This week a patient came in who was a lifelong martial arts expert. His right knee had been hurting for several months and was limiting his ability to do what he loved, so he went to an orthopedic surgeon. The surgeon didn’t order an MRI, but an x-ray. This is becoming increasingly common in our world of medical cost containment under the ACA. The x-ray showed some narrowing of the inside of the joint, but of course was incapable of looking at structures like the meniscus or cartilage. Based on a cursory exam and the x-ray he was diagnosed with a probable meniscus tear and scheduled for surgery. A friend who knew that the planned knee meniscus surgery was no better than placebo or physical therapy told him to see us.
I want to digress a moment here. If the patient had been sent to any one of the magic stem cell clinics popping up all over the country right now that will treat your wrinkles, knee, erectile dysfunction, MS, ALS, or any other alphabet soup disease you may have, the patient would have gotten an injection of fat stem cells into the joint without much additional work-up. This wouldn’t have included any attempt to inject the cells into specific damaged parts of the joint (like the meniscus) nor would guidance have been used (i.e. a “blind” injection), so the likelihood that the stem cells would end up outside the joint all together would be about 20-40%.
Without an MRI, I was able to see under ultrasound that the front/inside meniscus had a cyst and was torn and the back/inside part was degenerated. Again, to digress, if the surgeon had operated, these tears would have been seen under arthroscopy and the torn bits of the meniscus removed, leaving him with less protection for the joint. Based on the research, the removal of these torn bits of meniscus would likely lead to more arthritis down the road.
I then noticed something odd on his exam as I used ultrasound to see inside the joint as I moved it around. His ACL ligament was slightly loose, certainly not enough for a surgeon to believe that it needed to be replaced, but when I rotated his tibia on his femur and looked at the meniscus, the damaged tissue freely jumped in and out of the joint, traumatizing it with each move. On further exam, his ALL ligament was also lax, likely due to years of rotating his tibia on the femur with each kick. Why was this a critical finding to help this patient? Because it explained why the meniscus tears were there in the first place. In addition, without also performing injections into the ACL and ALL ligaments under highly exacting guidance, this patient would never truly recover, as his “surgerized” meniscus would be further injured with each kick.
We are very different in how we approach these problems, so I wanted to walk you through the process of figuring out what’s wrong with a patient and which specific technologies applied to which specific structures will help. If I had been the surgeon, I would have removed parts of his torn meniscus, being oblivious to the instability in the knee that caused the tears. If I had been a doctor at a “schlocky”, cure all, magic stem cell clinic, I wouldn’t have even gotten that far, I would have just tried to blindly place the magic somewhere in the vicinity of the knee joint and would have never been able to inject the meniscus tears or the ACL or ALL ligament under guidance.
The upshot? We are a network of Interventional Orthopedic clinics that seek to use biologic therapies to help patients avoid surgeries that don’t work. However, the expertise needed to diagnose what’s wrong is what our traditional medical care system lacks and is getting rarer by the day in our ACA mandated world. In this gentleman’s case, the more sophisticated approach will take more time, but we believe that in the end it will make the difference between a successful long-term result and either more arthritis through surgery or a gimmick therapy.