Cut, Copy, Paste

A myriad of progressive solutions for injured knees

Photo: Hannah Hardaway

Photo: Hannah Hardaway

(Ed’s note: An abridged version of this story originally appeared in the December 2011 issue of Powder. More knee procedures are listed below than in the original version.)

By Tess Weaver

In January 2009, Jen Hudak crashed at a World Cup halfpipe event in Park City, Utah, attempting a 720 and severely injured her knee. Unsatisfied with her first two diagnoses, Hudak visited Dr. Kevin Stone of the renowned Stone Clinic in San Francisco. He was the first to diagnose her posterolateral corner tear (along with a cartilage tear) and the doctor most confident she would make a 100-percent recovery.

Dr. Stone took healthy cartilage (stem cells) from the notch in Hudak’s femur (a non-weight bearing surface) and created a paste that was adhered to the lateral surface of her femur, where the cartilage was missing. The posterolateral corner of the knee, which causes instability, was reinforced with cadaver grafts, and her meniscus was repaired. Ten excruciating months of rehab later, Hudak won Winter X Games gold.

Orthopedic surgery has been evolving alongside skiing at a vigorous pace, yielding numerous cutting edge options that weren’t available to skiers even five years ago. “When tissues are injured or missing, we no longer harvest a patient’s own tissue,” says Stone. “Results from sterilized donor tissue have been exactly the same, but there is much less pain, less weakness and a quicker recovery.”

Dr. J. Richard Steadman, widely regarded as one of the top knee specialists in the country and founder of the Steadman Philippon Research Institute in Vail, believes the best choice for a quick return to sports is harvesting your own patella tissue. His colleague, Dr. Robert LaPrade, director of Biomechanics Research at the Institute, recently announced a new anatomic MCL reconstruction technique that’s able to restore native stability to a knee with acute or chronic medial injury. The cutting-edge approach is the most effective for long-term viability, LaPrade says.

Meniscus replacement is a growing field. Stone notes a 12-year study proving an 80 percent success rate of meniscus transplantation in arthritic or injured knees when combined with the paste graft technique. Partial knee replacements, which didn’t used to be a reliable solution, are on the rise. Now, a micro robot ensures precise implant positioning and alignment to result in a more natural knee motion following surgery.

Whether it’s to avoid surgery, address chronic post-op pain or alleviate tendonitis, numerous professional skiers from Bode Miller to Tanner Hall are proponents of the Ensenada, Mexico, based Dr. Milne Ongley and his controversial Ongley Solution, which is opposed by most Western physicians due to the injection of phenol (acid used for herbicides and plastics) to stimulate tissue growth. Hall says the injections were a game changer for his recovering knees and that he’ll be returning for maintenance injections throughout his ski life, while Miller found the first real relief to his patellar tendinitis.

In addition to those procedures, the following is a roundup of innovative knee treatments:

Procedure: Autologous Chondrocyte Implantation uses a patient’s own stem cells to re-grow cartilage in a knee that has been damaged by trauma or arthritis. Patient’s own bone, cartilage and cells are transplanted to defective area.
Candidates: People with cartilage injuries and arthritis.
Pros: Single, outpatient procedure. Minimally invasive.
Cons: Expensive; growing cells costs $30,000, not including three-hour surgery.

Procedure: Osteochondral allografting works by replacing all or a portion of the meniscus with donor cartilage. Delays or avoids artificial knee replacement.
Candidates: Patients with joint pain after having previously lost their meniscus cartilage.
Pros: Minimally invasive outpatient arthroscopic procedure.
Cons: Cartilage has to be fresh (seven to 10 days old) and size has to match patient’s knee dimensions. Four month intensive rehab program.

Procedure: Partial knee replacement surgery utilizes specially designed implants made to resurface one side of the knee joint, eliminating activity-limiting arthritic pain and restoring more normal knee function.
Candidates: Patients with osteoarthritis in medial, lateral or patellofemoral (top) sections of knee, or a combination.
Pros: Keeps all four ligaments, which is better for skiing. Outpatient procedure using robotic accuracy. Decreased recovery time, trauma and post-op pain.
Cons: More expensive. Very few trained robotic surgeons.

Procedure: Moximed is when the KineSpring Knee Implant System is implanted in the subcutaneous tissue alongside the joint, cushioning the knee from excessive loading.
Candidates: Patients with knee osteoarthritis.
Pros: Minimally invasive (no bone, ligament, or cartilage removal) and reversible.
Cons: Only available in Australia and Europe.

Procedure: Autologous blood therapy (platelet-rich plasma) uses patient’s own blood components to stimulate a healing response in damaged tissues.
Candidates: Patients with patellar tendonitis.
Pros: More rapid, efficient and thorough restoration of the tissue to a healthy state.
Cons: Chronic injuries require more than one injection. Health insurance companies are rejecting it as an office procedure, so patient usually is forced to pay cash.

