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Author Topic: Looking to treat severe knee medial compartment OA  (Read 554 times)

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Offline ubercool

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Looking to treat severe knee medial compartment OA
« on: December 18, 2021, 05:37:26 PM »
Hi, a long-time lurker here. I’m a 70-year-old man who had what I believe to be a partial meniscectomy in 1985 (still trying to track down my records from Dr. Jeffrey Schwartz in New York). I re-injured my left knee running after a grocery delivery boy, which was initially damaged jogging with a GF in 1981 in San Francisco.

Recently, I re-inflamed this 40-year-old injury by bicycling a bit too much, so I have been visiting this forum to gather information. Like @silver_maple, I too had been optimistic that stem-cell therapy would rehab my knee and return me to about 80% of prior functionality.

I was, however, quickly brought back to earth. Despite the fact that we have emerging evidence that stem-cell therapy can increase the volume of cartilage ([Intra-Articular Injection of Mesenchymal Stem Cells for the Treatment of Osteoarthritis of the Knee](https://pubmed.ncbi.nlm.nih.gov/24449146/)), the unpredictability of results is worrisome.

The biggest challenge is finding the *right* doctor. After many years of reading the blog posts of Dr. Chris Centeno, I decided to pay him a visit in Broomfield, CO. My diagnosis was “severe left knee medial compartment OA.” Several forum members have a negative opinion of Regenexx and, based on my visit experience, I must concur, but will save my comments for a later post.

Next on my list is Dr. Kevin Stone in San Francisco. I realize that some members see a red flag in that Stone is the only doctor that practices the Articular Cartilage Paste Grafting technique, but I need a second opinion and Stone offers one free of charge over the phone.

My compiled data suggests that Dr. Joseph Broyles in Baton Rouge is highly regarded but his [BAM-12 technique](https://www.cartilageregenerationcenter.com/bam-timeline) is simply too time-consuming and expensive. This treatment, pardon the pun, jointly developed with Malaysia’s Dr. Khay Yong Saw, requires a minimum of seven visits to Louisiana, which makes it largely impractical.

Of all the doctors I have data on, it appears that Dr. Joseph Purita in Boca Raton, FL is the best all-around choice, although I have no visibility into the number of visits and costs involved.

Based on my Las Vegas location, I would prefer an OS that practices regenerative medicine in Southern California, allowing me to drive there for the many trips required. San Francisco is also a distinct possibility since my daughter lives in Oakland, which explains my choice of Dr. Stone. The other recommended OS in San Francisco, Dr. Scott Dye, has unfortunately permanently closed his office.

AFAIK Dr. William Bugbee in San Diego doesn’t practice regenerative medicine and I’m also not sure I would trust a doctor of naturopathy, Dr. Harry Adelson in Park City, UT, with something as complex as a knee. But I understand Dr. Adelson is highly regarded, albeit very expensive.

Does anyone have any other suggestions for me? Could I just start with a PRP treatment at [Cedars-Sinai](https://www.cedars-sinai.org/programs/imaging-center/exams/musculoskeletal-radiology/platelet-rich-plasma.html) in L.A. to see if that helps with walking pain?

What other treatment options are there for medial compartment OA? Thanks in advance! :)

Offline vickster

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Re: Looking to treat severe knee medial compartment OA
« Reply #1 on: December 18, 2021, 05:46:21 PM »
There are a number of articles around OA and alternatives to joint replacement parts in the site learning portfolio
https://www.kneeguru.co.uk/KNEEnotes/learning-portfolio
Unfortunately for severe issues, the effective options are limited especially given your age. If happy to throw a lot of time and money at the problem, you might find some relief from injections, but ultimately if the pain is unliveable a PKR or TKR might be your only option. In reality, once the cartilage is gone in large amounts and the subchondral bone is damaged, there’s not much left in terms of getting it back. An osteotomy might be less drastic than a replacement but usually for patients too young for replacement.
If it’s just medial pain on walking, have you invested in a professionally fitted unloader OA brace eg from Donjoy?
Good luck :)
« Last Edit: December 18, 2021, 05:57:38 PM by vickster »
Came off bike onto concrete 9/9/09 (lat meniscus, lat condyle defect)
LK scopes 8/2/10 & 16/12/10
RK scope 5/2/15 (menisectomy, Hoffa’s fat pad trim)
LK scope 10.1.19 medial meniscectomy, trochlea MFX
LK scope 19.4.21 MFX to both condyles & trochlea, patella cartilage shaved, viscoseal, depo-medrone

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #2 on: December 18, 2021, 06:21:24 PM »
Thanks for the quick reply and link, much appreciated. Let me add some more perspective:

I can walk fine, I just can't bicycle, or walk for more than 15 minutes, without getting knee pain, probably on the 5-7 scale. I would like to be able to bike again.
I was just about to order a Donjoy brace to replace my cheapie Cho-Pat, so thanks for the specific Donjoy recommendation. :)
I can’t read MRIs but thought I would post an MRI of mine for forum feedback (not sure if I have sufficient permission to post images yet, so here’s the URL: https://imgur.com/a/mJeJ3W9):



There are a number of articles around OA and alternatives to joint replacement parts in the site learning portfolio
https://www.kneeguru.co.uk/KNEEnotes/learning-portfolio
Unfortunately for severe issues, the effective options are limited especially given your age. If happy to throw a lot of time and money at the problem, you might find some relief from injections, but ultimately if the pain is unliveable a PKR or TKR might be your only option. In reality, once the cartilage is gone in large amounts and the subchondral bone is damaged, there’s not much left in terms of getting it back. An osteotomy might be less drastic than a replacement but usually for patients too young for replacement.
If it’s just medial pain on walking, have you invested in a professionally fitted unloader OA brace eg from Donjoy?
Good luck :)

Offline vickster

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Re: Looking to treat severe knee medial compartment OA
« Reply #3 on: December 18, 2021, 06:43:15 PM »
Well that’s good as you specifically mentioned walking pain

I’m a cyclist with tri compartment OA in one knee (20 years younger than you)… have you had your set up checked by a physiotherapist, especially cleats if you use them?

