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Orthobiologics Case

10/30/2020

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It’s always nice to share success stories. We had a 57 year old female patient recently present to our office with knee pain. She had X-rays that showed moderate to severe medial joint space narrowing. She had prior arthroscopic knee surgery and corticosteroid injections with decent but temporary relief. She wanted to avoid further surgical intervention if possible. We discussed the risks of additional corticosteroid injection, indicating the relief was temporary and came at a cost of toxicity to the cells in the knee. She opted to pursue an orthobiologic option. Orthobiologics are interventions that typically use the patient’s own tissue (platelet rich plasma or bone marrow concentrate) to help assist with the body’s natural recovery process. After the procedure, we typically see a window of 4-8 weeks where the procedure takes effect. For this case, the patient mentioned that she had about 70% relief at the 2 month check in mark. I feel that anything above 50% improvement is a successful and satisfactory result. There are often secondary benefits including, resuming enjoyable activities that were previously limited by pain, improved sleep, and decreased reliance on medication.
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The Croissant Diet

10/30/2020

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At Black Stone Physical Medicine, our primary goal is to help our patients minimize their pain and by doing so we hope to improve their quality of life. Optimizing nutrition to minimize pain and inflammation is often part of our recommendations for treatment. For most people the science behind nutrition seems to be a moving target. We hear all sorts of different recommendations from doctors and online. It doesn’t help when these recommendations can be night and day different, for example, ketogenic diet vs vegan diet. You will find both extremes supported by experts quoting medical studies and reporting anecdotal success stories. We also realize that each individual is different and that it may be too good to be true to have a perfect diet. A few things we can do with these limitations are allergy testing, genetic testing, and microbiome testing. We have been recommending Viome recently (blackstone15 for 15% off) for our patients. ​
Even in this setting of conflicting recommendations, there are pieces of truth that can be obtained as we learn more about nutrition. Paul Saladino, MD, a proponent of the carnivore diet recently discussed with Brad Marshall a few new theories on nutrition. They feel the main driver of the obesity epidemic has been polyunsaturated fats (PUFA) rather than refined carbohydrates. They agree that carbohydrates adds fuel to the fire in the setting of metabolic dysfunction with conditions like diabetes mellitus.
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If you’re interested in seeing their arguments, check out The Croissant Diet. Or you can check out some of Dr Saladino’s podcasts on the Fundamental Health Podcast.
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What are Exosomes?

10/16/2020

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In the realm of orthobiologics, every passing year brings us additional understanding of the disease processes that we are treating as well as new possible treatment options. For years we have known that using bone marrow aspirate concentrate, which contains mesenchymal stem cells, may help certain conditions, such as knee osteoarthritis. The experts had their theories on how injecting the concentrate from bone marrow could help pain. Initially they thought that these mesenchymal stem cells were honing in to the area of injury and changing into cartilage cells where they would then create more cartilage and repair site of injury.
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Lately, there has been a focus on the role of exosomes and microvesicles. These are secreted by all cells and play a role in cell to cell communication. There is a theory that these play a role in the symptomatic improvement in conditions like knee osteoarthritis after injection with mesenchymal stem cells. The thought is that the stem cells release these exosomes and microvesicles which then act as signals to the existing cells and tissue to stimulate changes that result in improvement of symptoms. Below is a reference from a recent study discussing the roles of exosomes and their therapeutic potential.
Currently, exosomes are not FDA approved for any treatments in humans. More research is needed before we can use this treatment for any human condition. There are ongoing trials using exosomes to assess safety in humans.

Ma ZJ, Yang JJ, Lu YB, Liu ZY, Wang XX. Mesenchymal stem cell-derived exosomes: Toward cell-free therapeutic strategies in regenerative medicine. World J Stem Cells. 2020;12(8):814-840. doi:10.4252/wjsc.v12.i8.814


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What To Do For A Torn Meniscus?

11/15/2018

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ANATOMY
The meniscus is a fibrocartilage structure that sits between the tibia and femur in the knee.  There is a lateral and a medial meniscus. The menisci provide cushioning, joint stabilization, joint lubrication, and proprioception.  
Image: BruceBlaus, via wikimedia

