Looking to treat severe knee medial compartment OA

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ubercool
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Looking to treat severe knee medial compartment OA

Post by ubercool »

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 ... m-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/i ... lasma.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! :)
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Re: Looking to treat severe knee medial compartment OA

Post by vickster »

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 edited by vickster on Sat Dec 18, 2021 5:57 pm, edited 1 time in total.
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
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Re: Looking to treat severe knee medial compartment OA

Post by ubercool »

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):

Image
vickster wrote: 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 :)
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Re: Looking to treat severe knee medial compartment OA

Post by vickster »

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 edited by vickster on Sat Dec 18, 2021 6:56 pm, edited 1 time in total.
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
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Re: Looking to treat severe knee medial compartment OA

Post by ubercool »

No physiotherapist consulted, so I don't use cleats. And MRIs are all I have at this point.
vickster wrote: 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?
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Re: Looking to treat severe knee medial compartment OA

Post by vickster »

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
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Re: Looking to treat severe knee medial compartment OA

Post by silver_maple »

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
2021/22 - PRP x4 in RK, PRP x2 in LK
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Re: Looking to treat severe knee medial compartment OA

Post by Dave33 »

ubercool wrote: 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.
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Re: Looking to treat severe knee medial compartment OA

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silver_maple wrote: 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.
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Re: Looking to treat severe knee medial compartment OA

Post by ubercool »

Dave33 wrote:
ubercool wrote: 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. ;)
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Re: Looking to treat severe knee medial compartment OA

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ubercool wrote:
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 edited by vickster on Mon Dec 20, 2021 12:04 pm, edited 1 time in total.
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
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Re: Looking to treat severe knee medial compartment OA

Post by ubercool »

vickster wrote:
ubercool wrote:
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.
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Re: Looking to treat severe knee medial compartment OA

Post by silver_maple »

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
2021/22 - PRP x4 in RK, PRP x2 in LK
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Re: Looking to treat severe knee medial compartment OA

Post by ubercool »

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:
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:
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.
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Re: Looking to treat severe knee medial compartment OA

Post by silver_maple »

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
2021/22 - PRP x4 in RK, PRP x2 in LK
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