See a podiatrist too, see if any misalignment on the medial side could be helped with custom insoles

I don’t think anyone here will be able to read your MRI, and not from just one slice…do you have an X-ray showing the joint space from the front?
« Last Edit: December 18, 2021, 06:56:55 PM by vickster »
Came off bike onto concrete 9/9/09 (lat meniscus, lat condyle defect)
LK scopes 8/2/10 & 16/12/10
RK scope 5/2/15 (menisectomy, Hoffa’s fat pad trim)
LK scope 10.1.19 medial meniscectomy, trochlea MFX
LK scope 19.4.21 MFX to both condyles & trochlea, patella cartilage shaved, viscoseal, depo-medrone

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #4 on: December 18, 2021, 06:58:32 PM »
No physiotherapist consulted, so I don't use cleats. And MRIs are all I have at this point.

Well that’s good as you specifically mentioned walking pain

I’m a cyclist with tri compartment OA in one knee (20 years younger than you)… have you had your set up checked by a physiotherapist, especially cleats if you use them?

I don’t think anyone here will be able to read your MRI, and not from just one slice…do you have an X-ray showing the joint space from the front?

Offline vickster

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Re: Looking to treat severe knee medial compartment OA
« Reply #5 on: December 18, 2021, 07:10:42 PM »
You’ll want a physio to assess you for the brace properly, get your gait and rom checked thoroughly too. Orthotics have made a big difference to my walking and the right footwear
Came off bike onto concrete 9/9/09 (lat meniscus, lat condyle defect)
LK scopes 8/2/10 & 16/12/10
RK scope 5/2/15 (menisectomy, Hoffa’s fat pad trim)
LK scope 10.1.19 medial meniscectomy, trochlea MFX
LK scope 19.4.21 MFX to both condyles & trochlea, patella cartilage shaved, viscoseal, depo-medrone

Offline silver_maple

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Re: Looking to treat severe knee medial compartment OA
« Reply #6 on: December 19, 2021, 01:11:06 AM »
Ubercool,

I'd take a guess the partial meniscectomy you likely had was on the medial side. There is strong evidence partial meniscectomy increases the likelihood of arthritis. There is incontrovertible evidence full meniscectomy leads to arthritis. Pretty much all docs know that and I don't believe full meniscectomy is practiced anymore. Partial is, however, as it is sometimes unavoidable (e.g. dangling pieces). So much for the pathogenesis. Now, what to do.

The hope that many people have for regenerative medicine is understandable. I (still) have it. This forum was brimming with euphoria ~ 8-9 years ago when PRP and stems came onto the market. There was this feeling that arthritis had finally been vanquished. The notion that stem cells, once injected, detect damage and morph into whatever cell type is needed to restore tissue is now known to be a fantasy. It has at least been shown that under current protocols stem cells don't do damage - no cancer formation or other major complications.

PRP could ease some of your pain but will not reverse your arthritis. Also, the effect wears off after 3-6 months. No downside to PRP apart from cost. It is the least invasive "regenerative" modality to try. I've had about half a dozen PRP shots which neutralized inflammation and may have restored the natural homeostasis of anabolic and catabolic processes in the knee. But despite multiple growth factors in PRP I don't believe there is any regeneration. MRI imaging showed no effect on my chondromalacia and torn meniscus.

There are multiple stem cell treatments. Anyone over 40 should not be looking at bone marrow, the yield is low. Fat's the way to go. The Korea study you quoted is with pure stems, this is not allowed in the US outside clinical trials. Dr Centeno took it offshore to the Caymans ~ 10 years ago - pure stems have failed to live up to the hype or he would've brought it back to the U.S. if there were evidence.

Research continues.

I think micro-fractured fat (a cocktail of stems and other bits) is the best there is at the moment but keep your expectations low. You may get pain relief that lasts longer than with PRP but actual tissue regeneration is a toss. Lipogems runs $3-4K. There are other similar systems.

Longer term some look at genetic approaches but that generally remains at the pre-clinical stage. Both of us would run out of runway even if gene therapy ends up successful eventually.

The U.S. sees about 800,000 total knee replacements annually, which is the currently accepted end-stage definitive knee arthritis "treatment".
2019 - Chondromalacia patella gr 1-2, both knees; early bilateral tibio-femoral arthritis; 5mm focal chondral lesion (LK); degenerate meniscus tear (RK)
2020 - PRP x3 in RK
2021 - PRP x3 in RK, PRP x1 in LK

Offline Dave33

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Re: Looking to treat severe knee medial compartment OA
« Reply #7 on: December 19, 2021, 05:16:14 AM »
What other treatment options are there for medial compartment OA? Thanks in advance! :)

I'll be totally honest; at 70, I think you could spend a lot of time and money on largely unproven and low-percentage regenerative techniques, or you could simply get a partial or full replacement with an extremely high % chance of success, which will very likely easily last your lifetime.

But absolutely, it's a personal decision, and significant one.

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #8 on: December 20, 2021, 12:01:08 AM »
Ubercool,

I'd take a guess the partial meniscectomy you likely had was on the medial side. There is strong evidence partial meniscectomy increases the likelihood of arthritis. There is incontrovertible evidence full meniscectomy leads to arthritis. Pretty much all docs know that and I don't believe full meniscectomy is practiced anymore. Partial is, however, as it is sometimes unavoidable (e.g. dangling pieces). So much for the pathogenesis. Now, what to do.

The hope that many people have for regenerative medicine is understandable. I (still) have it. This forum was brimming with euphoria ~ 8-9 years ago when PRP and stems came onto the market. There was this feeling that arthritis had finally been vanquished. The notion that stem cells, once injected, detect damage and morph into whatever cell type is needed to restore tissue is now known to be a fantasy. It has at least been shown that under current protocols stem cells don't do damage - no cancer formation or other major complications.

PRP could ease some of your pain but will not reverse your arthritis. Also, the effect wears off after 3-6 months. No downside to PRP apart from cost. It is the least invasive "regenerative" modality to try. I've had about half a dozen PRP shots which neutralized inflammation and may have restored the natural homeostasis of anabolic and catabolic processes in the knee. But despite multiple growth factors in PRP I don't believe there is any regeneration. MRI imaging showed no effect on my chondromalacia and torn meniscus.

