Can Rooster Comb Injections Prevent Knee Replacement?

Osteoarthritis (OA) of the knee is one of the most common problems seen by both rheumatologists as well as orthopedists in the office. The standard forms of therapy include maintenance of proper weight, exercise, application of cold, bracing, analgesics (pain killers), anti-inflammatory medicines, steroid injections, and viscosupplementation. This latter type of treatment involves the injection of a lubricant directly into the knee.

These lubricants consist of a purified form of a protein called hyaluronic acid (HA). These preparations are effective in relieving pain. pain relief from OA of the knee starts between the 5th and 13th week follwoing injection. While HA is felt to be effective for pain relief, it has been unclear as to whether there are any other benefits.

Two recent studies have demonstrated that viscosupplementation may actually forestall the need for eventual knee replacement surgery and also may represent a long term cost savings.

The first study from Louisiana State University surveyed patients from a large orthopedic practice. A total of 863 patients (1187 knees) were evaluated. All patients had grade 4 changes, meaning they had "bone on bone" and were candidates for total knee replacement.

Using survival analysis of the data, it was estimated that total knee replacement was delayed approximately 3.8 years in 75 percent of the knees receiving viscosupplementation (Waddell DD, et al. J. Managed Care Pharm. 2007; 2:113-121.)

In another study, investigators in Thailand studied one hundred and eighty three patients with knee OA (208 knees) who failed conservative treatments and did not have contraindications for surgery were enrolled. All patients were treated with one course of three hyaluoronic acid injections at weekly intervals and followed up for a minimum 2-year period. In case of successful treatment (response group), repeated doses were recommended. If the patients did not improve within one month after completion of the injections, they would be classified as a non-response group and total knee replacement surgery was considered. Cost of direct medical costs (drugs), hospitalization, and resource utilization were recorded and analyzed.

They concluded that IA-HA (joint injection with HA) should be considered as a medical intervention before surgical procedures in knee OA patients who failed conservative treatments. Even though the cost of IA-HA treatment would increase the total costs of treatment and some patients might fail, it was only 6.44% of the total costs. On the other hand, if patients responded to IA-HA treatment, then the surgical procedures were not required. This treatment would represent a savings of 63.26% of total costs. (Turajane T, et al. J Med Assoc Thailand. 2007; 90;1839).

While, the exact analyses and conclusions of these two studies are different, they do suggest that HA may be cost effectve in delaying the need for total knee replacement.

There are five HA preparations available. They are Hyalgan, Synvisc, Supartz, Orthovisc, and Euflexxa. Only Euflexxa is not derived from a chicken source.

The number of injections required varies from 3-5 depending on the preparation used. Hyalgan and Supartz generally are given as weekly injections for 5 weeks while Synvisc, Orthovisc, and Euflexxa are given as weekly injections for 3 weeks.

Thes injections should be administered using either fluoroscopic or ultrasound needle guidance to ensure accuracy.

Side-effects are minimal when administered by trained specialists.

HA injections are worth a try even with grade 4 knees if patients wish to delay surgery.

Author: Nathan Wei

Stem Cell Therapy For Osteoarthritis: What is the Data?

In the last few years, a number of methods have been developed to repair cartilage damage. These include osteochondral transplantation, microfracture surgery and autologous chondrocyte (cartilage cell) implantation.

A feature common to all of these techniques is that they are limited to the repair of focal lesions. Patients with OA are excluded from treatment.

OA cartilage lesions are usually larger and unconfined and so do not provide an appropriate environment for chondrocytes to be retained long enough to build a framework (matrix).

So...successful repair of OA cartilage damage is dependent on the ability to form a matrix within the joint.

Effective cartilage engineering protocols have already been developed in which chondrocytes in young animal models have been shown to be effective in creating cartilage.

Generating cartilage using adult human cartilage cells is far more challenging. Older OA patients have cartilage that is less responsive to stem cell stimulation and their stem cells seem to respond less well to the usual growth factors.

There are three potential avenues for obtaining stem cells. The first are embryonic stem cells which have the attraction of being relatively pristine. However, political and ethical interests have made this source of stem cells unobtainable. Plus, there is the theoretical possibility that theses stem cells may grow unchecked leading to unregulated growth, ie cancer.

A second source are mesenchymal stem cells grown in a laboratory from normal volunteers. While carefully screened for diseases and genetic problems, these stem cells do carry the potential for possible rejection reactions.

Finally, the last source and the one that seems to have the most promise- at least for now- are autologous stem cells. These are stem cells harvested from the iliac crest of the patient.

Autologous stem cells provide an attractive option for osteoarthritis patients and their clinicians. However it must also be recognized that autologous therapies are expensive. Ideally, it would be good to treat the specimen obtained from the iliac crest to growth factors, cytokines, and chemokines, to stimulate an increase in the number of stem cells.

However, both governmental regulations as well as sterility concerns preclude this step.

In addition, the search for better matrix production to allow stem cells a "home" to grow in and multiply is still being studied.

