Cartilage, Part 6

In this final installment of the cartilgage series, we'll address "healing with steel."

Are you getting the idea that dealing with cartilage wear is a difficult problem for Masters athletes who want to stay active? It is a difficult problem. This is because cartilage has a poor healing capacity at any age and this simply gets worse the more years we accumulate.

Despite amazing conservative, surgical and biologic advances in the care of worn cartilage, there sometimes is a point where even the athlete must consider "healing with steel."

Just because you have arthritis does this mean you have to quit being active? ABSOLUTELY NOT It may mean that you have to change how you train.You might have to cycle instead of run, or start cross training to give your joints a rest. Even getting a joint replaced doesn't mean you have to stop. There are many participants in the Senior Olympics who have artificial joints, and these athletes run, pedal and swim their way into the winner's circle. Being bionic is not all bad.

Many of you probably think that knee replacement means that you are doomed to sit on a rocking chair for the rest of your life. The truth is that I and many of my colleagues view joint replacement as a LISCENSE for MOBILITY. This is because instead of hobbling around in with pain and with stiffness for years, you are finally able to get back to doing the activites you love to do and do them with none or little difficulty.

Seriously, many of my patients return to sports: tennis, cycling, rowing, team sports, swimming. Everything except distance running. I'm sure some of my patients even try to run; they just don't tell me.

So what is joint replacement? When cartilage wears down and the bones begin to rub on one another, it causes both pain and deformity. One side of the knee wears out faster than the other and the bones become lopsided. For most, we wear out the inside (medial) portion of our knee joint and the top of our hip joint first. This is why you see many people becoming bow-legged as they age.
 
All joint replacements, therefore, are meant to decrease pain and realign joints straight again. Joint replacement is performed by making an incision over the involved joint and removing the ends of the bones that no longer have cartilage on them. Special jigs are used to measure and align the cuts made on the ends of the bones to make sure the new joint is anatomically aligned like the natural joint was before arthritis wore it down. Now we are even using computer navigation in the operating room to more precisely align the bone cuts back to their natural anatomic position.  

Once all the bone cuts have been made, the ends of the bones are replaced with metal replicas. Prior to surgery, X-rays are measured to ensure the proper sized implants are available, and during surgery the surgeon measures to determine what size joint replacement is needed. When the surgeon confirms the proper size and alignment of the implants, they are cemented into place. This is why you can walk on joint replacements immediately.

The implants are made out of cobalt-chrome, ceramic or titanium alloys and are polished to a highly shiny surface. They reflect light like a polished chrome bumper or a mirror. Between the two polished steel implants, a very tough piece of plastic, called polyethylene or poly, is inserted. The two bone ends move over this poly surface like your natural joint moved over its cartilage.

Rehabilitation after a this operation can take three to six months depending on the kind of shape a patient is in prior to surgery. The post-operative results, however, are generally excellent with significant relief of pain and return of function. More than 90 percent of people continue to have good or excellent results more than 10 years after joint replacement.

You can find more information about joint replacement at the American Academy of Orthopaedic Surgeon's Web site:

http://orthoinfo.aaos.org/menus/arthroplasty.cfm

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Cartilage, Part 5

Cartilage care is getting more and more high tech, and armies of scientists and clinicians are working to solve the dilemma of worn out knees. A sophisticated way to get the body to work for itself is called ACI or Autogenous Cartilage Implantation. This procedure does not use whole plugs of tissue, like the OATS procedure we spoke of last blog, but instead uses your own cells to grow new cartilage. 

ACI is used for cartilage holes measuring 2 to 10 square centimeters and for people aged 15 to 55. ACI requires two surgeries.In the first surgery, the doctor arthroscopically harvests small amounts of your healthy cartilage and evaluates whether the hole in your cartilage is a good candidate for ACI. The harvested cartilage is sent to a commercial lab where the cartilage cells, chondrocytes, are isolated and grown in flasks. When the cells have multiplied enough, they are preserved for you until the time of your second surgery.