There are multiple stem cell treatments. Anyone over 40 should not be looking at bone marrow, the yield is low. Fat's the way to go. The Korea study you quoted is with pure stems, this is not allowed in the US outside clinical trials. Dr Centeno took it offshore to the Caymans ~ 10 years ago - pure stems have failed to live up to the hype or he would've brought it back to the U.S. if there were evidence.

Research continues.

I think micro-fractured fat (a cocktail of stems and other bits) is the best there is at the moment but keep your expectations low. You may get pain relief that lasts longer than with PRP but actual tissue regeneration is a toss. Lipogems runs $3-4K. There are other similar systems.

Longer term some look at genetic approaches but that generally remains at the pre-clinical stage. Both of us would run out of runway even if gene therapy ends up successful eventually.

The U.S. sees about 800,000 total knee replacements annually, which is the currently accepted end-stage definitive knee arthritis "treatment".
silver_maple Thanks so much for your very considered response. It was one of your earlier posts that made me rethink my stem-cell therapy approach. I guess I was influenced by Purita’s spectacular success with New York Yankees pitcher Bartolo Colon.

There are a number of other solutions I’m still researching. You said you like lipogems, how about osteochondral autograft transplantation, osteochondral allograft, or autologous chondrocyte implantation? Or are these not applicable to OA?

I will begin investigating total knee replacements. I’m sure that’s another science all its own.

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #9 on: December 20, 2021, 12:11:43 AM »
What other treatment options are there for medial compartment OA? Thanks in advance! :)

I'll be totally honest; at 70, I think you could spend a lot of time and money on largely unproven and low-percentage regenerative techniques, or you could simply get a partial or full replacement with an extremely high % chance of success, which will very likely easily last your lifetime.

But absolutely, it's a personal decision, and significant one.

Thanks, Dave33, point well-taken. No need to waste money, much prefer patient satisfaction. ;)

Offline vickster

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Re: Looking to treat severe knee medial compartment OA
« Reply #10 on: December 20, 2021, 08:48:32 AM »

There are a number of other solutions I’m still researching. You said you like lipogems, how about osteochondral autograft transplantation, osteochondral allograft, or autologous chondrocyte implantation? Or are these not applicable to OA?

I will begin investigating total knee replacements. I’m sure that’s another science all its own.

Cartilage repair techniques are pretty much reserved for smaller focal defects in younger (<40, 50 at a push) patients not widespread deep wear and tear, they need pristine cartilage around them. They also don’t work well if there’s any sort of malalignment as can occur with extensive loss of joint space (bow legged with medial arthritis).

In terms of TKR, it’s important to find a super experienced surgeon with access to a wide range of replacement options and technology to suit the individual patient. As well as access to a top notch physio for prehab and rehab
« Last Edit: December 20, 2021, 12:04:54 PM by vickster »
Came off bike onto concrete 9/9/09 (lat meniscus, lat condyle defect)
LK scopes 8/2/10 & 16/12/10
RK scope 5/2/15 (menisectomy, Hoffa’s fat pad trim)
LK scope 10.1.19 medial meniscectomy, trochlea MFX
LK scope 19.4.21 MFX to both condyles & trochlea, patella cartilage shaved, viscoseal, depo-medrone

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #11 on: December 20, 2021, 03:35:01 PM »

There are a number of other solutions I’m still researching. You said you like lipogems, how about osteochondral autograft transplantation, osteochondral allograft, or autologous chondrocyte implantation? Or are these not applicable to OA?

I will begin investigating total knee replacements. I’m sure that’s another science all its own.

Cartilage repair techniques are pretty much reserved for smaller focal defects in younger (<40, 50 at a push) patients not widespread deep wear and tear, they need pristine cartilage around them. They also don’t work well if there’s any sort of malalignment as can occur with extensive loss of joint space (bow legged with medial arthritis).

In terms of TKR, it’s important to find a super experienced surgeon with access to a wide range of replacement options and technology to suit the individual patient. As well as access to a top notch physio for prehab and rehab

Thanks, vickster, I will heed your advice. The best orthopedic surgeon I found in Las Vegas, who is both board-certified and in-network for insurance purposes, is Parminder Kang (https://www.doclv.com/doctors/parminder-s-kang-md). In terms of physical therapy, this outfit is highly rated: Performance Physical Therapy (https://www.physicaltherapylasvegas.com/).

Will post my experiences here.

Offline silver_maple

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Re: Looking to treat severe knee medial compartment OA
« Reply #12 on: December 20, 2021, 04:11:27 PM »
Ubercool,

I concur with Vickster, the various grafts and transplantation approaches are meant for focal defects. In the case of advanced generalized arthritis grafting is not done. You appear a good candidate for total knee replacement; it is pain that may eventually force your hand.

If you are otherwise in good health, think you can hit 95 and beyond, and cash is not an issue, I wouldn't dismiss a round of MFAT stem treatment. No guarantee of regeneration, esp. in advanced OA cases, but you are likely to get pain relief. Look up some studies, for example your pain level of 5-7 could drop to 2-3. There are many studies of MFAT and I don't have time to find you the best one. You could spend a whole month just reading MFAT studies. This one covers a 3 year follow-up but is in younger patients: https://pubmed.ncbi.nlm.nih.gov/30569417/

If cash is not an issue you could literally buy time with MFAT. If you could lower pain and this lasts till you hit 75 (through one or more MFAT treatments), you could then proceed with TKR (from which there is no going back) and that should last without the need for revision, if done well. If you don't assess your longevity at 95+ you could go to TKR straight away.

In L.A. I'd recommend Dr Vangsness. Have not been treated by him but have read his research plus a whole book (The new science of overcoming arthritis : prevent or reverse your pain, discomfort, and limitations). A practicing surgeon with a solid interest in research, incl. regenerative medicine. A 2014 stem study of his, through which he managed to partially regenerate meniscus, is often quoted (https://pubmed.ncbi.nlm.nih.gov/24430407/). Note also the pain reduction. Nevertheless, as far as I know, Dr Vangsness remains a stem skeptic. At the 15th World Congress of the International Cartilage Regeneration and Joint Preservation Society, held in October 2019 in Vancouver, BC, in the debate session "Cartilage Regeneration - Mini Battlefield", Dr Vangsness argued that stem treatments should be restricted to clinical trials only (his opponent, Dr S Samson, also from LA, argued the opposite - that stems should be available to the broad public). You may be able to get the 58 page congress program at cartilage.org, it's too large to attach here. If you meet Dr Vangsness, I'd be very interested to know what he says. Don't know how long he has before he retires. https://www.vangsnessmd.com.
2019 - Chondromalacia patella gr 1-2, both knees; early bilateral tibio-femoral arthritis; 5mm focal chondral lesion (LK); degenerate meniscus tear (RK)
2020 - PRP x3 in RK
2021 - PRP x3 in RK, PRP x1 in LK

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #13 on: December 22, 2021, 07:40:06 AM »
Hi silver_maple, thanks again for the feedback and suggestions.

