New Knees (Stem Cells)

It might be helpful to provide an update on my experience:

My worser knee was doing pretty good; but the upper bone was deforming markedly where it met the joint.  Was also concerned about reaching the age where TKR surgery would would be a very rough haul, and possibly unsuccessful.  Most of my delay involved not being satisfied with the doctors I consulted and/or the hospital staffs for reasons that ranged from bad chemistry to out and out dishonesty and/or incompetence.  (Not going on a high horse here, I’ve done some incompetence in my time.)   Some of this is also reflected in comments from others in the above posts.

Fortunately, I found a doctor who I felt comfortable with and decided to go ahead.  I almost died from underlying conditions; but fortunately was blessed by doctors and staff at a local hospital who acted quickly and effectively to diagnose and treat and bring me back.  So would say a TKR may be fine when younger, but not so much when reaching the age where a number of underlying chronic conditions may be present.

In my case, the osteo arthritic disease had progressed to the point that it could be fatal if the bone (not just the meniscal cartilage) failed in the backcountry.  (do carry a PLB).  So felt there was no other option.  Am now almost three months out from the surgery, and on new physical therapists who are much better, and seem to be improving (took the dogs on a hilly 3 mile road walk this week with minimal discomfort, and still felt strong when reaching home).  We will see how it goes when we hit Colorado in August; but it will be only day hikes this year.

Conceivably, from a lay person’s standpoint, there should be a better way to address osteoarthritis, and better ways to replace damage and wear to the cartilage.  There are great articles on the Stanford Medicine News Center, and appreciate D K’s link.  But the reality is that spectrums of ability of professionals run from good to bad in medical as well as other professions, and often there are simply no definitive answers in any case.  I was also fortunate that one of my past interns in mediation is a highly experienced nurse, has worked in numerous hospitals, and knows the players and their scores.  Bottom line:  Nobody lives forever, and the effects of aging present new challenges that require some serious attitude adjustments.

I wish you all good fortune in your searches for solutions.   Daryl, the usual next step is a three shot series, a week apart, of OrthoVisc injections.  My brother and I both have found that to be way more helpful.

I was also fortunate that one of my past interns in mediation is a highly experienced nurse, has worked in numerous hospitals, and knows the players and their scores.
And THAT is the real bottom line: inside knowledge of the players.

Cheers

My recent post may have given the impression that after 3 months all was well with the TKR after hiking several miles. Alas, it is more of an up and down process. There are stronger days and weaker days, and days that produce stiffness and days that do not. Not knowing how things will end up is not so great either. I will post again on this thread in a few months to try to give a better picture. Do not want anyone considering a TKR to be misled at this point.

OK 6 months later update.        Just did the Uinta Highline Trail.

Knees are rock solid.    No pain whatsoever.

I am at a loss for any explanation at this point.  At first they are good. Then not so good.  Now they are  really good.

WTH?

Just to close this thread out forever, in case anyone finds it by Google.   I will be going in for a traditional knee replacement.  Stems cells in the end were no better than steroid injections.

Jay, if it helps, I am three years into a total knee replacement and without pain in that knee, except oddly there are sometimes shooting pains, but they quickly subside.

The worst part of it was choosing a surgeon.  After a pathetic excuse of a pre-op at the hospital affiliated with the first surgeon,  the second one I had chosen waited until the covid test a few days before the surgery, and then had the nurse taking the blood for the test also show me a document for me to sign before surgery.  Were I not an  experienced lawyer, probably might not have known that the document was a total release from any liability.   Confronted the doctor on the phone, and he acknowledged the document was as I thought. That was the first time any surgeon pulled that one, and was amazed.

My nurse friend then steered me to an experienced knee surgeon who unlike many doctors, uses computer technology to control the surgery.  But the staff let me go too early, leading to weakness in the leg and a week’s stay in a facility to insure recovery.  Could have done the same thing at home; but was OK with the doctors’ opting for caution.

I’ve learned that there are many doctors as well as hospital staff who behave irresponsibly, and are often motivated in large part by profit.  So the choice of both surgeon and hospitals are critically important.

Am doing fine now, and will probably need to do the other knee at some point.   The doctor who does annual orthovisc injections on the other knee warned me if I wait too long, it may be too late for a total knee replacement.  That happened to the mother of a friend who ended up with a metal rod in her leg.  My friend now says, “They killed my mother.”