During your second surgery, the doctor will open your knee up with a small incision and prepare the cartilage hole to be filled with your own cartilage cells. They do this by using an instrument to remove cartilage debris until the sides of the hole in your cartilage are straight up and down like a canyon. They then use a piece of tissue from your body to cover the hole like a lid. They sew the "lid" in place with tiny sutures. This portion of the procedure is very tedious and involves microsuturing techniques. The suturing technique is analogous to sewing tissue paper to a hard-boiled egg. It is important to make sure that the sutures are placed correctly on the first attempt, because holes in the periosteum lid or cartilage could result in leakage of some of the cells out from under the graft. The edges of the lid are sealed and YOUR OWN Cartilage cells are slowly injected under the lid into the canyon prepared in your cartilage.

These cells will then set up housekeeping and recreate healthy cartilage over time. The outcomes of ACI are variable and some people get excellent results while others don't. There seems to be a decrease in the outcome of this procedure with time -- meaning that in the first few years it does well and then the function declines.

As with the other cartilage "re-growth" procedures, ACI requires a long rehab course.

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Cartilage, Part 4

So far we have discussed non-operative at home cartilage solutions, the non-operative cartilage remedies you must get from a doctor and a surgical technique for small cartilage lesions called micro-fracture. 

As we discussed last time, micro-fracture has good outcomes for small cartilage holes, and doesn't burn any bridges for future cartilage work, if needed, but fills in the defects with "scar cartilage" called fibro- cartilage.

The next cartilage "fix" is called OATS. No, we are not talking about multi-grain here. OATS stands for Osteoarticular Transplant System. Essentially, we take plugs of cartilage and bone from a part of your knee that does not bear weight and transfer it to the area of cartilage wear that does bear weight. It's like robbing Peter to pay Paul&.except it is in the knee.  The beauty of this procedure is that we transfer healthy "hyaline" cartilage instead of the fibro-cartilage that grows after microfracture.

We have instruments that literally take a plug of cartilage and bone out en bloc and then transfer the whole block to the new site and tap the plug in. This technique works best in small cartilage holes in the femur (thigh bone) and less well in the tibia (shin bone). It is not a great solution for the knee cap. 

Multiple plugs can be used in the same cartilage hole. When this is done it is called "Mosaicplasty." The outcomes of the OATS procedure seem to work best in knees that are less than 50 years old.

Again, as with microfracture, the rehab from this procedure is long, with six weeks on limited weight bearing and three to six months of rehabilitation prior to returning to all out sports. The purpose of this procedure is to provide pain relief and improve function when a knee replacement is not warranted.

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Cartilage, Part 3

Here's the third installment in my series on treatments for cartiage issues in Masters athletes. In this installment, I explore "microfracture." 

Well Masters athletes, when conservative measures do not relieve the pain and swelling of damaged knee cartilage, there are several techniques for cartilage repair. The important factor to remember, however, is that cartilage is inherently avascular (it has basically no blood supply), and blood is vital for repair of any tissue. When it comes to cartilage you are essentially born with what you are going to have for the rest of your life. The type of cartilage you are born with is called "hyaline cartilage."

One method for filling in lost cartilage is called "microfracture." When this technique is successful the "hole" in your cartilage is replaced with "scar cartilage." This type of cartilage is called "fibrocartilage." Fibrocartilage fills in the gap in your native knee surface, but the material you grow is not as biomechanically sound as your original cartilage.

The microfracture technique essentially uses your body's own blood stem cells (cells that can become any cell) to grow the scar cartilage. The stem cells get to the hole in your cartilage through small holes your surgeon makes (microfracture) in the bone underlying the bad spot in your cartilage.

Microfracture is normally performed by first examining your knee with an arthroscope (camera).The area of cartilage loss is prepared with special instruments called curettes in order to make the side of the hole straight up and down like a canyon. An awl is then used to make several small holes in the bone to allow the bone marrow containing stem cells to fill the canyon. This bone marrow forms a clot and over the next 6 months will become scar cartilage.

This procedure is appropriate for small holes (smaller than 2 centimeters) in cartilage and works best for younger people. If the procedure works, 80 percent of patients report good to excellent results even 11 years out. If the procedure does not work, it does not burn any  bridges for future cartilage procedures.

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Cartilage, Part 2

A little help from your doctor

When you have been treating your knee or hip pain yourself and getting no relief, it is time to seek medical care. You must be careful, however, that your sports doc understands that you are a Masters athlete and does not simply tell you to act your age. Many docs are as behind in their expectations of aging athletes as those people you meet who think you are crazy for pushing yourself so hard. If you can't get your doctor to treat you like the athlete you are -- look around. This sounds harsh but as one of the only sports docs focusing both research and clinical time on the care of the Masters athlete I know it is true.