I downloaded a host of studies on Microfragmented Adipose Tissue Injection from the Lipogems site, which has a terrific resources section (https://www.lipogems.com/en/publications/). Looks very promising but the therapy appears not yet to be FDA approved so it may require a trip to Europe. Also, this passage from one study was interesting:

Quote
The ASCs that emerged from MFAT were cultured for 7–21 days and representative cells were observed and photographed with light microscopy.

If I understand that correctly, an optimal treatment would require at least a seven-day, or more, stay.

I also finally got my radiologist’s report today with these findings:

Quote
There is truncation of the inner free edge of the body, anterior, and posterior horn of the medial meniscus over a 3.5 cm segment with small severely macerated remnant portion of the meniscus suggesting prior arthroscopic partial medial meniscectomy.

The lateral meniscus is intact without tear.

Medial compartment articular cartilage shows severe full-thickness cartilage loss central weight-bearing region medial femoral condyle medial tibial plateau with exposure of subchondral bone and moderate subchondral stress response. There are tri-compartmental marginal osteophytes.

Offline silver_maple

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Re: Looking to treat severe knee medial compartment OA
« Reply #14 on: December 22, 2021, 02:59:48 PM »
Ubercool,

I have good news and bad news. The good news - Lipogems is available in the U.S., you do not need to travel to Europe. Lipogems has not explicitly been approved for arthritis, I'll spare you the legal details. But the procedure is legally available and you can find a provider off Lipogems' site.

The bad news - based on the radiology report you shared, your medial compartment appears to be too far gone to expect anything meaningful from MFAT.

Recommend seeing a knee surgeon who also has a sideline doing regenerative, like Dr Vangsness. This type of physician will not push regenerative if they think it's meaningless, given they have a mainstay surgery business. If you go to a "stem cell clinic" (tend to have "regenerative" in their business name), some of the better ones may turn you away but I suspect most will be happy to take your money, possibly arguing that you don't know if it'll work until you try it.

Best!
2019 - Chondromalacia patella gr 1-2, both knees; early bilateral tibio-femoral arthritis; 5mm focal chondral lesion (LK); degenerate meniscus tear (RK)
2020 - PRP x3 in RK
2021 - PRP x3 in RK, PRP x1 in LK

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #15 on: December 23, 2021, 04:58:30 PM »
silver_maple that’s what I was afraid of. :( But maybe I should still try LIPOGEMS to help postpone a TKR. Here’s what I found out about the company. The patent holder and founder of LIPOGEMS is Carlo Tremolada (https://www.linkedin.com/in/carlo-tremolada-b0913522/). He also heads up Image Regenerative Clinic in Milan (https://www.istitutoimage.it). I will have a friend of mine in Italy contact him to request a telehealth consultation to see if it’s worthwhile to fly to Italy and have him perform an MFAT procedure. I think you will agree that it would be great to get the scoop directly from the horse’s mouth. ;)

Thanks for the Dr. Vangsness recommendation. I checked out his site and he does look remarkably accomplished. Unfortunately, UnitedHealthcare will likely consider him an out-of-network doctor, which will make a TKR at $30,000 to $50,000 an onerous burden.

Ubercool,

I have good news and bad news. The good news - Lipogems is available in the U.S., you do not need to travel to Europe. Lipogems has not explicitly been approved for arthritis, I'll spare you the legal details. But the procedure is legally available and you can find a provider off Lipogems' site.

The bad news - based on the radiology report you shared, your medial compartment appears to be too far gone to expect anything meaningful from MFAT.

Recommend seeing a knee surgeon who also has a sideline doing regenerative, like Dr Vangsness. This type of physician will not push regenerative if they think it's meaningless, given they have a mainstay surgery business. If you go to a "stem cell clinic" (tend to have "regenerative" in their business name), some of the better ones may turn you away but I suspect most will be happy to take your money, possibly arguing that you don't know if it'll work until you try it.

Best!

Offline silver_maple

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Re: Looking to treat severe knee medial compartment OA
« Reply #16 on: December 23, 2021, 06:34:05 PM »
Yes, Ubercool, Dr Tremolada is the driving force behind Lipogems. Have not dealt with him directly. There are parallels in some respects to Dr Centeno in that one needs a major entrepreneurial drive to translate research into practice. Dr Centeno has had his critics, he's taken flak in this forum, too. I haven't seen similar attacks on Dr Tremolada. A lot of good research is done by pure academic types, languishes in journals, and gets nowhere fast. And then there is the not so good research.

If you consult with Dr Tremolada it would be great if you let the forum know of what he says in your situation. I am open to trying MFAT even though I hold no high hopes. A lot of people spend $3-4K on a beach or cruise vacation, basically eating and lounging around. I am willing to spend that kind of money on my knees. May not work but I would sooner kick myself for not trying. I am at an earlier stage of this disease where any supposed benefit is more likely. Otherwise I am trending in your direction and in 15-20 years may well be where you are now, if not sooner.
2019 - Chondromalacia patella gr 1-2, both knees; early bilateral tibio-femoral arthritis; 5mm focal chondral lesion (LK); degenerate meniscus tear (RK)
2020 - PRP x3 in RK
2021 - PRP x3 in RK, PRP x1 in LK

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #17 on: December 24, 2021, 02:10:25 AM »
Hi silver_maple, thanks for the feedback. Dr. Tremolada just shared a LinkedIn post about an OS based in Post Falls, ID, right outside Spokane, WA, lauding her MFAT presentation at OrthoSummit:

https://www.linkedin.com/feed/update/urn:li:activity:6877407671088152576/

Dr. Joanne Halbrecht’s presentation was entitled: “Painless Adipose Harvest In The Office: Ignore My Colleagues.” She also participated in a panel entitled, “Final Jeopardy: Two Answers Only - Preservation Or Replacement - Time To Stand Your Ground - Lightning Round (Medial & Lateral Narrowed Joints, Non-Narrowed Joints With Bone Edema).

