Regenerative approaches to stimulate of the body’s ability to heal itself are increasingly recognized in Orthopedics as an effective way to repair and preserve musculoskeletal tissue. Joint preservation is the process of optimizing and preserving a joint’s anatomy and biological structure rather than replacing damaged joint tissues with artificial joint prostheses. Regenerative joint preservation is focused on the treatment of osteoarthritis and other types of cartilaginous and bony joint damage using a variety of approaches. The most effective joint preservation treatment may vary depending on each patient's individual condition. Which treatment is best for each patient can be best determined after a thorough clinical evaluation of your condition including physical examination, X-rays and other imaging tests. To achieve the best possible outcomes, it is important that treatment should be determined by an experienced specialist that understands and frequently uses the entire spectrum of regenerative therapy methods including both surgical and non-surgical options.
Dr. Kai Mithoefer an internationally recognized expert in the field of joint preservation and regenerative orthopedics and regularly utilizes a broad spectrum of established and innovative non-surgical and/or surgical regenerative treatment options specifically designed to achieve the best result for each individual patient.
Preservation or restoration of the natural biologic joint structure and function aims to reduce pain, increase mobility, and delay or prevent the need for joint replacement. Joint preservation requires a complex understanding of joint anatomy, biology and biomechanics and includes several components:
- Joint Surface Restoration (Articular Cartilage Repair)
- Biomechanical Joint Realignment (Osteotomy)
- Joint Stabilization (Ligament Repair/Reconstruction)
- Meniscus Restoration (Meniscus Repair, Substitution, Transplantation)
- Individualized Rehabilitation Programs
- Regenerative Medicine (PRP, Stem Cell Injections, Viscosupplementation)
Articular Cartilage Restoration
Proper joint function requires a surface that allows for smooth gliding of the ends of the bones. This surface is made up of a thin cushioning tissue layer, called articular cartilage, which covers the end of the bones involved in the joint articulation. In addition to enabling movement, joint cartilage also helps absorb and distribute the force of joint loading during joint movement and activities. High-impact loading of the articular cartilage can occur particularly with athletic activities and can present a challenge for the joint over time. Damage to the articular cartilage from either acute joint trauma or chronic overuse can severely affect the cartilage biology and structure and result in restricted use of the affected joint. If the articular cartilage has been damaged, several surgical techniques can be used for restoration of the damaged cartilage:
Microfracture: This minimally invasive technique uses special instruments to gain access to the stem cells contained in the bone below the area of the joint injury and these bone marrow-derived stem cells help to fill in the articular cartilage defect.
Matrix-assisted Chondrocyte Implantation (MACI): This technique uses the patients’ own cartilage cells (chondrocytes) to grow new cartilage cells in the laboratory that are then implanted into the injured joint surface area to repair the defect.
Cartilage Autograft: With this restoration technique, a fragment of bone and cartilage is harvested from a less weight bearing area of the injured joint and then used to repair a joint surface injury located in a main weight bearing part of the affected joint.
Cartilage Allograft: This surgical technique that removes a damaged section of bone and cartilage and replaces it with size-matched healthy tissue from a donor.
Meniscus Preservation and Restoration
The meniscus is the crescent-shaped fibrocartilage that is located between the joint surfaces and acts as a shock-absorber. This shock absorber plays an important role for the integrity of the joint but can get damaged from either acute trauma or chronic degeneration. Preservation or restoration of the meniscal shock absorber presents an important clinically and scientifically proven factor for prevention of joint degeneration.
Meniscus Repair: Meniscus repair preserves the shock absorbing capacity of the meniscus by stitching the torn fragments of the torn meniscus so they can heal back together. Meniscus repair and preservation have been shown to have a preventive effect for the development of joint arthritis.
Meniscus Transplantation: A size-matched meniscus from a donor is implanted into the knee to replace a meniscus that has been completely lost or damaged.