Will go to the same surgeon for the other knee, and speak to him only, not staff and administration, to determine when I’m ready for discharge.  Major surgery can be a bummer, so it is important to take maximum precautions.  Money is the root of all evil, and doctors and hospitals are no exception.

I asked my surgeon at Kaiser how many total knee replacements he’d done before committing. He said, “knees and hips are all I do. I do about three hundred knees a year. I’ve been here five years.” Well, good enough for me! He did my right knee about five years ago and it’s given me my life back.

Look, these are safe and straightforward procedures when done by experienced doctors. I was sedated but not out cold during my procedure. They had me up and moving an hour and a half after surgery. The recovery was a bit painful–think of when you bump your knee wrong–but well worth it.

I think as we age it’s important to assess our various developing health issues carefully. Are these issues that can improve on their own, or with life style changes? Or will they continue to worsen no matter what? If the latter, early intervention is always more successful than waiting. Get out ahead of the issue. Don’t wait for things to degenerate before acting. Once knees are bone-on-bone, no amount of exercise or steroids or stem cells will help. We hoped for stem cells but they haven’t worked. At that point, surgery is the only option. Again, it’s a strightforward safe surgery.

As for signing a waiver–this is standard procedure. It’s not nefarious. Sometimes surgeries fail through no fault of the surgeon. there’s a half million lawyers who will prosecute every surgery that failed to deliver what the patient wanted. It drives up costs for the rest of us to a great degree.

Recall that surgeons are acting along with team on hand. This team is experienced. It’s standard for team members to intervene if something doesn’t look right when a surgeon is acting. Surgeons usually explain what they’re about to do before doing it in order to cross check with the team that the action is appropriate. Done well, this system is a beautiful thing.

Egregious errors are another matter, and my guess is that they could still be prosecuted.

Be selective in seeking advice from medical personnel.  A surgeon’s experience:   Scrub nurses assisting the surgeon (not paid by the doctor) used to say “If I needed surgery, I would have you do it.”  He would say why?  “You are nice and respectful to work with, operate efficiently, loose little blood, did anesthesia before becoming a surgeon, we can just tell you are a good surgeon.” Etc.  He says “wrong, bad reasons.”  “Go to the nurses, physical therapists, home health care staff, people that take care of my patients post op.  They know how my patients do.  Look at my readmission rates.  Infection rates.”  I know that surgeon very well.

Secondly, be weary of any “series of one” medical testimonials, even if from your most trusted source.  If stem cells, surgery, no surgery, crystals, religion, worked for one person, erase that from your decision-making process.  Read the literature. Many peer reviewed publications are now available without subscriptions.  Also, good medical treatment does not need advertisement in the popular press. If it is good, it will become popular on its own and in its own time.

Yeah!

“Secondly, be weary of any “series of one” medical testimonials”

Like, I have tried treatment X with my patients and it worked well

very susceptible to cognitive biases

And do your PT. If you don’t, you don’t stand a chance of a full recovery. So many people don’t do it.

Also on cost and greed and motivated by profit. If you want to see how much Americans waste on health care bureaucrats, 45% – instead of spending on actual treatment, check out this article from the Economist. Imagine if we could spend half of that on including more people in getting health care.

I don’t know whether this is a good idea, me posting this….

I’m a physio.

The degree of change you see on a scan (cartilage loss etc) does not correlate that well with pain or function. You can have horrible looking scans and be doing pretty well. And the reverse. Which is sort of comforting: pain etc can improve even when scans don’t look great.

There is a lot of evidence supporting exercise to reduce pain and improve strength and function in knee osteoarthritis. Exercise creates systemic effects, not just local mechanics.

Sometimes we need interventions beyond exercise tho. Knee replacements are pretty good now-a-days. Still major surgery…..  I hope the stem cell side of things goes well.

Skate boarding is PERFECTLY designed to upset menisci 🙂.

PS I had an ACL rupture one knee, meniscal tear and a tibia plateau fracture on the other. I treat my knees with love, exercise and gratitude (whenever I walk another mountain). I love walking poles and anti- inflammatory 😁.

Cheers.

That all makes sense to me.

