Bobic - 2024 Update on Knee OrthoBiologics - Nuffield Edu Seminars 280924.pdf
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About This Presentation
2024 Update on joint preservation and OrthoBiologic.
Slide Content
Knee Joint Preservation:
OrthoBiologic
Treatment Options
(relatively) new trends and developments which may delay or avoid surgical treatments
Prof Vladimir Bobić, MD FRCS Ed
Consultant Orthopaedic Knee Surgeon
Chester Knee Clinic at Nuffield Health, the Grosvenor Hospital Chester
www.kneeclinic.info [email protected] @ChesterKnee
Nuffield Health
The Grosvenor Hospital Chester Educational Seminars
St David’s Park Hotel, Ewloe, Wales, 28th September 2024
OrthoBiologic
Treatment Options
(relatively) new trends and developments which may delay or avoid surgical treatments
Prof Vladimir Bobić, MD FRCS Ed
Consultant Orthopaedic Knee Surgeon
Chester Knee Clinic at Nuffield Health, the Grosvenor Hospital Chester
www.kneeclinic.info [email protected] @ChesterKnee
Nuffield Health
The Grosvenor Hospital Chester Educational Seminars
St David’s Park Hotel, Ewloe, Wales, 28th September 2024
Relevant personal commercial interests and financial gains:
The entire presentation will be available later today on:
www.slideshare.net/vbobic
The entire presentation will be available later today on:
www.slideshare.net/vbobic
My clinical and surgical practice is based at Chester Nuffield since 1996.
Knees only (OA and Work/Sports Related Problems), 50% private, 50% NHS
Knees only (OA and Work/Sports Related Problems), 50% private, 50% NHS
Senior Surgeon’s Position:
Standard and Customised Knee Replacement Implants
• A TKR is one of the most successful operations!
• Great majority of replaced knees are satisfactory functionally.
• We are doing too many knee replacements
• Patient dissatisfaction rate has gone up to almost 25%!
• A TKR is not a substitute for a normal knee!
• We should address the problem before it gets to a TKR
• Keep what your parents gave you as long as you can!
• A TKR is one of the most successful operations!
• Great majority of replaced knees are satisfactory functionally.
• We are doing too many knee replacements
• Patient dissatisfaction rate has gone up to almost 25%!
• A TKR is not a substitute for a normal knee!
• We should address the problem before it gets to a TKR
• Keep what your parents gave you as long as you can!
Joint Preservation Initiative
Keen Interest in Cycling and Skiing Knee Problems and Injuries
Sports Knee Injuries and OA
Ageing and OA: An inevitable Encounter?
T Huegle et al.: Ageing and OA - An Inevitable Encounter? JAR 2012
OA is a whole joint disease!
T Huegle et al.: Ageing and OA - An Inevitable Encounter? JAR 2012
OA is a whole joint disease!
The Main Topic Today: Joint Preservation
2017
2017
Joint Preservation: OrthoBiologics or BioOrthopaedics
2017
Joint Preservation: OrthoBiologics or BioOrthopaedics
1st Orthopaedic Stem Cell Seminar in the UK
OrthoBiologicTreatment Options:
Oral Supplements (Glucosamine + CS)
Viscosupplement Injections
Shockwave Therapy (SWT)
PRP Injections
Autologous Stem Cell Injections
Arthroscopic Subchondral Drilling
Nanofracture with Intra-osseous Injections
ChondroTissue (scaffold)
Subchondroplasty
OATS with Autologous Bone Marrow Aspirate
AMIC (nanofracture site covered with membrane)
ACI (Autologous Chondrocyte Implantation)
14
Oral Supplements (Glucosamine + CS)
Viscosupplement Injections
Shockwave Therapy (SWT)
PRP Injections
Autologous Stem Cell Injections
Arthroscopic Subchondral Drilling
Nanofracture with Intra-osseous Injections
ChondroTissue (scaffold)
Subchondroplasty
OATS with Autologous Bone Marrow Aspirate
AMIC (nanofracture site covered with membrane)
ACI (Autologous Chondrocyte Implantation)
14
A game changer …
A game changer …
A game changer …
A game changer …
https://www.arthrex.com/resources/VID1-005647-en-US/autocart-surgical-technique
https://www.arthrex.com/resources/VID1-005647-en-US/autocart-surgical-technique
A game changer …
MARIARC MRI, UK (1997)
The orange pixels correspond to normal T2 values for bone. The blue and
purple pixels are anomalous: the T2 relaxation times are elevated because the
tissue is "wetter" than normal (the fluid interface between recipient and
donor bone).