There have been a few clinical trials that have demonstrated some promise. The first comes from Murdoch University in Australia.

Working with Australia's adult stem cell company, Mesoblast Limited (ASX:MSB), the University's pre-clinical trials of Mesoblast's patented adult stem cells had shown the therapy to significantly protect cartilage against damage in knee osteoarthritis.

The project's principal investigator, Professor Rick Read stated, "We are delighted with the significant cartilage protective effects of Mesoblast's allogeneic (donor unrelated) cells in our large animal model of knee osteoarthritis, without any adverse events of the cells at all."

Mesoblast's cartilage trials evaluated the effectiveness and safety of the company's allogeneic adult stem cells to treat osteoarthritis of the knee in 48 arthritic sheep joints.

The results showed that osteoarthritic sheep knee joints receiving Mesoblast's stem cells had significantly greater thickness of joint cartilage, reduced cartilage breakdown, and greater biomechanical strength three months later than did control joints receiving hyaluronic acid.

In another study, Duke University Medical Center researchers have "reprogrammed" adult stem cells taken from a small deposit of fat behind the kneecap into functioning cartilage, bone, or fat cells that could potentially be grown into replacement tissues for osteoarthritis.

The research team has provided evidence that stem cells taken from different adult sources have the potential to be transformed into multiple specialized cell types.

In the current study, the researchers took the fat pads from patients whose knee joints were removed during total joint replacement surgery. The fat pad is a dense structure behind the patella, or kneecap that is unlike typical fat tissue found throughout the body.

They were able to isolate and grow adult stem cells from this tissue.

According to scientists at Cardiff University, stem cells identified in their studies can be turned into cartilage cells (chondrocytes) in huge quantities. This may mean that limitations in cartilage transplants, in which healthy cartilage cells are collected and transplanted into a damaged joint, could be overcome.

However, despite recent media reports that heralded the identification of these stem cells as a breakthrough in the treatment of osteoarthritis, this research is currently only being considered to treat people with limited cartilage damage only.

Dr. Nathan Wei states, "Our current understanding of stem cell biology is obviously not where it needs to be. However, early work at our center using autologous stem cells obtained from iliac crest bone marrow and then concentrated has shown very promising results in patients with osteoarthritis of the knee. It is important to comment on the fact that prior to introduction of the stem cells, irritation of the cartilage and adjacent capsule is important to initiate an inflammatory response which then leads to cell proliferation which is an essential part of healing and subsequent cartilage regeneration."

Dr. Wei adds, "For sure, though, I feel that this approach which is relatively painless will prove to be more effective than other therapies we currently have for osteoarthritis." 

Author: Nathan Wei

"Ooohhh, My Aching Knee!" Insider Secrets on How You Can Get Relief Quickly and Easily!