I’m interested to know what systemic effects exercise creates and how those might improve function and reduce pain in a knee, for example. It makes sense that there would be more blood flow and increased chemistry happening throughout the body and that could help a keep a knee happy.

I did an extensive exercise regimen focused on my knees over two years as the pain grew worse and worse over two years. Yes, there are good reasons exercise can help. I also went from steroid shots to a ‘gel’ injection therapy that the specialist tried twice over a half year. Meanwhile I could not go upstairs except one foot at a time, or even walk a block and a half down to the gym except in excruciating pain. All walking was painful. Looking at my x-ray, there was the issue: there was no padding between the two knee bones. Bone on bone. exercise could do nothing for this. The so called knee replacement inserted a pad between the bones. When I first stood up from the bed in the hospital after the surgery, I could tell: no pain from bone on bone. It was gone. So worth it. Kaiser forced me through exercise regimens and other therapies in an attempt at a cure when they must have known from the x ray that nothing would work. Oh well, the cost for the surgery was $250.00 to me, so I have no complaints.

I’m interested to know what systemic effects exercise creates and how those might improve function and reduce pain in a knee, for example. It makes sense that there would be more blood flow

The knee itself is a complex joint with cartilage, menisci, and other connective tissue that can be tough to heal due to relatively poor nutrient supply (blood supplies nutrients and the microscopic distances may be too far for the nutrient molecules).

BLUF  (bottom line up front): You want to keep strong skeletal muscles surrounding the joints as the joints themselves have tissues that are very hard to heal.

Long version: Traditionally keeping strong and toned skeletal muscle surrounding the knee (and other vital joints) is key to joint health as a person can exercise those to increase tonus (aka “tone” .. which is partial muscle fiber contraction at “rest”), cross-section (“size”) and then even increase/decrease a bit of different fibers subject to genetics.

The toner and stronger the surrounding muscles, the better a joint can withstand injury and likely the physical therapy after any joint replacement will go much smoother.

So more muscle mass provides more stability around the joint and there will be more blood flow if healthy (note: some people may have developmental problems with joints .. heredity or previous injury trauma causing quicker deterioration).

Reading about stem cells, these are precursor cells usually required for growth.  Just scanning the articles, the presence of these is said to stimulate more cells in the region to grow (= heal).   I’m just going to take a guess that this growth may cause a nutrient gradient (chemistry speak) and potentially attract some nutrients. It’s still listed as an experimental therapy in the US (insurance doesn’t have to pay for it) but it’s also said the side effects are minimal.

… systemic

That actually gets into correct physical training as muscle/joint  problems in one area can lead to muscle/joint problems in other areas .  I threw out my back exiting a Blackhawk helicopter in Iraq (so painful I had to be put to sleep w/morphine initially … luckily we were back at the base) but found out that it was a muscle imbalance problem from training stateside … my quadriceps were too powerful while my hamstrings too weak.  So I spent every other morning getting physical therapy (thankfully as I’ve never seen a back operation go well .. a painful way of learning everything is connected in the human body though).  So that’s why a good physical fitness regime  stresses that opposing muscle movements in the gym may require something different than 1:1 weight ratios.

So as the actual docs told me, … with muscles it’s physical therapy, but bones/joints worn out, lacerated shattered, …  it’s probably surgery (perhaps arthroscopic for the knee) unless stem cells can help.

I actually tracked mostly joint injuries in my military staff job but I’m no physician.  You can learn all the skeletal muscles and mobile joints (“synovial”) by reading an old Human Anatomy and Physiology text book or a A&P study guide at a book store.  It’s really a memory game.  The chemistry part is where a student needs to likely take or review college level courses in chemistry/biology.

I need to add that anatomy comes into play here. Knee issues aren’t ‘one size fits all’. For example someone with one leg that’s shorter than the other, or with fallen arches that cause pronation, or a high arch on one foot and not the other, etc. etc. will have effects that extend to the knees and even the hips. Again, in some of these cases, muscle strengthening will have little or no effect. Yes, of course, the latter is always a good idea!! My knee issue did not result from my being a lazy schlub who should have worked out more. Quite the opposite. (NOW I’m a lazy schlub, but my knee is fine!). In my case, my right leg/knee pronated inward at each step due to my left foot being extremely flat, which resulted in nearly an inch of differential in height between right and left. One can’t muscle their way out of this and similar scenarios.

so it'[s good to understand what’s behind your knee issues. If simple weight bearing exercise can strengthen the muscles around the knee and cause it perform optimally, good! Most backpackers who are serious have good leg strength, however. So examine your stance, your feet, how your hips align, as well as how your knees align, or don’t.