OAT MRI analysis
MR Imaging Protocol 1997: Dr David Ritchie, Consultant Musculoskeletal Radiologist, Liverpool (Glasgow), UK
The orange pixels correspond to normal T2 values for bone. The blue and
purple pixels are anomalous: the T2 relaxation times are elevated because the
tissue is "wetter" than normal (the fluid interface between recipient and
donor bone).
OAT MRI analysis
MR Imaging Protocol 1997: Dr David Ritchie, Consultant Musculoskeletal Radiologist, Liverpool (Glasgow), UK
“Chronic” BME and Cartilage Delamination
CKC UK
CKC UK
ICRS Standards Workshop 2000, Schloss Münchenwiler, Switzerland, January 27 -29, 2000
ICRS ARTICULAR CARTILAGE IMAGING COMMITTEE
ICRS MR Imaging Protocol for Knee Articular Cartilage
By Vladimir Bobic, MD
The Royal Liverpool University Hospital, Broadgreen Hospital Knee Service
newsletter 2000, III, p. 12
Introduction
Articular cartilage lesions are common and impor-
tant clinically. New treatment modalities have
mandated a non invasive method of imaging artic-
ular cartilage.
MR imaging is the best non invasive modality to
image articular cartilage. MR has been shown to
be highly accurate in assessing morphology. This
is useful in diagnosing diagnosing chondral
lesions (with sensitivities and specificities in the
80-95% range in the knee) and in the assessment
of post operative repair tissue.. The biochemical,
histologic and clinical correlates of this mor-
phologic information remains an active research
area. We believe that cartilage imaging should
be a part of every MR exam of the knee. A carti-
lage specific sequence like those described below
should be performed in the sagittal plane on every
patient. If a chondral lesion is found, additional
sequences in other planes may be added to more
fully define the lesion.
Technique of MR imaging of cartilage
The two types of MR sequences that have been
found to be the most accurate in detecting car-
tilage abnormalities are fast spin echo (FSE)
sequences and a fat suppressed T1weighted 3D
gradient echo (FS T1W GRE) sequence. Here are
examples of such images:
Each sequence has unique advantages and dis-
advantages. Two advantages of FSE sequences
are:
1. the acquisition of high-resolution images with
a short image time and
2. improved image contrast by the generation of
an MT effect when using a multislice acquisi-
tion due to off resonance excitation resulting
from multiple refocusing pulses. (1).
A number of recent articles have demonstrated
high sensitivity and specificity of FSE sequences
in the evaluation of articular cartilage in the knee
(2-4). FSE sequences are equally effective whether
using proton density or T2 weighting and or fat
suppression. Fat suppression can improve the
assessment of the subarticular bone marrow for
edema and reduce chemical shift artifacts. Car-
tilage defects appear as areas of signal abnor-
mality within the articular cartilage on FSE images.
The second sequence that has been shown to be
accurate in detecting cartilage pathology is a fat-
saturated T1W GRE sequence (5,6-8). The use of
fat suppression increases the dynamic range of
signal intensities within the articular cartilage
allowing the detection of more subtle changes in
signal intensity. Two additional benefits of fat
suppression are the elimination of chemical shift
artifact and the reduction of motion-induced
ghosting artifact from extraarticular fat signal.
On FS T1W GRE images there is high contrast
between bright cartilage and relatively dark fluid,
bone, fat, and muscle. The FS T1W GRE images
are relatively insensitive for assessment of mar-
row edema and subchondral cysts because both
fluid and marrow appear dark. Cartilage is high
in signal compared to low signal fluid because of
the T1-weighting of this sequence. The intrinsic
signal intensity on T1W 3D GRE images is uniform
throughout the thickness of the cartilage; how-
ever, truncation artifacts can produce low signal
laminae in the mid-portion of the cartilage which
do not interfere with image interpretation (9).
Although increasing the resolution of the images
can eliminate truncation artifacts, the resultant
decrease in the signal to noise requires longer
image times that are not practical in clinical prac-
tice. However, truncation artifacts have not been
a detriment to identification of cartilage lesions
in our experience and, in fact, can be a helpful
marker in assessing the depth of focal cartilage
defects. A number of studies have documented
the high accuracy of the FS T1W GRE sequence
for the detection of chondral abnormalities (5,6-
8). Cartilage abnormalities are routinely seen as
contour defects with this sequence, unlike FSE
images which, as stated above, appear as signal
abnormalities.
