fall within the Boomeritis age group.  Should it be joint replacement surgery or rejuvenative cellular medical management?  The former is covered by insurance; the latter is an out of pocket expense.  A joint replacement will require compromise in your recreational and functional profile; successful stem cell management will not. Stem cell management holds the promise of unlimited recreation.   There is a 15% chance of needing revision surgery within 15 years after a joint replacement with a predictable marginal outcome thereafter; as contrasted to unknown data on the long-term success of rejuvinative cellular management, for now it is all anecdotal. The lack of success of stem cell management of arthritis would be the indication for a total joint replacement.  Should you first consider stem cells?

 Is Joint Replacement Surgery the Right Fix or Should You First Consider Platelet Rich Plasma and Stem Cells?

There is a very unique challenge concerning how to manage the results of aging and its effects on musculoskeletal well-being and continued participation in sports-from the weekend to the master athlete. Better understanding of the basic science of aging allows for better management of the physiological and biological issues and challenges facing the athletic baby boomer patient. The major problem as we age is weight gain despite a high level of activity and the same nutritional patterns as when we were younger. One must be aware that the body’s Resting Metabolic Rate (RMR) comprises 60-75% of daily energy expenditure and that RMR decreases 20% from childhood to retirement. 

The Basic Science of Aging :Implications for the Male and Female Master Athletes

We all must recognize the normal physiologic effects of aging and how our activities of daily living, work related undertakings, recreational enjoyment, and participation in sports are impacted Are there appropriate non-operative treatment plans for patients with traumatic, degenerative, and arthritic conditions, particularly related to the knee, hip, shoulder and spine that might allow you to postpone or even avoid a joint replacement? By analyzing with you, the impact of joint replacement, cartilage regeneration techniques and rotator cuff procedures, I might assist you with the informed decision making process?

Joint replacement patients today are younger and more active than ever before. Half of all hip replacement surgeries this year are expected to be on people under age 65, with the same projection for knee replacement candidates by 2016 according to the American Academy of Orthopedic Surgeons. It is thought that many middle aged athletes-the reader is empowered to define middle age and athlete-are wearing out their joints and suffering osteoarthritis years earlier than previous generations. I don’t necessarily subscribe to the notion; it may be that degeneration is no greater than in the past but functional demand and expectation has increased. In either case, if your G-d given joints don’t last a lifetime, what should you expect from an artificial joint with a predicted survivorship of 15 years average under minimal demand? What is the present indication for Platelet Rich Plasma and Autologous Mesenchymal Bone Marrow Derived Stem Cells? Caution to the reader, while the content of this blog does not necessarily lend itself to sexual content and nudity ratings; be aware that PRP and Stem Cell management are not covered by third party payers at this time (XXX rated). Both are an out of pocket expenses

To be continued as I am leaving for my run, bike and rowing workout