Dr. Joanne Halbrecht would be a good US-based resource for Lipogems:

https://halbrechtorthopedics.com

BTW, doctors participating in the Executive Education Committee might be a good barometer of their interest in keeping up with state-of-the-art techniques. I only recognized Dr. William Bugbee:

https://orthosummit.com/wp-content/uploads/2021/11/361015-OSET_Program-v2.pdf

I’m with you in trying to find out if Lipogems could be useful at this stage of the game. Having more time on the biological clock certainly helps.

Yes, Ubercool, Dr Tremolada is the driving force behind Lipogems. Have not dealt with him directly. There are parallels in some respects to Dr Centeno in that one needs a major entrepreneurial drive to translate research into practice. Dr Centeno has had his critics, he's taken flak in this forum, too. I haven't seen similar attacks on Dr Tremolada. A lot of good research is done by pure academic types, languishes in journals, and gets nowhere fast. And then there is the not so good research.

If you consult with Dr Tremolada it would be great if you let the forum know of what he says in your situation. I am open to trying MFAT even though I hold no high hopes. A lot of people spend $3-4K on a beach or cruise vacation, basically eating and lounging around. I am willing to spend that kind of money on my knees. May not work but I would sooner kick myself for not trying. I am at an earlier stage of this disease where any supposed benefit is more likely. Otherwise I am trending in your direction and in 15-20 years may well be where you are now, if not sooner.

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #18 on: January 07, 2022, 07:18:06 PM »
Happy New Year! ;D The holidays took a toll on my posting time, but I’m back! Just to let you know, I spoke to Dr. Purita’s assistant who informed me that Purita recommends the $6,000 stem-cell and PRP therapy. She tells me that Purita is “not worried about my meniscus damage” but definitely concerned about my OA. I don’t exactly know what that means but I can speak to Purita directly to have him explain his diagnosis.

The reason I’m hesitant to engage him directly is because of what was recommended here and also because I’m about to schedule a call with both Dr. Kevin Stone and Dr. Carlo Tremolada to get their inputs on my MRI. Hopefully, those consults will take place in the next few weeks, so stay tuned.

Offline silver_maple

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Re: Looking to treat severe knee medial compartment OA
« Reply #19 on: January 07, 2022, 08:39:40 PM »
Ubercool, thanks for the update and Happy New Year to you, too. It is good to get 2-3 recommendations and then decide which one to take up. I'd be all ears as to what Dr. Tremolada says, you certainly aim for the top players globally.

An interesting study was published last year on the efficacy of MFAT in cases of advanced knee OA (such as yours) and the ability to delay total knee replacement. One of the authors is Dr. Adrian Wilson, who, as far as I know, enjoys good reputation in the UK - local posters could confirm.

The study's results and conclusion:

Results: MFAT injection provided a statistically significant improvement in the quality of life (EQ-5D) at 24 months in patients with a baseline OKS of 39 or less (p value: <0.001) as well as those with OKS of 27 or less who are deemed suitable for a knee replacement (p value: <0.001).
Conclusion: MFAT injection improves quality of life in patients with KOA who are deemed suitable for the knee replacement. MFAT is a low-morbidity alternative biological treatment and can delay the need for total knee replacement in suitable patients.


The question then is, are you suitable? If you can delay TKR by 5 years I'd say it's worth it. Could you hope to avoid TKR altogether? A long shot, up to the docs to say, I don't know.

The whole study:
https://pubmed.ncbi.nlm.nih.gov/34211557/
2019 - Chondromalacia patella gr 1-2, both knees; early bilateral tibio-femoral arthritis; 5mm focal chondral lesion (LK); degenerate meniscus tear (RK)
2020 - PRP x3 in RK
2021 - PRP x3 in RK, PRP x1 in LK

Offline vickster

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Re: Looking to treat severe knee medial compartment OA
« Reply #20 on: January 07, 2022, 08:57:02 PM »
Prof Wilson is a regular contributor to the Learning Portfolio on the site, couple of links about him/Lipogems

https://www.theregenerativeclinic.co.uk/teams/professor-adrian-wilson/
https://profadrianwilson.co.uk/knee-treatments/adipose-tissue-therapy/
Came off bike onto concrete 9/9/09 (lat meniscus, lat condyle defect)
LK scopes 8/2/10 & 16/12/10
RK scope 5/2/15 (menisectomy, Hoffa’s fat pad trim)
LK scope 10.1.19 medial meniscectomy, trochlea MFX
LK scope 19.4.21 MFX to both condyles & trochlea, patella cartilage shaved, viscoseal, depo-medrone

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #21 on: January 14, 2022, 11:33:14 PM »
Thanks so much for the info @silver_maple and @vickster. I downloaded the PDF and will keep Prof. Wilson in mind.

Good news, I spoke to Dr. Carlo Tremolada this morning and his assessment was that if my meniscectomy had happed today, it would be considered malpractice. ;D He said that most of the meniscus was removed, which ended up damaging a major part of the adjoining bone, leaving a few holes.

This confirms my MRI report, which states “There is a truncation of the inner free edge of the body, anterior, and posterior horn of the medial meniscus over a 3.5 cm segment with small severely macerated remnant portion of the meniscus suggesting prior arthroscopic partial medial meniscectomy. Medial compartment articular cartilage shows severe full-thickness cartilage loss central weight-bearing region medial femoral condyle medial tibial plateau with exposure of subchondral bone and moderate subchondral stress response.”

His opinion is that a Lipogems treatment will help stave off a TKR for 3-5 years just like you said silver_maple, but that another procedure will be needed in 2-3 years.

I'm looking at flights to Milan around March 1. Dr. Kevin Stone's assistant is now also asking for x-rays, which I have scheduled for Monday.