Specific advantages and disadvantages
FSE sequences are less sensitive to magnetic sus-
ceptibility artifacts (which can be an advantage
for patients who have undergone previous surgery)
than the FS T1W GRE sequence, and they can be
used to accurately detect associated meniscal and
ligamentous pathology. Choices in instrument
materials and surgical technique to decrease metal-
lic debris should be considered a high priority
among surgeons and manufacturers. The 3D nature
of the FS T1W GRE sequence allows the use of mul-
tiplanar reconstructions and, in most instances,
thinner slice thicknesses, which are often impor-
tant in evaluating the curved surfaces of joints and
the ability to perform volume measurements. There-
fore, if time permits use of both types of sequences
are recommended to assess articular cartilage.
We have listed parameters that have been found
useful for FSE and FS T1W GRE sequences. In
Appendix A. All of these sequences can be per-
formed on commercially available state of the art
scanners. We recommend if possible to perform
cartilage imaging on magnet strengths of 1.0 T
and greater.
One possible protocol for a knee MR examina-
tion tailored specifically for cartilage consists of
the FSE proton density sequence acquired in the
coronal plane, the fat suppressed T2 weighted
FSE in the axial plane, and the FS T1W GRE in the
sagittal plane. The GRE sequence can be recon-
structed in the coronal and axial plane as well.
For postoperative patients the FS T1W GRE
sequence can be problematic secondary to sus-
ceptibility artifacts and more emphasis should
be placed on the FSE sequences. It should be
remembered that the above protocol is for artic-
ular cartilage imaging. A sagittal proton den-
sity/T2 Weighted sequence (conventional spin
echo or FSE) should be added to evaluate for
meniscal and ligamentous pathology.
MR evaluation
At this point MR evaluation is mainly based on
morphology and signal intensity changes. A
means for documenting changes are being cod-
ified into the ICRS MR grading scheme. Parame-
ters will include depth, size and location of lesion,
and signal intensity changes. Cartilage thickness
and volume measurements have been validated
in the knee and in small joints of the hand and
play an important role in the serial assessment
of patients (Image analysis protocols to be
included in Appendix B).
Image Distribution
The utility of MR will be greatly enhanced with
the ability to electronically distribute images to
referring physicians and consultants. This needs
to be cost effective and reliable.
A practical and acceptable method at the current
time is to take digital images of film using a dig-
ital camera (preferably above 2 megapixel reso-
lution) and saving the image as a JPEG file.
In the future, direct digital capture of images and
distribution over the internet in a DICOM(stan-
dard radiology digital image format) format should
be achievable.
Research and future technologies
While MR imaging has been well demonstrated
to provide morphological information, the histo-
ICRS ARTICULAR CARTILAGE IMAGING COMMITTEE
ICRS MR Imaging Protocol for Knee Articular Cartilage
By Vladimir Bobic, MD
The Royal Liverpool University Hospital, Broadgreen Hospital Knee Service
newsletter 2000, III, p. 12
Introduction
Articular cartilage lesions are common and impor-
tant clinically. New treatment modalities have
mandated a non invasive method of imaging artic-
ular cartilage.
MR imaging is the best non invasive modality to
image articular cartilage. MR has been shown to
be highly accurate in assessing morphology. This
is useful in diagnosing diagnosing chondral
lesions (with sensitivities and specificities in the
80-95% range in the knee) and in the assessment
of post operative repair tissue.. The biochemical,
histologic and clinical correlates of this mor-
phologic information remains an active research
area. We believe that cartilage imaging should
be a part of every MR exam of the knee. A carti-
lage specific sequence like those described below
should be performed in the sagittal plane on every
patient. If a chondral lesion is found, additional
sequences in other planes may be added to more
fully define the lesion.
Technique of MR imaging of cartilage
The two types of MR sequences that have been
found to be the most accurate in detecting car-
tilage abnormalities are fast spin echo (FSE)
sequences and a fat suppressed T1weighted 3D
gradient echo (FS T1W GRE) sequence. Here are
examples of such images:
Each sequence has unique advantages and dis-
advantages. Two advantages of FSE sequences
are:
1. the acquisition of high-resolution images with
a short image time and
2. improved image contrast by the generation of
an MT effect when using a multislice acquisi-
tion due to off resonance excitation resulting
from multiple refocusing pulses. (1).