1. Joint Injections
Two main types of joint injections are given for arthritis pain and swelling. These are steroid injections and joint lubrication. Steroid injections have been around a long time and consist of injecting the joint with a mixture of numbing medicine, such as lidocaine or marcaine, and steroids. The point of this injection is to decrease the pain and inflammation of arthritis. Although used commonly, these injections usually last an average of three weeks and most physicians will give only three a year to any joint. I tend not to use steroids unless my patients have acute, excruciating pain.

I prefer to use joint lubrication with a class of injection called hyaluronic acid. There are currently five of these on the market. Four are purified from the comb of roosters and the fifth is grown in bacteria and then purified for injection. The hyaluronic acid works to decrease inflammation and lubricate the joint. It causes the joint lining to secrete substances that feed the remaining cartilage. Hyaluronic acid injections, or the chicken "stuff," as it is referred to by many of my patients, works best in early arthritis and can be effective up to six months or longer. They are given once a week for three to five weeks and can be repeated every six months if patients receive significant relief.  

Using hyaluronic acid injections and having patients strengthen their quads, I have returned many athletes to their sports, which have included an ultramarathon and skiing in Vail.

2. Joint Bracing
As the cartilage and then bone wears down inside the knee, your leg will often change from straight to bowed or knock kneed. Braces can unload the affected side of the joint by pushing on the opposite side and effectively straightening the leg again. For instance, if you have arthritis on the inside or medial side of your knee and develop bow legs, the brace will unload that side by pushing against the outside or lateral side of the knee. The problem with knee braces is that they only work if they are worn daily, and many people simply put them in the closet. These braces are custom braces made especially for you and must be ordered by your physician. The stretchy knee sleeves you buy in a pharmacy are not effective in unloading the knee and are not what I am describing here. Some of my patients like the sleeves, because it makes them more aware of their knees and they feel more stable. For many sports docs the jury is out on the use of knee braces for arthritis. Many of you may not want to admit that you need them. The fact is that for many people they unload the joint sufficiently to allow less painful activity and increased stability. 

3. Arthroscopic joint debridement
"Washing the joint out" by surgically removing loose tissue or debris in the joint with small camera and instruments through tiny incisions has not been found to be effective for long-term treatment of arthritis pain. The only true indication for arthroscopic surgery with arthritis is if the person has mechanical catching or locking (feels like popping, snapping or sharp pain) due to a torn meniscus. Arthroscopic surgery is useful if loose bodies (pieces of cartilage or bone that break off) are getting caught in the joint. The surgery will eliminate the mechanical symptoms, but will not touch the aching pain of arthritis. I always make this distinction to my patients.

You can read more about these suggestions at the orthopaedic surgery web site: www.aaos.org

Next time: Surgical interventions for cartilage gone bad -- microfracture

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Cartilage

This is the first installment in a series of blogs about cartilage. If any of you road warriors were looking for an Orthopod around town early this month you may have been out of luck. Many of us were playing hooky and attending our annual meeting in San Francisco. This annual event is a time for old friends, peers and even rivals to come together and share the latest advances in musculoskeletal research. The next several blogs will cover a hot topic at this meeting -- cartilage care.

Aging cartilage is a big problem in the general population, but it can be especially vexing for the Masters athlete who has no time nor inclination to be slowed down by the pain or swelling that often accompanies cartilage that is "running out."

Cartilage is normally the glistening, smoother than ice, biomechanical wonder that lines the ends of our bones -- until it starts to break down. Technically, the definition of cartilage wear is osteoarthritis. Yes, I said the awful word. For most of you this cartilage break down is most problematic in the knees and hips.

These cartilage-care blogs that I'm going to write will cover the following topics: 

1. Do it yourself cartilage care.
2. Help from a friend&your doctor.
3. Surgical interventions for cartilage gone bad
4. Microfracture
5. Cartilage transplantation
6. Natural and synthetic plugs
7. Joint replacement

First, do it yourself cartilage care,Caring for your knees and hips begins at home. The following is a short list of treatments you can try on your own.