Offline silver_maple

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Re: Looking to treat severe knee medial compartment OA
« Reply #22 on: January 15, 2022, 02:13:14 AM »
Ubercool, thank you very much for sharing this! I wish you a successful and effective MFAT procedure. To the best of my knowledge no one in this forum has reported Lipogems experience with the doctor who invented it. You are going to the top!

With respect to repeating in 2-3 years, par for the course I would say. This is not a miracle shot by any means, no one-and-done here, even at earlier stages of the disease, much less so in advanced KOA cases. The June 2021 study that Dr. A. Wilson co-authored also states, on p. 13 "There may even be utility in repeating the injection in order to “top-up” the effect in those who have return of symptoms at 2 years."

There haven't been recent MFAT post-op experience reports in the forum. If time allows you could go into the archives and read razuzin's posts (he had Lipogems in Nov. 2015 in New Jersey). MDAL and psny also had adipose stem cell cocktails (2014-2016) although theirs were collagenese-digested, not microfractured.

If you can stave off TKR for 5 years, that would be a success. Anything beyond that would be gravy. I know it takes time and effort to write so up to you if you want to update us post-procedure. I for one would be interested to learn how it went and how you feel. Best!
2019 - Chondromalacia patella gr 1-2, both knees; early bilateral tibio-femoral arthritis; 5mm focal chondral lesion (LK); degenerate meniscus tear (RK)
2020 - PRP x3 in RK
2021 - PRP x3 in RK, PRP x1 in LK

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #23 on: January 15, 2022, 05:13:19 PM »
silver_maple I too was all excited to get treated by the inventor himself then I read this report published last May that brought me back to earth (Autologous Micro-Fragmented Adipose Tissue (MFAT) to Treat Symptomatic Knee Osteoarthritis: Early Outcomes of a Consecutive Case Series https://pubmed.ncbi.nlm.nih.gov/34064010/). Specifically:

Inflammatory flare – During the first 2–4 weeks after MFAT administration, an inflammatory reaction (flare) was observed as shown by the presence of at least one inflammatory sign in 79% of injected knees. Unfortunately, since I plan to be in Italy for only 10 days (the study reports a reaction on average within 16.6 days), I could end up with an inflammatory flare while traveling back, which would be uncomfortable to say the least. Also, was not planning to stay in Milan the entire time, so I would have to drive back from who knows where to see Tremolada.

Injection area pain/stiffness – As suggested by Barfod et al. [18], patients eligible for MFAT should be properly informed about abdominal discomfort after lipo-aspiration and significant flares (pain, swelling, or stiffness) during the first 2–4 weeks, as found in this study. Of note, arthralgia after MFAT injection in this study was assumed to be part of an inflammatory reaction, although it could also be attributed to a mechanical volume effect of MFAT (8–10 cc). So, you have a lot of pain and stiff knees (Tremolada is treating both) and can’t take any NSAIDs because they’re discouraged. Since I’m planning to travel with my GF (for emotional support ;D), that might make her first Italy experience a big downer.

* Effectiveness – But what really concerned me was this conclusion: “The study demonstrated an early clinical improvement but a mediocre response rate of 45% at 12 months after a single intra-articular injection with autologous MFAT.” I had been grappling with how to interpret TRR (therapeutic response rate) until I read this sentence. So, only 45% effective after 12 months but that could improved: “Assessment of bone marrow lesions on MRI can be helpful to increase the therapeutic responsiveness of MFAT up to 70% at 12 months.” That suggests that a U.S.-based follow-up treatment would be helpful.

I will pose these observations to Dr. Tremolada and see what he says. Thanks for reading.

Offline SuspectDevice

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Re: Looking to treat severe knee medial compartment OA
« Reply #24 on: January 15, 2022, 09:08:19 PM »
This thread has been a very interesting read.

Useful to know that 'regenerative' options are still pretty sketchy.  Knee replacements seem like the only 'proven' solution.

My surgeon warned me (in 2012, age 49) that my partial (1/3rd) medial menisectomy may well lead to arthritis later on.  The fact that I continued to cycle hard before the menisectomy with the loose piece flopping around did me no favours at all, as it caused chaffing on my femur cartilage which still gives me grief today.

My approach now is to work on strength & balance issues, try to manage my weight (increasingly harder in middle-age) while still training/racing shorter triathlons in an attempt to stave off replacement, and still do a little of the sport I enjoy (Ironman aspirations are on hold - maybe I'll have a crack at my one and only in my late 60's or 70's if I'm lucky). 

But it is a very fine line that I sometimes stray across = medial pain.
L Medial menisectomy 2012
PFPS both knees 2012-2017
Pre-CRPS diagnosed 2014 (I think this was crap)
2017 - 90+% cured via Dr Dye's research
2018 - MTB crash, busted collarbone & ribs - easy compared to knees!
2021 - ride 3x/week, swim 2x/week, gym 2x/week, short runs 2x/week, back to short races

Offline silver_maple

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Re: Looking to treat severe knee medial compartment OA
« Reply #25 on: January 15, 2022, 11:04:19 PM »
Ubercool,

I had read this study in Sep. 2021 and now re-read it so I can comment while fresh. I won't dwell on the fact the study design is a prospective case series, i.e. lower level of evidence (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3124652/). The study was good in that it tried to answer an important question - what baseline characteristics of KOA make for a better or poorer response to Lipogems MFAT.

The good news for you is that age was not an issue at 12 months - younger patients (<=50 y.o.) responded more quickly at 3 months but by 12 months the older ones had caught up.

The bad news is that the presence of bone marrow lesions (BML) is a huge negative for effectiveness. I can't recall if you had BML but you have osteophytes and these tend to be correlated (https://pubmed.ncbi.nlm.nih.gov/28115233/). Also, medial meniscus damage, esp. to the posterior horn, is a negative, at least at 6 months. (I am in this camp too with a complex medial meniscus tear involving the posterior horn).

Don't worry too much about the initial inflammatory flair. Such a flair was actually associated with a stronger 12 month response, you'd want some early inflammation. The study also briefly compares against other injectables and notes such flairs are common after PRP, too. I have had 6-7 PRP shots and I found the inflammatory flairs quite manageable (no medication needed).