A number of recent articles have demonstrated
high sensitivity and specificity of FSE sequences
in the evaluation of articular cartilage in the knee
(2-4). FSE sequences are equally effective whether
using proton density or T2 weighting and or fat
suppression. Fat suppression can improve the
assessment of the subarticular bone marrow for
edema and reduce chemical shift artifacts. Car-
tilage defects appear as areas of signal abnor-
mality within the articular cartilage on FSE images.
The second sequence that has been shown to be
accurate in detecting cartilage pathology is a fat-
saturated T1W GRE sequence (5,6-8). The use of
fat suppression increases the dynamic range of
signal intensities within the articular cartilage
allowing the detection of more subtle changes in
signal intensity. Two additional benefits of fat
suppression are the elimination of chemical shift
artifact and the reduction of motion-induced
ghosting artifact from extraarticular fat signal.
On FS T1W GRE images there is high contrast
between bright cartilage and relatively dark fluid,
bone, fat, and muscle. The FS T1W GRE images
are relatively insensitive for assessment of mar-
row edema and subchondral cysts because both
fluid and marrow appear dark. Cartilage is high
in signal compared to low signal fluid because of
the T1-weighting of this sequence. The intrinsic
signal intensity on T1W 3D GRE images is uniform
throughout the thickness of the cartilage; how-
ever, truncation artifacts can produce low signal
laminae in the mid-portion of the cartilage which
do not interfere with image interpretation (9).
Although increasing the resolution of the images
can eliminate truncation artifacts, the resultant
decrease in the signal to noise requires longer
image times that are not practical in clinical prac-
tice. However, truncation artifacts have not been
a detriment to identification of cartilage lesions
in our experience and, in fact, can be a helpful
marker in assessing the depth of focal cartilage
defects. A number of studies have documented
the high accuracy of the FS T1W GRE sequence
for the detection of chondral abnormalities (5,6-
8). Cartilage abnormalities are routinely seen as
contour defects with this sequence, unlike FSE
images which, as stated above, appear as signal
abnormalities.
Specific advantages and disadvantages
FSE sequences are less sensitive to magnetic sus-
ceptibility artifacts (which can be an advantage
for patients who have undergone previous surgery)
than the FS T1W GRE sequence, and they can be
used to accurately detect associated meniscal and
ligamentous pathology. Choices in instrument
materials and surgical technique to decrease metal-
lic debris should be considered a high priority
among surgeons and manufacturers. The 3D nature
of the FS T1W GRE sequence allows the use of mul-
tiplanar reconstructions and, in most instances,
thinner slice thicknesses, which are often impor-
tant in evaluating the curved surfaces of joints and
the ability to perform volume measurements. There-
fore, if time permits use of both types of sequences
are recommended to assess articular cartilage.
We have listed parameters that have been found
useful for FSE and FS T1W GRE sequences. In
Appendix A. All of these sequences can be per-
formed on commercially available state of the art
scanners. We recommend if possible to perform
cartilage imaging on magnet strengths of 1.0 T
and greater.
One possible protocol for a knee MR examina-
tion tailored specifically for cartilage consists of
the FSE proton density sequence acquired in the
coronal plane, the fat suppressed T2 weighted
FSE in the axial plane, and the FS T1W GRE in the
sagittal plane. The GRE sequence can be recon-
structed in the coronal and axial plane as well.
For postoperative patients the FS T1W GRE
sequence can be problematic secondary to sus-
ceptibility artifacts and more emphasis should
be placed on the FSE sequences. It should be
remembered that the above protocol is for artic-
ular cartilage imaging. A sagittal proton den-
sity/T2 Weighted sequence (conventional spin
echo or FSE) should be added to evaluate for
meniscal and ligamentous pathology.
MR evaluation
At this point MR evaluation is mainly based on
morphology and signal intensity changes. A
means for documenting changes are being cod-
ified into the ICRS MR grading scheme. Parame-
ters will include depth, size and location of lesion,
and signal intensity changes. Cartilage thickness
and volume measurements have been validated
in the knee and in small joints of the hand and
play an important role in the serial assessment
of patients (Image analysis protocols to be
included in Appendix B).