Yes, I agree, jscott – both with that anatomy is important and about not being a lazy schlub :). It is really important to know what is contributing to your particular knee pain and osteoarthritis (OA). It can be specific biomechanics – like pronated feet (and the shoes/boots you wear), leg length differences, patterns of movement and strength. OA that just develops over time (and sometimes ‘runs in the family’) has different characteristics to that which occurs after an injury. e.g. what compartment of the knee is most affected, what movement ‘habits’ people fall into. Anterior knee OA (behind your kneecap) is different to other knee OA.

The trouble with the word ‘exercise’ is it covers a multitude of things…..an analogy for BPL might be the word ‘backpack’ – which would included my Dad’s old Karrimore (canvas and external metal frame which was hollow and could contain fuel !!) to the ultralight things you all carry. And there is similarly a LOT of argument/discussion about what exercise is best.
Probably neuromuscular exercise currently has the best evidence in knee OA (exercise which is largely weight bearing and concentrates on the movement pattern and the ‘function’ of a movement as well as the ‘strength’). – like the GLA:D program (evidence based, developed in Denmark, hasn’t reached USA yet, is in Canada by the looks 😊).

And sometimes exercise is tried and is not enough ( in terms of the clunky analogy – “ You need a truck, not a backpack”). Total knee replacements frequently give brilliant results! Recovery takes time – as this thread points out.

Hello Matthew –
Beneficial effects of exercise for knee OA other than local strengthening/support for the joint – that I know of with evidence :
• Positive changes for the components of cartilage (e.g. glycosaminoglycans – good things) assisting to reduce cartilage breakdown and encourage some recovery.
• Reduces oxidative stress.
• Reduces the presence of pro-inflammatory molecules – inhibits inflammation.
• Alters tendon structure (exercise done well can increase the load bearing capacity).
• Alters brain area activity and functional linking (e.g. can do nice things to your endogenous opioids and dopamine circuits). Reduces sensitisation.
• Reduces joint fluid viscosity and frees up range of movement.
• Improves immune function (immune system function has a major impact on pain etc)
• Improves balance, movement control and functional stability of the joint.
• Improves mood and sleep.

When I see people with knee pain, what I like them to know is:
• Scan results do not tell you everything; and there is hope even if the scan doesn’t look great.
• There are things you can do to improve how your knee is functioning – specific exercise, looking at your biomechanics, footwear, general health approaches etc.
• OA doesn’t have to mean surgery.
• If you end up needing a joint replacement, they usually do well. I know people who get back to jumping fences while chasing sheep, back-country skiing, multiday hard hiking after replacements.
• And – as a lot of posts have emphasised ++ – check the evidence for whatever you consider doing.

Cheers

All very interesting! Thank you!

To all this wonderful conversation, I’d add what you eat is important. The closer you can get to a low/no inflammation (alkaline/non-acidic) way of eating the better (this means ditching animal products as much as possible, or better yet, 100%). Losing weight is also important, but will naturally follow if going to a whole-food, plant based, low inflammation diet.

Diet is hugely important. If you are at all in tune with your body, it’s pretty easy to start making a mental list of what foods/drinks cause inflammation. It’s different for everyone but for me the worst knee pain/inflammation sources are alcohol-any kind, soybean oil-which is in most processed foods, gluten and excessive caffeine. The difference between my inflamed state vs. not inflamed is drastic as it relates to knee pain.

What I don’t understand about inflammation is, why do my joints hurt even when my blood markers are low? I have been diagnosed with psoriatic arthritis (similar to rheumatoid but less extreme and with psoriasis added) but when they do my blood, my numbers always look fine. But the joint pain comes and goes regardless. Asking the doctor this question does no good; they don’t have an answer. One day I cannot open a jar, the next day I am splitting wood, chopping kindling, doing handstands. No one knows why this is.