Some discomfort at the adipose harvest side is well known to occur and some clinics advise the wearing of a compression belt for 24-48 hours. Eventually this resolves. Could lead to minor cosmetic changes, e.g. a dimple. Not sure whether you can "iron" these out eventually through nutrition, in any case minor stuff compared to the knee.

You have to be fully prepared that you are not the ideal patient. Responder/non-responder is not a boolean division, see the chart on p.4. Quite possibly you could end up a "low responder".

As previously discussed, the alternative is TKR or maybe unicondylar KR. Please see ref [5], Evans et al in the Lancet about how long these last. You may be ok if you go straight to TKR/UKR now but if you live long and need a revision in your 90s I am not sure how many docs would do revisions in patients 90+, that's something you could explore. If docs won't do revisions 90+ and you are in pain, then you could be on opiates until the end of your days.

Yes, effectiveness of stem cells is sketchy. Because there is no going back from TKR, if cash is not an issue trying a stem cell treatment seems defensible to me given lack of serious complications. If it doesn't work, well at least it's been tried and then a TKR/UKR could be done knowing full well there is no other option left (not seriously counting joint distraction, https://pubmed.ncbi.nlm.nih.gov/28618871/). If there is some effectiveness from stems then, of course, this is good news. If the effectiveness is low, maybe not bother with repeats - start making plans for TKR/UKR. If the effectiveness is moderate then repeat shots could be worthwhile.

Best!
2019 - Chondromalacia patella gr 1-2, both knees; early bilateral tibio-femoral arthritis; 5mm focal chondral lesion (LK); degenerate meniscus tear (RK)
2020 - PRP x3 in RK
2021 - PRP x3 in RK, PRP x1 in LK

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #26 on: January 16, 2022, 02:19:17 AM »
Thanks for your post, SuspectDevice. I’m currently plowing through a host of PRP studies Centeno has graciously collected for us. There is a remarkable similarity between the results of MFAT, PRP, and even HA. These treatments all work better for a short period of time on people who, as the MFAT study says, are “well-selected patients with symptomatic knee OA.” Well-selected means younger patients with less severe OA and meniscus damage.

My goal here is to avoid TKR as long as possible. While I’m not an optimum patient, I can walk normally and I’m not in severe pain, as long as I don’t try any Ironman stuff. ;D

But may well have to eventually admit that it’s the only solution.

This thread has been a very interesting read.

Useful to know that 'regenerative' options are still pretty sketchy.  Knee replacements seem like the only 'proven' solution.

My surgeon warned me (in 2012, age 49) that my partial (1/3rd) medial menisectomy may well lead to arthritis later on.  The fact that I continued to cycle hard before the menisectomy with the loose piece flopping around did me no favours at all, as it caused chaffing on my femur cartilage which still gives me grief today.

My approach now is to work on strength & balance issues, try to manage my weight (increasingly harder in middle-age) while still training/racing shorter triathlons in an attempt to stave off replacement, and still do a little of the sport I enjoy (Ironman aspirations are on hold - maybe I'll have a crack at my one and only in my late 60's or 70's if I'm lucky). 

But it is a very fine line that I sometimes stray across = medial pain.

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #27 on: January 16, 2022, 03:26:17 AM »
silver_maple, thanks for pointing out that the study is a prospective case series. Not familiar with that nuance, however, I did notice that one unidentified author is a paid consultant for Lipogems. Then again, the lead author, Peter Verdonk, has published more than 90 peer-reviewed papers. ([Verdonk Peter | ICRS Main Site](https://cartilage.org/member/verdonk-peter/))

I did see the results improvement over time among older test subjects but that was before I understood what TRR meant, so thanks for emphasizing that point.

My MRI report does not mention bone marrow lesions (BML), so that’s good news. Your post-op experience feedback is very valuable. I will take that into consideration.

As you conclude, giving a stem-cell therapy a try before TKR would be a logical thing to do, even it works for only two years. By that time, I will have been able to do far more research into state-of-the-art total knee arthroplasty. And since my mom lived to be 90, and I will be dabbling in other futuristic anti-aging science, I must take possible knee revision surgery into strong consideration.

Then again, I reviewed your earlier posts and those of @vickster which seem to suggest that I’m too far gone for anything but a TKR.

I’m also more inclined to revisit your earlier recommendation of consulting with Dr. Thomas Vangsness, since he’s intimately familiar with the entire spectrum of possible therapies.

Thanks again, everyone, for helping me on my knee journey.


Ubercool,

I had read this study in Sep. 2021 and now re-read it so I can comment while fresh. I won't dwell on the fact the study design is a prospective case series, i.e. lower level of evidence (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3124652/). The study was good in that it tried to answer an important question - what baseline characteristics of KOA make for a better or poorer response to Lipogems MFAT.

The good news for you is that age was not an issue at 12 months - younger patients (<=50 y.o.) responded more quickly at 3 months but by 12 months the older ones had caught up.

The bad news is that the presence of bone marrow lesions (BML) is a huge negative for effectiveness. I can't recall if you had BML but you have osteophytes and these tend to be correlated (https://pubmed.ncbi.nlm.nih.gov/28115233/). Also, medial meniscus damage, esp. to the posterior horn, is a negative, at least at 6 months. (I am in this camp too with a complex medial meniscus tear involving the posterior horn).

Don't worry too much about the initial inflammatory flair. Such a flair was actually associated with a stronger 12 month response, you'd want some early inflammation. The study also briefly compares against other injectables and notes such flairs are common after PRP, too. I have had 6-7 PRP shots and I found the inflammatory flairs quite manageable (no medication needed).

Some discomfort at the adipose harvest side is well known to occur and some clinics advise the wearing of a compression belt for 24-48 hours. Eventually this resolves. Could lead to minor cosmetic changes, e.g. a dimple. Not sure whether you can "iron" these out eventually through nutrition, in any case minor stuff compared to the knee.

You have to be fully prepared that you are not the ideal patient. Responder/non-responder is not a boolean division, see the chart on p.4. Quite possibly you could end up a "low responder".

As previously discussed, the alternative is TKR or maybe unicondylar KR. Please see ref [5], Evans et al in the Lancet about how long these last. You may be ok if you go straight to TKR/UKR now but if you live long and need a revision in your 90s I am not sure how many docs would do revisions in patients 90+, that's something you could explore. If docs won't do revisions 90+ and you are in pain, then you could be on opiates until the end of your days.