Image Distribution
The utility of MR will be greatly enhanced with
the ability to electronically distribute images to
referring physicians and consultants. This needs
to be cost effective and reliable.
A practical and acceptable method at the current
time is to take digital images of film using a dig-
ital camera (preferably above 2 megapixel reso-
lution) and saving the image as a JPEG file.
In the future, direct digital capture of images and
distribution over the internet in a DICOM(stan-
dard radiology digital image format) format should
be achievable.
Research and future technologies
While MR imaging has been well demonstrated
to provide morphological information, the histo-
Knee Osteoarthritis:
Overview and Treatment Options
Osteoarthritis is a degenerative joint disease that is
increasing in prevalence, and the knee is the most
commonly affected joint.
Factors such as increased incidence of obesity and
participation in sports, as well as the ageing of the
population, may contribute to this increased
prevalence.
The treatment options for osteoarthritis, which
range from conservative treatment options to
surgical intervention, have varying degrees of
success, but new therapies are on the horizon.
Overview and Treatment Options
Osteoarthritis is a degenerative joint disease that is
increasing in prevalence, and the knee is the most
commonly affected joint.
Factors such as increased incidence of obesity and
participation in sports, as well as the ageing of the
population, may contribute to this increased
prevalence.
The treatment options for osteoarthritis, which
range from conservative treatment options to
surgical intervention, have varying degrees of
success, but new therapies are on the horizon.
Most patients in my practice do not have classic OA, as progressive, destructive
inflammatory disease of the entire knee joint and most of the time they do not have OA
of any other joint(s).
Most of my patients have one bad knee, usually the medial or patello-femoral side of it,
because of trauma, sports, work, etc. and they develop meniscal, chondral and ligament
injuries which in turn cause accelerated wear and tear (which is different from
inflammatory nature of classic OA and RA) and subsequent reactive synovitis and
subchondral degeneration resulting in stiff subchondral plate and further damage to
articulating surfaces.
Most of those people respond well to arthroscopic surgery, including deep subchondral
drilling (which seems to re-establish osteochondral nutritional and other communication
channels, which is the same reason why microfracture works for some people) and other
arthroscopic treatments, which does not work well in OA and RA knees.
So, there is a difference, if we think about this as accelerated wear and tear (known
as gonarthrosis or osteoarthrosis in many European countries or PTOA in the USA),
which most people have, vs “classic” OA (as inflammatory multi-joint disease).
This is, perhaps, too simplistic and even scientifically naive but that is my impression,
based on my clinical experience over the past 30+ years in the UK, but let’s talk about it:
OsteoArthritis or OsteoArthrosis?
or just accelerated wear and tear?
inflammatory disease of the entire knee joint and most of the time they do not have OA
of any other joint(s).
Most of my patients have one bad knee, usually the medial or patello-femoral side of it,
because of trauma, sports, work, etc. and they develop meniscal, chondral and ligament
injuries which in turn cause accelerated wear and tear (which is different from
inflammatory nature of classic OA and RA) and subsequent reactive synovitis and
subchondral degeneration resulting in stiff subchondral plate and further damage to
articulating surfaces.
Most of those people respond well to arthroscopic surgery, including deep subchondral
drilling (which seems to re-establish osteochondral nutritional and other communication
channels, which is the same reason why microfracture works for some people) and other
arthroscopic treatments, which does not work well in OA and RA knees.
So, there is a difference, if we think about this as accelerated wear and tear (known
as gonarthrosis or osteoarthrosis in many European countries or PTOA in the USA),
which most people have, vs “classic” OA (as inflammatory multi-joint disease).
This is, perhaps, too simplistic and even scientifically naive but that is my impression,
based on my clinical experience over the past 30+ years in the UK, but let’s talk about it:
OsteoArthritis or OsteoArthrosis?
or just accelerated wear and tear?
Cross-talk Between Articular Cartilage,
Subchondral Bone and ACL
•Our focus now is on the role of enthesitis which seems to be the key to the start of the
inflammatory and subsequently degenerative processes of the ACL.
•MRI analyses indicates that the localization of bone marrow oedema in early OA is
often associated with ligament attachment site, the enthesis , which seems to play a
central role.
•The intimate cross-talk between synovitis, articular cartilage, ACL and
subchondral bone is no doubt the main feature of MDACL.
•The aetiology is also suggestive of disrupted neuromuscular network and joint
homeostasis at several intra-articular levels.
