Microfractures Revisited

This post that I wrote comparing whether to get a microfracture or ACI (autologous chondrocyte implantation) got a lot of reads. Perhaps surprisingly, I came down on the side of the traditional microfracture procedure. I partly based that on this study, which said that functional outcomes between microfracture and ACI patients were found to be about the same

I also happened to mention that, in support of microfracture, it’s the less extensive surgery that the NBA pros -- who could afford any kind of procedure -- choose. 

So recently, along comes this article featuring the NBA’s Greg Oden, a superstar talent felled at a young age by a pair of bad knees, that claims that doctors are moving away from microfracture to fix cartilage defects in NBA players. Among the alternatives, besides ACI: OATS (osteochondral autograft transfer, for small tears), platelet-rich plasma therapy and the Orthokine procedures that Kobe Bryant popularized that are similar to platelet-rich plasma therapy.

It’s certainly true that one or even all of these treatments may be superior to the old-fashioned microfracture, but a few points:

* The knees of NBA players take an epic amount of abuse. It’s important to appreciate that from the outset. It’s not just the jumping and running, but also the diving for loose balls, colliding with opponents in the normal course of play, making quick shifts in direction, etc.

* With that in mind, when someone writes, “the history of microfracture, especially among NBA players, has been dotted with success stories ... and failures,” I wouldn’t take that as necessarily an indictment. I’d be surprised if any knee operation ever had a 100 percent success rate, or even close to it, for such a subject population: too-tall men who bang their knees really hard every two or three days.

* The article tells us the problem is that the microfracture process (in which holes are drilled in bone, which creates bleeding that results in a new layer of cartilage) leads to rubbery fibrocartilage, not the good sort of hyaline articular cartilage. True, but interestingly enough, that fibrocartilage after a while can begin to take on characteristics of normal cartilage. In a study published in Arthroscopy in April 2006, researchers who took biopsies to inspect the cartilage that was formed after a microfracture observed that "this healed tissue is a combination, or hybrid, of fibrocartilage and hyaline-like cartilage."

So is fibrocartilage more of an intermediary state on the way to some form of cartilage that, if not normal, is at least much more normal in function and characteristics? Or what does fibrous cartilage created by a microfracture look like after 20 years, in a well-cared-for knee?

I don’t know. But I suspect that the answer may surprise some people who are critical of the procedure.

A Plea for “Real” Knee Exercise Models

Are you also tired of seeing models that look like this demonstrating the proper exercises to rehabilitate your bad knees? (The headline for this article: Knee Pain? Start Doing These Exercises ASAP)

And of course demonstrating “these exercises” are a number of women who are very toned, with pleasant faces, wearing that kind of tight-fitting workout clothing that you don’t put on (if you’re smart) unless you have sub 6 percent body fat.

What do you think is the chance that the models shown here are actually battling the kind of chronic knee pain that causes them to dissolve into tears and wonder if their lives will ever be normal again?

Yup, I’d say one in a million sounds about right.

So I’d like to advocate for “real” knee exercise models. Models we can believe in. Models we can look at and silently cheer, “Yes, you can beat this thing, hang in there!”

Instead we get these cheery fitness freaks whose barely suppressed smiles seem to be saying, “God, if you only knew how pathetically easy this exercise is for me!”

You’ll see there are a lot of recommendations here, a full page. And all of the “knee pain” models handle the exercises with ease. But if you’ve got delicate knees and bad pain, I wouldn’t recommend doing a number of these unless you want to wind up with even worse pain.

The Drumbeat of Studies Disparaging Glucosamine Keeps Getting Louder

I know, I know, I’ve written A LOT about the (probable) uselessness of glucosamine (unless you’re susceptible to the placebo effect)

Then along comes yet a new study slamming the supplement. The L.A. Times did a nice write-up here.

Below are the three most interesting things about the study, in my opinion. But first the study, in bare bones form, looked like this:

The 201 subjects were 35 to 65 years old and complained of knee pain. For six months, about half of them consumed a daily lemonade drink that contained glucosamine hydrochloride (which the study’s lead author notes doesn’t differ pharmacologically from the more common glucosamine sulfate). The others drank the lemonade but without the added glucosamine.

