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 Knee
Replacement and Prolotherapy
Ross
Hauser, M.D.
There are now 40 million people in the United States with arthritis and
this number is expected to grow to 60 million by the year 2020.
Why Are We In a Cartilage
Crisis?
This is not too difficult to figure out just from the figures of the
number of people needing joint replacement surgery (120,000
hip
replacements and 245,000
knee replacements) as directly correlated to the number of
people who are developing arthritis, which is directly related to the
number of people who have received
cortisone,
arthroscopy,
RICE treatment, and
anti-inflammatory medication
over the past 40 years. These treatments accelerate cartilage breakdown
tremendously, and thus also accelerate the arthritic process.
What is the Cartilage Crisis?
Most of the joints in the body are synovial joints, that is movable,
lubricated joints which are able to provide normal pain-free movement
because of the unique properties of the
articular cartilage. The
articular cartilage covers and protects the ends of the bones in joints.
The knee is the largest synovial joint.
At the top of the knee are the massive quadricep muscles which cause the
knee to extend. The
hamstring
muscles are at the back of the knee and cause it to flex. The knee
joint has a synovial membrane, which is tissue that lines the noncontact
surfaces within the joint capsule. This tissue secretes lubricating
synovial fluid, which nourishes all the tissues inside the joint
capsule. The knee has internal
ligaments (cruciate
ligaments) and external joint ligaments (collateral ligaments) which
stabilize the joint, especially during movement. The knee also has
menisci, pads of
fibrous cartilage which help the weight-bearing bones absorb shock. The
ends of the tibia, femur, and
patellar bones of the knee
joint are covered by articular cartilage. This is the structure that is
in crisis.
Articular cartilage allows near
frictionless motion to occur between the surfaces of two bones.
Furthermore, articular cartilage distributes the loads on the joint
articulation over a larger contact area, thereby minimizing the contact
stresses, and dissipates the energy force associated with the load.
Articular cartilage is made of specialized protein structures, called
Proteoglycans, water, and
collagen. The cells (chondrocytes)
of articular cartilage are responsible for the synthesis of both the
collagen and proteoglycans that make up the cartilage and have the
ability to synthesize all the various components of the specialized
proteins that make up the proteoglycans.
This ability of these chondrocytes to replicate is really the key
question when considering the potential of cartilage to proliferate or
to repair itself. It has been shown in studies on adult human cartilage
that there is no decrease in cell counts, even in individuals of
advanced age. This fact alone suggests that chondrocytes have the
ability to proliferate and repair. Additionally upon certain injury such
as mild compression,
Osteoarthritis, or lacerative injury, the
chondrocytes are capable of mitotic division, indicative of growth and
proliferation.
The notion of damaged cartilage having no regenerative properties is
responsible for many people being subjected to arthroscopies with
subsequent joint replacements. This falsehood or myth occurred because
healthy cartilage cells have very little, if any, mitotic activity, thus
very little or no ability to proliferate.
A bulk of research on articular cartilage regeneration was performed in
the 1980s and 1990s. Dr. H.J. Mankin discovered that the chondrocytes
reaction to injury was to change into a more immature cell, called a
chondroblast, which was capable of cell proliferation, growth, and
healing. This key fact is vital to understanding the power of
Prolotherapy
in proliferating cartilage regrowth.
The Role of Prolotherapy in Cartilage Growth
Prolotherapy involves the injection of substances, such as hypertonic
dextrose,
sodium morrhuate (extract of cod liver oil), various minerals,
Sarapin (extract of the pitcher plant), and various other substances
including
Growth
Hormone, which act by
stimulating the structures to repair. (The actual substances injected
depend on the individual case and the physician.) The current theory of
cartilage regeneration is that this irritation acts in the same
mechanism as above in inducing the chondrocytes into the chondroblastic
stage of development capable of proliferation and repair. The numerous
patients, who had no cartilage or were set for hip/knee replacements who
never needed them because of Prolotherapy, support this fact.
Can It Be Proven That Prolotherapy
Regenerates Knee Cartilage?
It is impossible to do a double-blind study on Prolotherapy because even
an injection of sterile water under the skin has a beneficial
therapeutic effect. Even if no injection was given on one side, as the
control, sticking a needle into a painful area is known to have a
beneficial effect (this treatment is called
acupuncture). It is very
difficult to prove using a traditional scientific model, that
Prolotherapy cures
chronic pain,
sports injuries, and regenerates cartilage tissue.
One doctor trying to validate the
treatment of Prolotherapy is
K. Dean
Reeves, M.D., Physical Medicine and Rehabilitation Specialist, in
private practice in Kansas City, Kansas. He has just completed three
double-blind studies on using 10 percent dextrose versus water
injections on finger/thumb arthritis, knee arthritis, and anterior
cruciate ligament injured knees. Injections were given every two months
of dextrose or water. After three injections, all patients were given
the dextrose proliferant for three more injections. In the knee studies,
only one intra-articular (inside the joint) injection was given per knee
at each session. As of this writing, the
x-rays readings at one year had
just been completed. In the finger/thumb arthritis study there was a 53
percent improvement in pain, and eight degrees of improvement in
flexibility. In the knee arthritis study there was a 44 percent
improvement in pain, 63 percent improvement in swelling, and a 14-degree
improvement in flexibility. There was an 85 percent reduction in knee
buckling episodes. The loss of cartilage not seen on x-rays by one year
and bone spur measurements showed improvement. Of interest was the fact
that those without cartilage did nearly as well. In the knee laxity
(ACL) study, pain improved 27.5 percent, swelling by 51 percent, and
knee buckling episodes by 54 percent. X-ray studies at one year showed
improvement in two measures of bone spur and near-significant
improvements in thickness of cartilage in the knee. One should remember
that this study involved just one knee injection per session and
articular cartilage growth was seen. Typically in actual practice, a
person with laxity in the
knee ligaments may get 20 injections per visit. Dr. Reeves
summarized the findings as "...these double-blind studies with objective
and measurable endpoints all show that simple injection of arthritic
fingers or knees, or knees with ACL laxity, with non-inflammatory levels
of osmotic stimulants can bring about favorable responses in pain,
flexibility, and x-ray findings."
Cartilage Regeneration with Human Growth Hormone
Despite the majority of Orthopedic Surgeons doubting that cartilage can
be regenerated, one physician in their own ranks has shown that
cartilage growth is possible. Alan Dunn, M.D., is an orthopedist in
private practice in North Miama, Florida, who has been studying
cartilage regeneration for 30 years. His innovative approach involves
the injection of
Human Growth Hormone into the deteriorated joint. He
reports, "In the rabbit studies that I conducted, just one injection
grew back the whole patello-femoral surface of the knee in five to six
weeks. These studies were biopsy confirmed."
He is currently conducting a study on
human knees using monthly Human Growth Hormone (HGH) injections into
knee joints with cartilage deterioration. Dr. Dunn says, "Over half of
the knees show major cartilage growth, and most of the rest have a good
result. The most amazing findings have been the near-complete relief of
pain in these degenerated knees." Dr. Dunn has been giving a total of
three HGH injections into the knees at monthly intervals.
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