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Platelet Rich Plasma Prolotherapy as First-Line Treatment for Meniscal Pathology, July 2010

Platelet Rich Plasma Prolotherapy as First-Line Treatment for Meniscal Pathology, July 2010

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53
Practical PAIN MANAGEMENT, July/August 2010
©PPM Communications, Inc. This copy is for personal use only. Do not reproduce, digitally transmit or post without permission.
nee injuries are a common con-cern resulting in over one millionsurgeries performed on the kneein the United States every year, includingthe meniscus.
1-3
There are an estimated650,000 arthroscopic meniscal proce-dures, with a total number of 850,000meniscal surgeries performed in the Unit-ed States every year.
1-3
Unfortunately, jointinstability is a common result of meniscalprocedures, which is not surprising con-sidering that the meniscus is a primarystabilizing component of the knee. Oneof the principle reasons for meniscal op-erations is to improve joint stability, yetmeniscectomy often appears to have theopposite effect, eliciting even more insta-bility, crepitation, and degeneration thanthe injury itself produced prior to opera-tion. This is why reoperation rates aftermeniscectomy can be as high as 29% toimprove the joint instability that themeniscectomy caused.
4-6
For this reason, itis desirable to look for non-operative in-terventions whenever possible. Plateletrich plasma prolotherapy offers hope inthis direction.
Meniscus Anatomy and Function
There has been a great deal of specula-tion and research dedicated to what exactfunction the meniscus serves, but todaythere is general consensus that the menis-ci provide stability in the joint, nutritionand lubrication to articular cartilage, andshock absorption during movement.
7-11
The menisci (plural of meniscus) are apair of C-shaped fibrocartilages which liebetween the femur and tibia in each knee,extending peripherally along each medi-al and lateral aspect of the knee (see Fig-ure 1). The anatomy of both menisci is es-sentially the same, with the only excep-tion being that the medial meniscus isslightly more circular than its hemispher-ical lateral counterpart. Each meniscushas a flat underside to match the smoothtop of the tibial surface, and a concave su-perior shape to provide congruency withthe convex femoral condyle. Anterior andposterior horns from each meniscus thenattach to the tibia to hold them in place.
Stability
Several ligaments work together with themenisci to prevent overextension of anymotion. Hypermobility is avoided throughligamentous connections—both mediallyand laterally. Medially, the medial collat-eral ligament (
MCL
) is strongly connect-ed to the medial meniscus, as well as themedial tibial condyle and femoralcondyle. Laterally, the lateral collateralligament (LCL) attaches to the lateralfemoral epicondyle and the head of thefibula. These ligaments provide tensionand limit motion during full flexion andextension, respectively. The anterior andposterior meniscofemoral ligaments forman attachment between the lateral menis-cus and the femur and remain taut dur-ing complete flexion. Lastly, the anteriorcruciate ligament (ACL) and posteriorcruciate ligament (PCL) are responsiblefor preventing too much backward or for- ward motion of the tibia.
9,10
Prolotherapy
Platelet Rich Plasma Prolotherapy as First-LineTreatment for Meniscal Pathology
Animal research together with five patient case reports demonstrate that Platelet RichPlasma Prolotherapy (PRPP) is effective in the treatment of MRI-documented meniscal tears.
Donna Alderman, DO
By Ross A. Hauser, MD; Hilary J. Phillips; and Havil Maddela
Meniscus injuries are a common cause of knee pain, accounting for a large number of surgeries in the U.S. annually. While sur- gical treatments range from total to partial meniscectomy, meniscal repair and even meniscus transplantation, all have a highlong-term failure rate with the recurrence of symptoms. The most serious of the long-term post-surgical consequences is an acceleration of joint degeneration. The poor healing potential of meniscus tears, along with the consequence of post-surgical  joint degeneration, has led to the investigation of methods to stimulate non-surgical, biological meniscal repair. While platelet  rich plasma prolotherapy (PRPP) has been studied for many types of connective tissue injuries, no study has focused specifical-ly on its use for meniscus tears. Hauser et al give a very comprehensive review of the anatomy and pathophysiology of menis-cus tears, with five case reports of MRI-documented meniscus tears successfully treated with PRPP. While further study under  more controlled circumstances is needed, the logic of the authors’ discussion and the results reported clearly validate the useof platelet rich plasma prolotherapy as a first-line treatment for meniscus tears. — Donna Alderman, DOProlotherapy Department Head 
F
IGURE
1.
 Anterior aspect of the right knee.
 