1. Heat
In the morning or prior to exercise when you are trying to loosen up your tight joints heat is a good fix. A slow steady application is the best way to get your circulation going, relax your tight joints and get ready for activity. There are a variety of ways to accomplish this -- from heating pads, hot water bottles to thermal wraps. In general, I prefer the thermal wraps. Several companies make these but the concept is the constant application of approximately 104 degrees of heat over time. Some of these wraps last up to 12 hours and are perfect for getting on the go (versus a heating pad that leaves you plugged into the wall).  Although they may feel warm and definitely smell funny, the heating gels that you rub into your skin do not reach deep enough to increase the circulation around your joint.

2. Ice
After activity, at the end of a long day or anytime your joints ache, ice is an excellent remedy. Not only does this simple solution calm the inflammatory process going on in your knees but it confuses the pain pathways and decreases pain. A minimum of 20 to 30 minutes is necessary. Apply the ice pack or simply a bag with ice onto a thin towel over your joint.  Our skin gets thinner with age and this will prevent damage.

3. NSAIDS (Non-steroidal anti-inflammatories)
Now I know most of you will say that you are not "pill people," but this class of drugs does not simply mask the pain but actually treats the source. Before you take these suggestions you should make sure with your doctor that this class of drugs is all right for you. This is especially key if you have stomach problems. In general, these medications are taken several times a day and take several days to build up a therapeutic level in your blood.

4. Do resistance training!
The key to healthy knees is strong quads and the key to healthy hips are strong cores and buttocks. If you are a typical Masters athlete -- or at least like the many I see each day in my practice -- you do your sport and little cross training or resistance work. All yes, all -- of my patients with cartilage wear are sent to the gym to lift with their quads, cores and butts. This will improve your game and keep your joints healthy. Note: if your knees hurt, especially in the front, NEVER do another knee extension. This exercise loads your kneecap 10 times whatever the weight is you are lifting.

5. Active Rest
If you have pounded out an intense workout and your joints are sore, rest them. This does not mean sitting on the couch for several days. Instead get on a bike and spin, row, use the elliptical, workout your upper body alone one day. Rest is great -- when it is active.

Next time:  A little help from your friend, your doctor

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How fast do we age? Lessons from Senior Olympians

Is aging a number, a feeling or an inevitable biologic process we can't alter? Much of what we know about the aging process has come from studying sedentary people. The problems typically attributed to aging have less to do with actual aging than the sedentary way that more than 70% of people in this country choose to spend their lives. This sedentary living results in 35 chronic diseases that kill more than 250,000 people a year in the U.S. This is many times more than any bacteria, spinach or bird flu out break. It is our couches that are not only aging us but killing us!

It occurred to me that in order to understand the true nature of musculoskeletal aging that we had to eliminate the variable of living a sedentary lifestyle& only this way could we answer the question of "What are our bodies really capable of if we aged the way we were designed for& actively?"

For this reason I started studying the Senior Olympians. This group of active agers consistently exhibit high levels of functional capacity and a high quality of life. I wanted to know why the 50-year-old male winner of the mile sprint was capable of finishing in 4:34 or why the 70-year-old winner still can blow away many sedentary people half their age by running a mile in 7 minutes.

I began looking at performance times of the top 8 finishers in every track distance from 100m to 10K from age 50 to 85 in the 2001 Senior Olympics. Would there be any kind of pattern to how we age? When does biology take over no matter how active we are?

What I found amazed me. Masters athletes' performance declined less than 2 percent per year for both men and women from age 50 to 75. This was true for the sprint distances as well as the endurance distances.This means that you could put a 50 year old and a 70 year old in the same race and no one gets lapped.

After 75 years old, however, something happens. The slow 2 percent decline in performance times suddenly becomes more than 8 percent decline per year. Why does performance plummet? Is it the cumulative factors of loss of muscle mass, flexibility, coordination or aerobic capacity that suddenly catch up with us?  

To evaluate this effect further I looked at American Track and Field record holders -- the bests of the best. From age 30 to age 50, there is less than a 1 percent decline in performance.  From age 50 to age 75, this increases to less than 2 percent and after 75 years old, there is again a sharp decrease in performance.

There are many reasons for these observations and maybe you have experienced them yourselves.  In the next several blogs I want to talk about these reasons and how you can stay at the top of your game or race for as long as you can.

If you want to read the full study it will be coming out in March in the American Journal of Sports Medicine. It's also attached here as a PDF file.

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