Non Surgical Orthopaedics

The advent of injectable treatments for osteoarthritis (such as platelet rich plasma  (PRP) and hyaluronic acid) may herald a new era for orthopedic treatment of this common and debilitating disease.  My comments apply to early and and moderate forms of osteoarthritis, and not to the end-stage, stiff and/or crooked joints that will require total joint replacement.

Over the last decade we have seen that about 2/3 of patients with knee arthritis “respond” to hyaluronic acid; that is, their symptoms remit, often for 6 months or more, and operative treatment is deferred.  Hyaluronic Acid is now an 800 M dollar business in the U.S.. Recently, it has been criticized by the American Academy of Orthopedic Surgeons…not for safety, and not for patient satisfaction…but for not altering the eventual need for joint replacement.  Well, that may be true; if you live long enough, all things fall apart. But in view of the well known complications and sometimes horrific results of total joint replacement- and everyone seems to know one of those unfortunate patients- this kind of a comment seems to beg the question. I frequently ask groups of orthopedic surgeons: Who in the room would like a knee replacement? There are very few hands raised.

As for platelet rich plasma,  if the platelet dose and concentrate is sufficient,the results are superior to hyaluronic acid, in the 90% range of improved symptoms, and up to a year or more of relief. ( Note: not all preparations of PRP are the same. It may be crucial to use PRP without a white blood cell component.). Because PRP is bioactive and contains such growth factors as Transforming Growth Factor Beta and Platelet Derived Growth Factor, the positive effects evolve over a period of weeks.  At the present time, no adverse side effects have been documented.

My present protocol is for (2) injections of PRP in high concentrate using the Angel device; each concentrate is analyzed before and after concentration to measure the number of platelets produced. Not only does this number vary between patients, it varies between the same patient donating at different times. PRP studies do not always document the platelet dose, so be aware of this in reading the literature.

Prior to injection therapy, many patients with osteoarthritic symptoms ended up having arthroscopic surgery based upon irrelevant MRI findings- the most common being the ‘torn meniscus“- often this represented a tiny, tiny abnormality that has nothing to do with the patient’s symptoms. The symptoms come from a loss of cartilage, often in a generalized way, and are not mechanical in origin. Most every orthopedic surgeon has had to face the patient who underwent arthroscopy only to state some months later they are no better, perhaps worse.  This is sometimes called the “failed menisectomy”.

It is now becoming clear that non surgical therapy has a big future in both improving patient satisfaction and lowering the risk of surgical treatments. Furthermore, no bridges are burned; for those patients who do not respond, surgical options are still available.  In my practice over the past four years I have noticed both a drop in surgery and an increase in patient satisfaction.  This is clearly a winning combination for all concerned.