​INJURY

The menisci are often injured resulting in tears. People with absent anterior cruciate ligaments (ACL) are at a higher risk for injury.  Tears to the meniscus often occur with excessive twisting movements seen in sports when an athlete plants a leg and pivots.  The meniscus is often injured in combination with the ACL and the medial collateral ligament.
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Mikael Haggstrom, via wikimedia. (CC0 1.0)
TREATMENT
These injuries are often treated conservatively with rest, NSAIDs, and physical therapy.  If symptoms don’t improve with conservative treatment or if they are severe enough, surgery is the next option.  For symptomatic degenerative meniscal tears that are non-surgical, corticosteroid injections are standard of care.
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R. Alex Durbin, via jble.af.mil
SURGICAL MANAGEMENT
If the tear is in the outer third of the meniscus, blood flow is good and healing can occur.  These will often be repaired surgically and with good results. If the tear is in the inner two thirds of the meniscus, then a partial meniscectomy is often pursued.  Recently, partial meniscectomy has been shown to be no greater than conservative management for degenerative tears. Partial meniscectomy is the most common orthopedic procedure, with more than 700,000 cases per year.  
ORTHOBIOLOGICS
With surgical options being limited, there has been a lot of interest in regenerative medicine treatments for meniscal tears.  Platelet rich plasma (PRP) research in meniscal injuries is limited but encouraging. PRP is known to release growth factors, cytokines, and chemokines which can facilitate the healing process.  There have been animal studies investigating the role of bone marrow derived mesenchymal stem cells (BM-MSCs) in the treatment of the avascular zone of the meniscus. There is early high-level evidence for the use of BM-MSCs after partial meniscectomy that show improvement in meniscal volume at 1 year.  There have also been numerous studies involving regenerative medicine during surgical intervention.
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Alice Pien MD, via wikimedia. (CC BY-SA 4.0)
FURTHER INFORMATION
If you suffer from a meniscus injury, schedule a consultation with Black Stone Physical Medicine to discuss what your best treatment options for you condition.  We serve the surrounding area including Albany, Newport, Salem, and Eugene.
Schedule Now!
References
Vangsness CT Jr, Farr J II, Boyd J, Dellaero DT, Mills CR, LeRoux-Williams M. Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial meniscectomy: A randomized, double-blind, controlled study. J Bone Joint Surg Am 2014;96:90-98.
Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Rep 2009;11:1-25.
Betancourt JP, Murrell WD. Leukocyte-poor platelet-rich plasma to treat degenerative meniscal tear: A case report. J Clin Orthop Trauma. 2016;7(Suppl 1):106-109.
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Osteoarthritis of the Knee

10/27/2018

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Osteoarthritis of the knee is the most common joint affected but arthritis.  Painful knee arthritis is present in up to 10% of men and 13% of women over the age of 60.  Factors that increase the risk for osteoarthritis include old age, obesity, prior knee injury, repetitive use of knees, muscle weakness, and joint laxity.

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Ester Max, via flicker (CC BY 2.0)
SYMPTOMS:
Symptomatic knee osteoarthritis begins with pain.  Pain will be present with certain activities such as running, climbing stairs, and walking.  Pain at night, joint swelling, knee stiffness, and locking/catching are other symptoms of knee osteoarthritis.  
 
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BruceBlaus, via wikimedia (CC BY-SA 4.0)
PATHOPHYSIOLOGY:
During osteoarthritis the articular cartilage degenerates, the lining of the joint (synovium) becomes inflamed, and the subchondral bone remodels and forms osteophytes and bone cysts.  Some of the known factors that play a role in this are proteolytic enzymes. Matrix metalloproteases (MMPs) are responsible for breaking down cartilage. Tissue inhibitors of MMPS (TIMPs) play a role by inhibiting these enzymes.  When there is an imbalance of MMPs and TIMPs the degenerative arthritis process proceeds. Inflammatory cytokines, like IL-1, IL-6, and TNF-alpha, also play a role by increasing creation of MMPs.


DIAGNOSIS:
The diagnosis is often made by careful questioning and physical exam by a healthcare practitioner then confirmed with imaging including x-rays and possibly MRI.  On X-rays we can see joint space narrowing, osteophytes, and subchondral bone cysts and sclerosis. The MRI will show detailed degenerative changes in the cartilage and bone.
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James Heilman MD, via wikimedia (CC BY-SA 3.0)
TREATMENT:
Conservative management for knee osteoarthritis includes ice/heat, non-steroidal anti-inflammatories (ibuprofen or naproxen), bracing, weight loss, and physical therapy.  Often when conservative treatment fails, physicians will often move on to corticosteroid injections which can help decrease pain and improve function temporarily. When symptoms and severity of arthritis become severe enough physicians will often refer to orthopedic surgery for possible joint replacement.  Corticosteroid injection combined with anesthetics can be toxic to chondrocytes, the cells that produce cartilage, and joint replacement comes with the risk of a major surgical procedure. According to the American Academy of Orthopedic Surgery (AAOS), complication rate is around 5% and the chance of dying within 30 days of surgery is 1 out of 400.
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Alice Pien MD, via wikimedia (CC BY-SA 4.0)
Orthobiologics, also known as regenerative medicine, is a new area of medicine that harnesses the healing ability of our own tissues.  These regenerative cells, often called stem cells, have the ability to decrease pain, improve function, and slow the degenerative process.  Platelet rich plasma (PRP) and mesenchymal stem cells from bone marrow aspirate concentrate (BMAC) have been used for knee osteoarthritis.  
References:
Brown GA. J Am Acad Orthop Surg. 2013. Sep;21(9):577-9.
Centeno C, Pitts J, Al-Sayegh H, Freeman M. Efficacy of autologous bone marrow concentrate for knee osteoarthritis with and without adipose graft. Biomed Res Int. 2014;2014:370621.
Freeley BT, Gallo RA, Sherman S, Williams RJ. J Am Acad Orthop Surg. 2010 Jul;18(7):406-16.
Wang M, Shen J, Jin H, Im HJ, Sandy J, Chen D. Ann N Y Acad Sci. 2011 Dec;1240:61-9.
Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Clin Geriatr Med. 2010;26(3):355-69.
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    Author

    Marc Musson DO is a Physiatry trained physician at Black Stone Physical Medicine.  He specializes in treating acute and chronic orthopedic and neurological pain conditions.

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