CKC UK
Subchondral Bone and ACL
•Our focus now is on the role of enthesitis which seems to be the key to the start of the
inflammatory and subsequently degenerative processes of the ACL.
•MRI analyses indicates that the localization of bone marrow oedema in early OA is
often associated with ligament attachment site, the enthesis , which seems to play a
central role.
•The intimate cross-talk between synovitis, articular cartilage, ACL and
subchondral bone is no doubt the main feature of MDACL.
•The aetiology is also suggestive of disrupted neuromuscular network and joint
homeostasis at several intra-articular levels.
CKC UK
OsteoArthritis vs. OsteoArthrosis vs. PTOA
CKC UK 30
CKC UK 30
A Landmark 2022 Publication:
OPTIKNEE 2022 Consensus
meeting and recommendations
aimed at promoting knee health
and prevention of PTOA
OPTIKNEE 2022 Consensus
meeting and recommendations
aimed at promoting knee health
and prevention of PTOA
Articular cartilage + Subchondral plate + Trabecualar bone are
biologically and functionally inseparable OsteoChondral unit
which absorbs and distributes loads across the joint.
CKC UK
We can not think and act in monolayer terms. Articular cartilage (surface)
repair is not good enough. We have to think and act in 3D terms!
biologically and functionally inseparable OsteoChondral unit
which absorbs and distributes loads across the joint.
CKC UK
We can not think and act in monolayer terms. Articular cartilage (surface)
repair is not good enough. We have to think and act in 3D terms!
Osteochondral Functional Unit
Source: Dr Carl Winalski, Boston, USA, 2003
Source: Dr Carl Winalski, Boston, USA, 2003
Sports Knee Surgery Symposium
The University of Warwick
3 and 4 November 2003
Bone Bruise and Bone Marrow
Oedema: The Bad News
for Articulating Surfaces
Vladimir Bobic, MD FRCSEd
Consultant Orthopaedic Knee Surgeon
The University of Warwick
3 and 4 November 2003
Bone Bruise and Bone Marrow
Oedema: The Bad News
for Articulating Surfaces
Vladimir Bobic, MD FRCSEd
Consultant Orthopaedic Knee Surgeon
Well, not exactly a brand new concept:
Source: Francis Berenbaum, 3 November 2016
Source: Francis Berenbaum, 3 November 2016
Nothing New!
Source: Francis Berenbaum, 3rd November 2016
Source: Francis Berenbaum, 3rd November 2016
JBJSA March 1974
The Structure of Subchondral Bone
Redrawn from: Imhof H, Breitenseher M, Kainberger F, Rand T, Trattnig S. (1999): Importance of subchondral bone to
articular cartilage in health and disease. Top Magn Reson Imaging 10:180–192
A surprisingly high number of arterial and venous vessels, as well
as nerves, can be seen in the subchondral region sending tiny
branches into the calcified cartilage …
Redrawn from: Imhof H, Breitenseher M, Kainberger F, Rand T, Trattnig S. (1999): Importance of subchondral bone to
articular cartilage in health and disease. Top Magn Reson Imaging 10:180–192
A surprisingly high number of arterial and venous vessels, as well
as nerves, can be seen in the subchondral region sending tiny
branches into the calcified cartilage …
The Structure of Subchondral Bone
•This is extremely important for cartilage repair: the
tidemark is crossed by collagen fibrils extending
from the articular cartilage into the calcified
cartilage, while no collagen fibrils connect the
calcified cartilage to the subchondral bone plate.
•Blood vessels from the subchondral region can extend into
the overlying calcified cartilage through canals in the
subchondral bone plate.
•Therefore, nutrients can reach chondrocytes in the
calcified zone via these perforations.
•Unsurprisingly, the perforations are grouped
together in the regions of subchondral plate where
the stress is greatest.
CKC UK
•This is extremely important for cartilage repair: the
tidemark is crossed by collagen fibrils extending
from the articular cartilage into the calcified
cartilage, while no collagen fibrils connect the
calcified cartilage to the subchondral bone plate.
•Blood vessels from the subchondral region can extend into
the overlying calcified cartilage through canals in the
subchondral bone plate.
•Therefore, nutrients can reach chondrocytes in the
calcified zone via these perforations.
•Unsurprisingly, the perforations are grouped
together in the regions of subchondral plate where
the stress is greatest.