Prolotherapy
54
Practical PAIN MANAGEMENT, July/August 2010
©PPM Communications, Inc. This copy is for personal use only. Do not reproduce, digitally transmit or post without permission.
Shock Absorption
The menisci also provide shock absorp-tion and stability by equally distributing weight across the joint. By acting as a spac-er between the femur and tibia, the menis-cus eliminates any direct contact betweenthe bones thus preventing any contact wear.
12
It is estimated that 45% to 70% of the weight-bearing load is transmittedthrough the menisci in a completely in-tact joint.
7
By channeling the majority of this weight evenly, the meniscus is able toavoid placing too much direct stress at anyone point of the knee. In turn, proper weight transmission in the knee reducesstress on any other joints in the body af-fected by load bearing.
11
Lubrication and Nutrition
One of the most vital roles of the menis-cus is to provide lubrication to the knee, which it accomplishes through diffusingsynovial fluid across the joint. Synovialfluid provides nutrition and acts as a pro-tective measure for articular cartilages inthe knee.
13
The femoral condyle in theknee is covered in a thin layer of articu-lar cartilage, which serves to reduce mo-tional friction and to withstand weightbearing. This cartilage is very susceptibleto injury—both because of its lack of prox-imity to blood supply and the high levelof stress placed on it by excessive mo-tion.
14,15
The meniscus, therefore, is ableto provide a much-needed source of nu-trition to the femoral and tibial articularcartilage by spreading fluid to that avas-cular area.
Injury
Meniscal damage can be caused by eithertrauma or gradual degeneration. Trau-matic injury is most often a result of atwisting motion in the knee or the mo-tion of rising from a squatting position,both of which place particular strain andpressure on the meniscus. Tears are themost common form of meniscal injuryand are generally classified by appear-ance into four categories: longitudal tears(also referred to as bucket handle tears),radial tears, horizontal tears, and obliquetears
16
(see Figure 2). Research indicatesthat radial or horizontal tears are morelikely to occur in the elderly population while younger patients have a higher in-cidence of longitudal tears.
17-19
Each canbe further described as partial thicknesstears or complete thickness tears, de-pending on the vertical depth of the tear(see Figure 3).
Limited Blood Supply
 An ability to preserve the meniscus, un-fortunately, is somewhat hampered by thefact that only a very small percentage(10% to 25% peripherally) of the menis-cus receives direct blood supply.
20
Thisarea is often referred to as the red zone,and the inner portion of the meniscus which does not receive blood supply is re-ferred to as the white zone (see Figure 4). While the red zone has a moderate chanceof healing from injury, the white zone isalmost completely incapable of healing it-self in the event of injury.
21
More often than not, traumatic injuriesoccur during athletic activity (see Figure5). The ratio of degenerative to traumat-ic tears increases from equal incidence inthose under 20 years of age to a ratio of 7:8 in the 30 to 39 age group and to near-ly 4:1 in individuals over the age of 40.
22
This pattern of increased degenerative
F
IGURE
2.
Common types of meniscal tears.
F
IGURE
3.
 Depths of tears in the meniscus.
F
IGURE
4.
Superior aspect of right knee showing red and white zones.
 