We should do what we can to stay healthy, but when your body doesn’t cooperate, don’t blame yourself. I have even heard people claim that if your body is experiencing pain, it’s because your soul is in turmoil, or your karma is coming back at you – all kinds of utter imaginary nonsense. Too much guilt and blame and shame over our bodies. Save it for your behavior toward others! and just do the best you can.

psoriatic arthritis … similar to rheumatoid [arthritis or “RA”]

Both of those are classified as autoimmune disorders.  Basically the immune system attacks the connective tissue.

Osteoarthritis is really the “wear and tear” arthritis.

I know for RA immunosuppressants are the treatment (best friend’s wife has it), and treatment looks similar for psoriatic with a basic web search.

I met a young woman with very severe osteoarthritis (we’re talking bone on bone if walking normally .. not sure how it occurred) who was hiking the 3 long trails with her husband.  She had some sort of cast-exoskeleton to twist her knee onto the part which had cartilage with every step (think she planned a knee replacement after 6k worth of hiking).  The medical profession has been working on it.

My knee doctor recommended daily glucosamine chondroitin supplements aster an ACL tear and grade 3 chondropathy of the knee cartilage.

Has anyone had any luck with this?  I gave it a shot but it gave me bad digestive issues so I hit the pause button.

For now I use an elastic knee brace with patellar stabilization with good results.  It significantly reduces knee pain on long days or with much elevation, is washable in the field and dries fairly quickly.  I need a pair (other knee: lateral meniscus tear) and the drawback is that they add significant effort.   After a lot of trial, I’d say they feel like ~ 30% effective distance added but its better than the alternative!

I don’t pretend to understand inflammation and I’m not a doctor or in any way medically qualified. But there’s more involved in osteoarthritis than just wear and tear. But inflammation plays a role in osteoarthritis too.

PS jscott I meant I agree you were NOT a lazy schlub (whatever a schlub is) and that is not what your knee issues were about.

Hello AK Granola – I think part of the answer is that there are lots of different levels of inflammation. My old boss was a Rheumatologist and Pain Medicine Specialist …. But he has retired and is playing with his tractor and his grandson so I can’t rope him in to help in answering this question. I’m not an immunologist but this is what I understand – (Earlier posts discussed checking your facts and not believing everything you read…. I agree. In the interests of transparency, I am a physio who has a master’s in pain management and works in pain clinics, so I have some understanding – there is a lot I dont know, tho).
The blood markers you might be talking about are things like Erythrocyte Sedimentation Rate and C-Reactive Protein for example? They are related to what red blood cells and your liver do in reaction to inflammation. They are sort of ‘downstream’ impacts of inflammation. There are also ‘upstream’ levels of inflammatory activity which are not sufficient to change ESR or CRP, but are enough to change how our bodies work, the level of ‘talk’ between our neurones and the amount of pain we have. You could look up ‘cytokines, inflammation and pain’ for example.
Inflammation is a result of immune system function…inflammation is often a great thing; protective and firing off the healing process. But it is frequently overdone – particularly in autoimmune disorders. Most of the cells in our nervous system are immune functioning cells, not neurons. Immune functioning cells such as astrocytes can determine how reactive our neurons are (how easily they will fire off signals) – so influence whether we have pain and how intense it is.
Many things impact our background inflammatory level – sleep, stress, food, isolation, social rejection, over exercise, under exercise etc etc
Similar with the many things which can influence pain intensity (as well as the load on the individual body part like an OA knee) – sleep, stress, mood, illness, hormones and menstrual cycle, vitamin D levels, activity level, food/sugars, etc etc. Some of my patients have relatives or colleagues who can increase their pain just by walking in the room! I often talk to people about the ‘multiple ingredients in their pain-cake’ (terrible metaphor) – and the ingredients change with time and situation.
On the flip side, it means that doing things you enjoy, being outside, being with people you like, sleep, taking breaks, exercise, self-compassion, good food benefit you in ++++ ways, including pain. Oh – laughing is really good – I’m sure reading the BPL thread on ‘long handled spoons’ reduced my background inflammatory level ++.
I so totally agree with your last comments. People do their best; sometimes, we are hardest on ourselves – fight our bodies, ignore our own needs for a bit of comfort and self-kindness. Pain is not karma – it is not a simple problem either, nor a complicated one – it is complex