Procedure: Ongley Solution is a biologic regenerating solution referred to as a proliferant and is injected into affected area to stimulate the body’s healing mechanisms and growth of new tissue.
Candidates: Patients with pain associated with bone, cartilage, ligaments and tendons.
Pros: Non-surgical. Short-term solution to chronic pain.
Cons: Four sessions at weekly intervals in Ensenada, Mexico. Check or cash only. No insurance policies accepted. May damage nerves in knee joint and cause future arthritis.

Procedure: Microfracture surgery
Removes damaged cartilage and increases blood flow from the underlying bone. Holes made in the affected area allow the formation of new, healthy cartilage.
Candidates: When cartilage loss is limited to one side of the bone. Defects less than two centimeters.
Pros: Minimally invasive. Significantly shorter recovery time than an arthroplasty (knee replacement).
Cons: Patient’s age and diligence in rehab, along with the severity and location of the injury can affect success rates.

Procedure: Anatomic MCL reconstruction
Patient’s tendon is used to reconstruct the injured ligament by placing it in the exact location, replacing torn structures with tissue at their natural attachment points.
Candidates: Patients who experience instability from an acute or chronic medial knee injury.
Pros: Mimics natural ligament’s dynamic range of motion. Ideal for athletes. Good option when tissue banks aren’t available.
Cons: Unknown

Procedure: Articular cartilage paste grafting
Utilizes a patient’s own stem cells to re-grow cartilage in a knee that has been damaged by trauma or arthritis. Patient’s own bone, cartilage and cells are transplanted to defective area.
Candidates: People with cartilage injuries and arthritis.
Pros: Single, outpatient procedure. Minimally invasive.
Cons: Re-grows variable tissue (sometimes cartilage, sometimes fibrous repair tissue).

Procedure: Biologic joint replacement
Surgical procedure to biologically replace damaged area with new meniscus or articular cartilage. .
Goal: Restore knee joint’s natural range of motion and reduce pain and stiffness.
Candidates: When damage to the joint is primarily in one area of the knee.
Pros: Smaller incision reduces pain and post-op recovery time. No future options are eliminated and procedure can be repeated. Existing ligaments and muscles are maintained for stability and movement of the knee.
Cons: Slightly less predictable pain relief and the potential need for further surgery. Extensive rehabilitation program required.

Procedure: Meniscus allograft
By replacing all or a portion of the meniscus with donor cartilage, patients can regain natural shock absorber in the knee and experience additional years of activity, even in the presence of arthritis.
Goal: Delay or avoid artificial knee replacement. Return to sports.
Candidates: Patients with joint pain after having previously lost their meniscus cartilage.
Pros: minimally invasive outpatient arthroscopic procedure.
Cons: Potential re-tearing of the transplanted meniscus, which may require surgical suturing or replacement. Four-month intensive rehab program.

Procedure: Makoplasty (robotic joint replacement) with a partial knee device or uni-condylar knee replacement
Uni-compartmental knee replacement surgery utilizes specially designed implants made to resurface one side of the knee joint, eliminating activity-limiting arthritic pain and restoring more normal knee function.
Candidates: Patients with osteoarthritis in medial, lateral or patellofemoral (top) sections of knee, or a combination.
Pros: Outpatient procedure using robotic accuracy. Decreased recovery time, trauma and post-operative pain. Smaller incisions lessen blood loss, risk of infection and scarring. Removes little bone without cutting of muscle or ligaments. Knee is able to bear weight and begin physical therapy the day after surgery.
Cons: More expensive. Very few trained robotic surgeons.

Procedure: Nerve block
Femoral nerve block high in the thigh. Non-narcotic meds can be used to numb the limb for two days after surgery.
Candidates: Patients undergoing knee surgery.
Pros: Minimizes need for narcotics. 95-percent reduction in post-op pain. Patients can undergo physical therapy much earlier
Cons: Remote possibility of complications from needle puncture and medications used.

Procedure: Healing Response
Mimics the way an MCL heals itself by creating and fusing a clot at the ACL tear using stem cells from femur. Femur and tissue is perforated, blood clot bonds to the tear and generates re-growth. Clot generates into a substance similar to a ligament and is completely fused to biologic ligament.
Candidates: Only 5-percent of ACL patients are eligible. Tear needs to be at ACL/femur connection.
Pros: Connection can be as strong as original. Small incision. Nothing is harvested or replaced.

Procedure: Prolotherapy
Injection of an irritant solution into an area where connective tissue has been weakened or damaged through injury or strain. Solution promotes healing through the process of inflammation and repair.
Candidates: Patients with chronic pain lasting six months or more.
Pros: As much as 30-40% strengthening of the connective tissue.
Cons: Not covered by most major medical insurance policies.

Procedure: FCL Reconstruction
Anatomical fibular collateral ligament (primary varus stabilizer of the knee) reconstruction using an accessory hamstring graft. New technique restores anatomy to its exact original location.
Candidates: Patients who have a complete tear of the FCL (causes side-to-side instability) or patients undergoing ACL reconstruction. Failure to reconstruct FCL during ACL reconstruction can lead to loosening or failure of ACL graft.
Pros: Very high success rate of restoring knee to near-normal lateral compartment stability.
Cons: Unknown.

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