Meniscus Substitution: This technique uses a bio-engineered collagen scaffold to restore a section of the meniscus if a torn portion of the meniscus cannot be repaired or has been previously removed.
Biomechanical Joint Realignment
Malalignment of maltracking leads to abnormal load distribution within the joint surface and presents a well-established factor that contributes to the development of articular cartilage damage and development of joint arthritis. Restoring normal alignment, restores normal biomechanical load distribution in the joint and is critical for joint preservation.
Unloader braces: These removable braces can help to reduce the effects of malalignment such as “bowleg” or “knock knee” by selectively reducing the mechanical load in the involved aspect of the joint. These unloader braces can be adjusted for different degrees of correction and are typically used for less severe cases of malalignment and patients that are not candidates for realignment surgery.
Osteotomy: This joint preservation procedure restores adequate distribution of joint loading in mal-aligned joints by shifting weight away from the area of damaged cartilage and onto an area with healthy articular cartilage. This procedure is useful if the joint surface is injured in only one compartment of the joint. Osteotomies are often performed together with an articular cartilage repair procedure to repair the damaged cartilage.
Joint instability can result from injury to the stabilizing structures of the joint. Ligaments present are the major stabilizers of joints and injury to the ligaments typically results in clinical symptoms of instability such as giving out or shifting of the joint. Besides the feeling of instability, ligament injury can lead to other acute or chronic joint injuries such as damage to the meniscus and joint surface. Therefore, stabilization of the joint presents a critical factor for joint preservation.
Joint bracing can be an effective measure for joint stabilization and often using braces specifically designed for certain ligament injuries, such as specific ACL braces for the injuries of the anterior cruciate ligament (ACL) of the knee. Joint bracing can be an effective way for stabilization and joint preservation in less active patients with joint instability. However, they are typically not recommended for active individuals in the long-term since persistent joint instability in this active population is associated with progressive joint degeneration and development of joint arthritis.
Ligament Repair or Reconstruction
Ligament repair is a surgical procedure that allows for direct suture or reinsertion of the torn ligament and is able to preserve the original ligament. Ligament repair may be possible depending on the ligament involved, the extent and location of the ligament injury. When a repair is not possible, ligament reconstruction can help to restore joint stability. Ligament reconstruction is a surgical procedure to rebuild damaged ligaments with the use of a new ligament fashioned from a tendon graft that can be obtained from the patient (autograft) or from a donor (allograft). The tendon graft is surgically implanted into the position of the damaged ligament to stabilize the joint and are gradually incorporated in to the joint (ligamentization process). Ligament reconstruction has been clinically demonstrated to effectively reduce the risk for joint degeneration following ligament injury.
Physical therapy is a supervised rehabilitation program performed with an experienced and licensed physical therapist. Guided in coordination with the physician’s recommendations the program is tailored individually to the patient’s injury/surgery, activity level, and rate of progression. Physical therapy presents a critically important aspect of restoring proper joint function after injury or surgery and a key component of surgical and non-surgical joint preservation.
Regenerative medicine is a rapidly evolving medical field that has been increasingly applied to treat common Orthopedic conditions. Regenerative technologies have been well-established for joint preservation by applying cutting-edge tissue engineering technologies to the involved joint. Using a variety of innovative biologic techniques Regenerative Orthopedics can be successfully used for joint preservation by restoring normal joint biology and biomechanics in an effort to improve and maintain joint function and to avoid or delay joint replacement. Regenerative joint preservation includes a treatment spectrum ranging from articular cartilage repair, novel ligament and meniscal preservation procedures, re-alignment techniques, as well as non-operative regenerative injection therapies such as viscosupplementation, PRP injections, stem cell treatments, and alpha-2macroglobulin treatment. Besides joint preservation, regenerative treatments are increasingly applied also in other areas of orthopedics and orthopedic sports medicine to biologically augment and promote the healing process and facilitate the return to sports activities:
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