CKC UK
The Structure of Subchondral Bone
The changes in the thickness of the subchondral bone plate depends on the
location and mechanical loads
Henning Madry, Saarland University, Homburg/Saar, Germany
The changes in the thickness of the subchondral bone plate depends on the
location and mechanical loads
Henning Madry, Saarland University, Homburg/Saar, Germany
From Minor Cartilage Damage to Advanced OA
... to Advanced Medial OA?From a Small MFC Chondral Lesion ...
... to Advanced Medial OA?From a Small MFC Chondral Lesion ...
Physiotherapy Better Than Steroid injections!
Beware of Intra-articular Steroid injections!
CHONDROTOXICITY OF INTRA-ARTICULAR
INJECTIONS OF LOCAL ANAESTHETICS
VB CKC UK
INJECTIONS OF LOCAL ANAESTHETICS
VB CKC UK
CHONDROTOXICITY OF INTRA-ARTICULAR
INJECTIONS OF LOCAL ANAESTHETICS
VB CKC UK
INJECTIONS OF LOCAL ANAESTHETICS
VB CKC UK
Oral Supplements: Glucosamine and Chondroitin Sulphate
Oral Supplements: Glucosamine and Chondroitin Sulphate
Hyaluronic Acid Injections
Hyaluronic Acid Injections
“The first great advancement in sports medicine was the arthroscope, the second is going to be
this (stem cells).” James Andrews, MD, “The Athlete’s Surgeon”, Birmingham, Alabama, USA
this (stem cells).” James Andrews, MD, “The Athlete’s Surgeon”, Birmingham, Alabama, USA
What are Mesenchymal Stem Cells?
•Adult stem cells can help
regenerate many tissues
•The best source is the
autologous tissue
•Many different tissues can be
used to process biologically
powerful stem cells
•It seems that the best tissue to
extract MSC is SVF (stromal
vascular fraction) adipose
tissue, which is the best source of
cells and regenerative factors
•Adult stem cells can help
regenerate many tissues
•The best source is the
autologous tissue
•Many different tissues can be
used to process biologically
powerful stem cells
•It seems that the best tissue to
extract MSC is SVF (stromal
vascular fraction) adipose
tissue, which is the best source of
cells and regenerative factors
Regenerative Medicine - Stem Cell Technologies
Well, MSCs are NOT Stem Cells!
The MSC: an injury drugstore
1942 - 2024
1942 - 2024
MSCs and Blood Vessels
•PERICYTES
•They “hugg” blood vessels and
they are “chemical factories”
which modulate immunology
(anti-scarring, angiogenic,
mitotic and anti-apoptotic
effect).
•Quiescent stem cells “lurk”
near the pericytes.
•
The nerves that supply blood
vessels also supply the
pericytes.
•
Blood vessel injury: pericytes
migrate off the blood vessel
and become MSCs (Medical
Signalling Cells), release
cytokines and activate stem
cells to multiply and
differentiate.
•They signal to the
environment to heal the
wound.
•They “hugg” blood vessels and
they are “chemical factories”
which modulate immunology
(anti-scarring, angiogenic,
mitotic and anti-apoptotic
effect).
•Quiescent stem cells “lurk”
near the pericytes.
•
The nerves that supply blood
vessels also supply the
pericytes.
•
Blood vessel injury: pericytes
migrate off the blood vessel
and become MSCs (Medical
Signalling Cells), release
cytokines and activate stem
cells to multiply and
differentiate.
•They signal to the
environment to heal the
wound.
Too old for stem cell therapy? Probably not!
Cell apoptosis and senescence do exist but basic biological
healing principles persist.
“Youth would be an ideal state if it came much later in life.”
Herbert Henry Asquith
Cell apoptosis and senescence do exist but basic biological
healing principles persist.
“Youth would be an ideal state if it came much later in life.”
Herbert Henry Asquith
Stem Cells No Better Than Placebo … So Far
(Editor of Arthroscopy Journal re JBJSA September 2016 Article)
(Editor of Arthroscopy Journal re JBJSA September 2016 Article)
PRP Today
More on PRP Injections …
Arthroscopy Journal, article in press, 2015
Emphasis on less (orthopaedic) carpentry and more biology!
THANK YOU FOR YOUR ATTENTION
KEEP MOVING AND LOOK AFTER YOUR KNEES!
KEEP MOVING AND LOOK AFTER YOUR KNEES!
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