Prolotherapy
55
Practical PAIN MANAGEMENT, July/August 2010
©PPM Communications, Inc. This copy is for personal use only. Do not reproduce, digitally transmit or post without permission.
breakdown is to be expected with age, as joint wear will result from years of me-chanical stress. Unlike the anatomy of  younger and more active patients, howev-er, the fibers in older patients are less ca-pable of healing themselves due to de-creased diffusion of synovial fluid as a re-sult of lessened motion.
23
Symptoms of Meniscal Tears
 A basic ability to identify meniscal tearsymptoms is essential for diagnosis andtreatment of injury (see Table 1). The firstsymptom typically indicative of a menis-cal tear is pain. In the case of a traumat-ic tear, pain may present immediately atthe time of injury and is often accompa-nied by an audible pop. In a degenerativetear, the onset of pain may be more grad-ual, with no definite moment of injury. Inboth cases, pain may be accompanied byswelling and subsequent limitation inrange of motion. Another hallmark of meniscal tears is clicking, popping, orlocking in the knee joint. These symptomsare mostly likely a result of a torn flap of meniscal tissue which catches in the jointduring movement. Instability and weak-ness are also both common symptoms be-cause a damaged meniscus—as well asdamaged ligaments and tendons—in-hibits normal mechanical function.The severity of initiating trauma, as wellas the nature and characteristics of thetear, plays an important role in the menis-cus’ ability to heal (see Table 2). Tears thatare shorter, partial thickness, and locatedin the vascular red zone have a much bet-ter chance of healing than extensive, com-plete thickness tears located in the whitezone.
24,25
 When other cartilages and liga-ments are injured in the knee, they canhave a detrimental effect on the menis-cus’ ability to heal on its own. Because of the interdependence of each of the knee’smechanisms, meniscal injuries oftenoccur in conjunction with other internalligament damage. The most common ex-ample of this is O’Donoghue’s “unhappytriad,” the correlated injury of the menis-cus (debatably either medial or lateral),tibial collateral ligament, and ACL.
26-28
The severity of meniscal lesions has beenfound to increase in direct proportion to ACL injury and/or laxity and create lessfavorable conditions for repair.
29
Further-more, previous injury to either the menis-cus or any other ligament inside the kneecan increase the risk of future injury to themeniscus, even if the injury has healed orbeen surgically repaired.
Discoid Meniscus Condition
 Another condition which can be both acause and complication of meniscal tearsis a discoid meniscus (see Figure 6). A dis-coid meniscus occurs when the lateralmeniscus takes on the shape of a discrather than a crescent and is most oftenmanifested in adolescence.
30
 Although thecause has never been officially deter-mined, the repercussions of a discoidmeniscus have been widely documented.Often referred to as “snapping knee syn-drome,” this condition is identified with itsonly symptom: snapping on extension.The “snap” is caused when the femur andthe meniscus are not able to move in sync with each other and the femur either slipsover a ridge in the meniscus or off themeniscus altogether.
31
Unlike the normalmeniscus, which is shaped to fit thecondyle of the femur, a discoid meniscuslacks the configuration to serve as a stablesurface for motion. This abnormal track-ing adds stress to the meniscus, increasingthe probability of lateral meniscus tears.
32
Unfortunately, discoid menisci often re-main undetected when no symptoms pres-ent prior to injury, and the only other wayto identify a discoid meniscus is by mag-netic resonance imaging (MRI).
Imaging
For decades, MRI has been used as a pri-mary determinant for meniscal injuries butthe fact that it is more sensitive to some tis-sues than others, however, can prevent itfrom producing a completely accurate pic-ture of an injured area. This can cause in-
F
IGURE
5.
 A hit on the knee causing a medial collateral ligament injury. If the hit is severeenough, the supporting ligaments of the knee could also be torn. (Used with permission from Hauser, R. Prolo Your Sports Injuries Away, Beulah Land Press, Oak Park, Ill. 2001)
F
IGURE
7.
 False-positive MRIs of the knee inteenagers. Because significant abnormalities show up in the menisci on MRI in teenagers,when no true injury exists, relying on this modality to make a diagnosis is a scary propo- sition, especially if surgery is contemplated.(Used with permission of Beulah Land Press, 2001, Oak Park, Il. “Prolo Your Sports Injuries Away!” fig. 16-10.)
F
IGURE
6.
 Discoid meniscus of right knee.

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