When your knee hurts, getting relief is all that's on your mind. Getting the right relief, though, depends on knowing what's wrong. The correct diagnosis will lead to the correct treatment.
Know Your Knee!
The knee is the largest joint in the body. It's also one of the most complicated. The knee joint is made up of four bones that are connected by muscles, ligaments, and tendons. The femur (large thigh bone) interacts with the two shin bones, the tibia (the larger one) located towards the inside and the fibula (the smaller one) located towards the outside. Where the femur meets the tibia is termed the joint line. The patella, (the knee cap) is the bone that sits in the front of the knee. It slides up and down in a groove in the lower part of the femur (the femoral groove) as the knee bends and straightens.
Ligaments are the strong rope-like structures that help connect bones and provide stability. In the knee, there are four major ligaments. On the inner (medial) aspect of the knee is the medial collateral ligament (MCL) and on the outer (lateral) aspect of the knee is the lateral collateral ligament (LCL). The other two main ligaments are found in the center of the knee. These ligaments are called the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). They are called cruciate ligaments because the ACL crosses in front of the PCL. Other smaller ligaments help hold the patella in place in the center of the femoral groove.
Two structures called menisci sit between the femur and the tibia. These structures act as cushions or shock absorbers. They also help provide stability for the knee. The menisci are made of a tough material called fibrocartilage. There is a medial meniscus and a lateral meniscus. When either meniscus is damaged it is called a "torn cartilage".
There is another type of cartilage in the knee called hyaline cartilage. This cartilage is a smooth shiny material that covers the bones in the knee joint. In the knee, hyaline cartilage covers the ends of the femur, the femoral groove, the top of the tibia and the underside of the patella. Hyaline cartilage allows the knee bones to move easily as the knee bends and straightens.
Tendons connect muscles to bone. The large quadriceps muscles on the front of the thigh attach to the top of the patella via the quadriceps tendon. This tendon inserts on the patella and then continues down to form the rope-like patellar tendon. The patellar tendon in turn, attaches to the front of the tibia. The hamstring muscles on the back of the thigh attach to the tibia at the back of the knee. The quadriceps muscles are the muscles that straighten the knee. The hamstring muscles are the main muscles that bend the knee.
Bursae are small fluid filled sacs that decrease the friction between two tissues. Bursae also protect bony structures. There are many different bursae around the knee but the ones that are most important are the prepatellar bursa in front of the knee cap, the infrapatellar bursa just below the kneecap, the anserine bursa, just below the joint line and to the inner side of the tibia, and the semimembranous bursa in the back of the knee. Normally, a bursa has very little fluid in it but if it becomes irritated it can fill with fluid and become very large.
Is it bursitis... or tendonitis...or arthritis?
Tendonitis generally affects either the quadriceps tendon or patellar tendon. Repetitive jumping or trauma may set off tendonitis. The pain is felt in the front of the knee and there is tenderness as well as swelling involving the tendon. With patellar tendonitis, the infrapatellar bursa will often be inflamed also. Treatment involves rest, ice, and anti-inflammatory medication. Injections are rarely used. Physical therapy with ultrasound and iontopheresis may help.
Bursitis pain is common. The prepatellar bursa may become inflamed particularly in patients who spend a lot of time on their knees (carpet layers). The bursa will become swollen. The major concern here is to make sure the bursa is not infected. The bursa should be aspirated (fluid withdrawn by needle) by a specialist. The fluid should be cultured. If there is no infection, the bursitis may be treated with anti-jnflammatory medicines, ice, and physical therapy. Knee pads should be worn to prevent a recurrence once the initial bursitis is cleared up.
Anserine bursitis often occurs in overweight people who also have osteoarthritis of the knee. Pain and some swelling is noted in the anserine bursa. Treatment consists of steroid injection, ice, physical therapy, and weight loss.
The semimembranous bursa can be affected when a patient has fluid in the knee (a knee effusion). The fluid will push backwards and the bursa will become filled with fluid and cause a sensation of fullness and tightness in the back of the knee. This is called a Baker's cyst. If the bursa ruptures, the fluid will dissect down into the calf. The danger here is that it may look like a blood clot in the calf. A venogram and ultrasound test will help differentiate a ruptured Baker's cyst from a blood clot. The Baker's cyst is treated with aspiration of the fluid from the knee along with steroid injection, ice, and elevation of the leg.
Knock out knee arthritis... simple steps you can take!
Younger people who have pain in the front of the knee have what is called patellofemoral syndrome (PFS). Two major conditions cause PFS. The first is chondromalacia patella. This is a condition where the cartilage on the underside of the knee cap softens and is particularly common in young women. Another cause of pain behind the knee cap in younger people may be a patella that doesn't track normally in the femoral groove. For both chondromalacia as well as a poorly tracking patella, special exercises, taping, and anti-inflammatory medicines may be helpful. If the patellar tracking becomes a significant problem despite conservative measures, surgery is need.
While many types of arthritis may affect the knee, osteoarthritis is the most common. Osteoarthritis usually affects the joint between the femur and tibia in the medial (inner) compartment of the knee. Osteoarthritis may also involve the joint between the femur and tibia on the outer side of the knee as well as the joint between the femur and patella. Why osteoarthritis develops is still being scrutinized carefully. It seems to consist of a complex interaction of genetics, mechanical factors, and immune system involvement. The immune system attacks the joint through a combination of degradative enzymes and inflammatory chemical messengers called cytokines.
Patients will sometimes feel a sensation of rubbing or grinding. The knee will become stiff if the patient sits for any length of time. With local inflammation, the patient may experience pain at night and get relief from sleeping with a pillow between the knees. Occasionally, locking and clicking may be noticed. Patients with osteoarthritis may also tear the fibrocartilage cushions (menisci) in the knee more easily than people without osteoarthritis.
So how is the arthritis treated? An obvious place to start is weight reduction for patients who carry around too many pounds.
Strengthening exercises for the knee are also useful for many people. These should be done under the supervision of a physician or physical therapist.
Other therapies include ice, anti inflammatory medicines, and occasionally steroid injections. Glucosamine and chondroitin supplements may be helpful. A word of caution... make sure the preparation you buy is pure and contains what the label says it does. The supplement industry is unregulated... so buyer beware!
Injections of the knee with viscosupplements - lubricants- are particularly useful for many patients. Special braces may help to unload the part of the joint that is affected.
Arthroscopic techniques may be beneficial in special circumstances. Occasionally, a surgical procedure called an osteotomy, where a wedge of bone is removed from the tibia to "even things out," may be recommended. Joint replacement surgery is required for end stage knee arthritis.
Research is being done to develop medicines that will slow down the rate of cartilage loss. Targets for these new therapies include the destructive enzymes and/or cytokines that degrade cartilage. It is hoped that by inhibiting these enzymes and cytokines and by boosting the ability of cartilage to repair itself, that therapies designed to actually reverse osteoarthritis may be created. These are referred to as disease-modifying osteoarthritis drugs or "DMOADs." Genetic markers may identify high risk patients who need more aggressive therapies.
Newer compounds that are injected into the knee and provide healing as well as lubrication are also being developed. And finally, less invasive surgical techniques are also being looked at. Recent technological advances in "mini" knee replacement look very promising.

By Nathan Wei