Drinking glucosamine-laced lemonade “failed to prevent deterioration of knee cartilage, reduce bone bruises or ease knee pain.”

Now on to my personal “three most interesting things.”

#1 "Roughly 10% of the U.S. population uses the supplement, study authors said."

Did not see that one coming. The U.S. population is, what, 310 million? So about 31 million people take glucosamine.

Hey, that gives me an idea. :) This is directed to those 31 million people spending $10 monthly on glucosamine pills:

You all need to buy this book, Saving My Knees (link on upper right). It will tell you why you shouldn’t bother taking glucosamine. You’ll recoup the cost of the book in one month and have a net savings of $110 the first year (and I’ll finally be a multi-millionaire, cough, cough).

#2 "The urine was tested for levels of C-terminal cross-linking telopeptide of type II collagen (CTX-II), a molecular marker for cartilage tissue degradation."

This is the first glucosamine study I’m aware of that analyzed urine samples to look at whether cartilage rates of deterioration had slowed. Why does that matter?

Well, it shows that attempts to ascertain whether glucosamine has any salutary effect are getting more sophisticated. And, whatever they look at, they’re still not finding a benefit.

#3 "Study authors said theirs was the first to use MRIs to evaluate glucosamine's effects on cartilage and bone marrow lesions."

So this study is the first, the authors claim, to use MRIs to peek directly at the condition of the cartilage and bone. And, using this more advanced technology, researchers still found no glucosamine-related improvement.

Beware of People Bearing Slick Stories

This happened to me very recently:

I was sitting in a Dunkin’ Donuts, enjoying a guilty pleasure (actually two, both frosting-covered). I had planned to finish my food quickly, when I picked up the frequency of a rather interesting conversation behind me. Two young men were talking -- or actually, one was doing most of the talking. He seemed to be telling a long story in a patient, smooth way. I recognized the patter as a well-practiced sales pitch, so I waited to see what the payoff would be. His listener appeared to be Hispanic, maybe a manual laborer, kind of quiet -- the sort of guy used to taking orders, and maybe not too sharp.

Mr. Salesman was saying how it would be great to work for yourself, then I recall him mentioning how much Elvis and Tupac made last year -- north of $10 million -- and they were dead guys, dead, and his listener kind of chuckled, because the implication was: “Hey, you can make more than a couple of dead guys.” And then the story shifted focus to a couple of men who became successful selling a product that was recession-proof -- soap -- because no matter how poor you are, you’re still going to bathe, right? And his listener had to agree this was true.

The mostly one-sided conversation was ongoing when I left. But I stayed long enough to hear one word that explained where all this was leading: Amway.

Amway, which has been likened to a pyramid scheme, is a multi-level marking system. As I understand it, Amway has a kind of pyramidal structure, where salespeople earn a certain percentage of sales they make, and a fraction of the sales by people who they brought into the selling network, and a fraction of the sales by people those people brought in, and so on. So if you were among the first generation of say five Amway salesmen, who then each brought in five people, each of whom brought in five, each of whom brought in five ... well, you get the idea. All of a sudden you’re making thousands a month (assuming your salespeople are good) without having to lift a finger!

Wow -- it seems. Actually there are a number of problems with this sales model, which I won’t get into, because that’s not the point of this blog.

My point is there are lots of smooth stories out there, promising suspiciously high returns for low investment.

In the world of knee pain, the biggest slick story I would be wary of is that of glucosamine. A pill a day chases the knee pain away! Could it be that simple?

Actually, no, as I’ve noted here, here and here for starters. Glucosamine’s story is appealing -- the supplement supposedly helps rebuild lost cartilage -- but the latest studies are suggesting that it’s a dud.

(Next week: I review the most recent glucosamine-doesn’t-work study.)

So beware slick sales pitches for knee pain relief. Hope is good, but make sure it’s informed hope.