Yes, effectiveness of stem cells is sketchy. Because there is no going back from TKR, if cash is not an issue trying a stem cell treatment seems defensible to me given lack of serious complications. If it doesn't work, well at least it's been tried and then a TKR/UKR could be done knowing full well there is no other option left (not seriously counting joint distraction, https://pubmed.ncbi.nlm.nih.gov/28618871/). If there is some effectiveness from stems then, of course, this is good news. If the effectiveness is low, maybe not bother with repeats - start making plans for TKR/UKR. If the effectiveness is moderate then repeat shots could be worthwhile.

Best!

Offline Dave33

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Re: Looking to treat severe knee medial compartment OA
« Reply #28 on: January 16, 2022, 03:35:45 AM »
I've been biting my tongue pretty hard reading most of these posts. Glad to see it changing direction.

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #29 on: January 16, 2022, 03:53:37 AM »
I've been biting my tongue pretty hard reading most of these posts. Glad to see it changing direction.

@Dave33 I have not forgotten your early advice not to waste my time and money and just go for a proven TKR. ;D

Offline SuspectDevice

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Re: Looking to treat severe knee medial compartment OA
« Reply #30 on: January 16, 2022, 05:58:51 AM »
I only know of one person who had stem cells about 5yrs ago (Regenerex??? $10,000 here in Oz) in her knee and several times I asked her did it help, and her answers were evasive & vague, which makes me think it did not.  She was a keen runner back in the day.

I had a few rounds of PRP for my knees at a pain clinic (PFPS - which really turned out to be chronic synovitis/loss of tissue homeostasis) and it did not help.  Mind you, I was largely mis-diagnosed by every expert I saw.  Had to work it out for myself in the end.
L Medial menisectomy 2012
PFPS both knees 2012-2017
Pre-CRPS diagnosed 2014 (I think this was crap)
2017 - 90+% cured via Dr Dye's research
2018 - MTB crash, busted collarbone & ribs - easy compared to knees!
2021 - ride 3x/week, swim 2x/week, gym 2x/week, short runs 2x/week, back to short races

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #31 on: January 16, 2022, 06:31:30 PM »
I was examined by Dr. Chris Centeno at the Regenexx clinic in Broomfield, Colo. Centeno bills himself as the “CMO” (Chief Marketing Officer) of Regenexx. After my ultrasound examination, Centeno disappeared to have a good laugh with colleagues in the adjoining office. It gave me an uneasy sense of foreboding.

The front office staff is also unusually poor at follow-up, which suggests mismanagement.


I only know of one person who had stem cells about 5yrs ago (Regenerex??? $10,000 here in Oz) in her knee and several times I asked her did it help, and her answers were evasive & vague, which makes me think it did not.  She was a keen runner back in the day.

I had a few rounds of PRP for my knees at a pain clinic (PFPS - which really turned out to be chronic synovitis/loss of tissue homeostasis) and it did not help.  Mind you, I was largely mis-diagnosed by every expert I saw.  Had to work it out for myself in the end.

Offline SuspectDevice

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Re: Looking to treat severe knee medial compartment OA
« Reply #32 on: January 16, 2022, 11:53:46 PM »
I was examined by Dr. Chris Centeno at the Regenexx clinic in Broomfield, Colo. Centeno bills himself as the “CMO” (Chief Marketing Officer) of Regenexx. After my ultrasound examination, Centeno disappeared to have a good laugh with colleagues in the adjoining office. It gave me an uneasy sense of foreboding.

The front office staff is also unusually poor at follow-up, which suggests mismanagement.


Scary isn't it.

I recall visiting a sports doc & knee surgeon who works with one of the national Rugby League teams, and who is supposed to be the 'go-to' knee guy for professional players in Australia....and weekend warrior like me.

To be fair, his analysis of my gait, running, jumping etc using video analysis was very thorough, but when I mentioned the possibility of synovitis to him, he gave my knees a quick prod, said they had no swelling and dismissed it out of hand.

But that's what I had.

Your knees do not necessarily swell with the Dr Scott Dye diagnosis of 'loss of tissue homeostasis' (which the wider profession call PFPS, which is not really a diagnosis, but code for "your knees hurt mostly at the front but we don't know why").
L Medial menisectomy 2012
PFPS both knees 2012-2017
Pre-CRPS diagnosed 2014 (I think this was crap)
2017 - 90+% cured via Dr Dye's research
2018 - MTB crash, busted collarbone & ribs - easy compared to knees!
2021 - ride 3x/week, swim 2x/week, gym 2x/week, short runs 2x/week, back to short races

Offline ubercool

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Re: Looking to treat severe knee medial compartment OA
« Reply #33 on: January 17, 2022, 05:12:54 PM »
Medical providers are now in a quandary, 20-40% of their patients now come armed with more information than they have. Clearly, the go-to knee guy curled up when you told him something he should have known. Shame on him. :(

I was examined by Dr. Chris Centeno at the Regenexx clinic in Broomfield, Colo. Centeno bills himself as the “CMO” (Chief Marketing Officer) of Regenexx. After my ultrasound examination, Centeno disappeared to have a good laugh with colleagues in the adjoining office. It gave me an uneasy sense of foreboding.

The front office staff is also unusually poor at follow-up, which suggests mismanagement.


Scary isn't it.

I recall visiting a sports doc & knee surgeon who works with one of the national Rugby League teams, and who is supposed to be the 'go-to' knee guy for professional players in Australia....and weekend warrior like me.

To be fair, his analysis of my gait, running, jumping etc using video analysis was very thorough, but when I mentioned the possibility of synovitis to him, he gave my knees a quick prod, said they had no swelling and dismissed it out of hand.

But that's what I had.

Your knees do not necessarily swell with the Dr Scott Dye diagnosis of 'loss of tissue homeostasis' (which the wider profession call PFPS, which is not really a diagnosis, but code for "your knees hurt mostly at the front but we don't know why").

Offline Dave33

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Re: Looking to treat severe knee medial compartment OA
« Reply #34 on: January 17, 2022, 10:17:22 PM »
Medical providers are now in a quandary, 20-40% of their patients now come armed with more information than they have.

Where did you get this statistic from?