LIGAMENT INJURIES

A ligament is made up of specific fibres, like an elastic rubber band which connects a bone and a cartilage, a bone to a meniscus, a bone to a bone, ligaments are very strong and when a ligament is stretched or torn it is called a sprain.

 LOCATION AND COMMON CAUSES OF LIGAMENT TEAR AND SPRAIN:

Any movement which causes extreme or unnatural turning and twisting can cause the ligament to undergo extreme stress and leads to sprain or a tear. The most common ligaments affected are

Knee:  The main ligaments of knee are anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament and lateral collateral ligament, the ACL is the most commonly injured ligament and the lateral collateral ligament injury treatment involves treating the illio-tibial band along with the ligament.

Ankle:  In ankle the inversion injuries that is ankle bending inwards causes more common injury to the lateral ligament injury complex which includes anterior talofibular (ATFL), calcenofibular and posterior talofibular (PTFL) ligaments. The medial deltoid ligament is lesser common. A high ankle sprain is more common in athletes and involves the distal tibiofibular ligaments

Wrist: The most common ligament injuries in wrist is the triangular fibrocartilage complex (TFCC) and the scapholunate ligament

Shoulder: shoulder joint is kept stable with different ligaments and any dislocation of the joint can cause injuries to these ligaments the common are Superior glenohumeral ligament and inferior glenohumeral ligament, usually using regenerative medicine protocols to tighten these ligament are sufficient to heal them

Along with these ligaments of back illio-lumbar ligament of spine, the interspinous ligament is common to undergo sprain and whiplash injuries causes’ injury to the neck ligaments as well.

Diagnosis and treatment of ligament injuries

Usually clinical examination history and using imaging modalities like real time musculoskeletal examination using ultrasound gives a good picture of the grade of tear and sprain and along with it MRI can be ordered to have even more accurate diagnosis

The grading of sprains/tears are done as follows

Grade 1; mild sprain with some changes in fibre structure but no tear

Grade 2: swelling some fluid collection with partial tear with no joint instability

Grade 3: complete sprain and tear with joint instability

Ligament injury Treatment

For any acute and mild to moderate grade 1 and 2 tears first line of treatment is conservative using RICE approach (REST, ICE, Compression  and elevation) once the swelling has subsided over some days advanced management can be planned  which includes minimally invasive injections.

For mild to moderate ligament injuries (grade 1 and 2 and some times grade 3)  treatment like ACL, lateral collateral ligament injury treatment, TFCC (triangular fibro cartilage of the wrist) and ankle ligament sprain  is done using the best and most advanced treatment modality that is using orthobiologics and regenerative medicine protocol, where under image guidance and with precision specific blood products are injected to the tear site which helps in healing and getting the strength of the ligaments back, this ligament tear treatment using your own cells has advantages of less down time, faster recovery no scar and less complications which are associated with surgery.

Surgery is only required in very complex cases of ligament tear where the ligament has totally torn and no fibre connection is seen on MRI and has retracted more than 5 to 6 mm, even then if you want can avoid surgery unless there is instability in the joint as surgeries come with their own risk and also aggravate arthritis development in longer stages.

Stem Cell Interventions for Knee? Where do we stand!!

These days orthobiologics and regenerative medicine  for musculoskeletal  pain conditions is making a big stride across the western hemisphere and also finding its roots in south Asia, but few questions always crop up how effectively stem cell work for knee? Can they repair knee cartilage? How long they last?

How this idea of injecting same day stem cell (orthobiologics) Come into existence?

Usually patients with moderate to severe knee arthritis are generally offered traditional remedy, mainly surgery if they fail to get better with physiotherapy and basic medicines, In Indian subcontinent option of surgery is given even a bit earlier due to various factors, in western studies approximately 7 lakh knee replacement were completed in 2006 alone in USA and that number was set to rise to 3.5 million annually by 2030 (1)

In India the incidence of Knee OA is around 28-30% for a population of over a billion, which makes it an epidemic if you look at it closely (2)

This is a big surgery, and though very safe due to advances in the techniques, a recent study demonstrated that in many patients the procedure did not work that well as expected (3), the problem was patient selection, younger age who are more in more age active group, plus the understanding that knee pain in OA is more complex than previously considered.

So the idea of knee stem cell came into play almost two decade back, which is less invasive, and pushes back the need for a knee replacement for years together in middle age group and younger till they are more older, and is also helpful in patients who do not want to undergo knee replacement by mitigating their pain for few years.

What do they do?

Lot of claims that it regenerates the knee cartilage, which is of course not right, most of publication is coming from same day BMC (bone marrow concentrate)(4) where, stem cell are obtained from your iliac crest on hip and after same day centrifugation re-injected on same day, it has shown to help small tears, cartilage defects by improving the microenvironment  and a positive view in MRI images (5,6), it helps by changing the chemicals in knee joint, improving your pain, improving the quality of remaining cartilage, avoiding fast progression of the knee arthritis , thus it makes the knee more healthier, so it does not regrow, but helps in improving the general health of knee joint which is more than just bone on bone.

How long does it last?

Studies have shown the beneficial of one time same day Bone marrow stem cell intervention to last anywhere between 2-7 years, depending on your wear and tear your activity level.

Reference:

  1. Kurts S, Ong K, Lau E, Mowat F. Projections of primary and revision hip and knee arthoplasty in United states from 2005 to 2030. J Bone Joint Surg Am. 2007 Apr; 89(4):780-5.
  2. Chandra Prakash Pal, Pulkesh Singh. Epidemiology of Knee Osteoarthritis in India and related factors, Indian Journal of Orthop.2016 Sep;50(5):518-22.
  3. Ferket Bart S, Feldman Zachary, Zhou Jing, Mazumdar Madhu et al. Impact of total knee replacement practice: Cost effectiveness analysis of data from Osteoarthritis Initiative BMJ 2017;356.
  4. Centeno CJ, Jusse D, Kisiday J Karli D. Increased knee cartilage volume in degenerative joint disease using percutaneoulsy implanted, autologous mesenchymal stem cell. Pain Physician.2008 May-Jun;11(3):343-53.

Vangsness Ct Jr, Farr J, Boyd J, Dellareo DT, Mills CR, LeRoux-Williams. Adult Human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial meniscectomy: a randomized, double –blinded, controlled study. J Bone Joint8. Surg

AC JOINT SEPERATION

BASIC OF AC JOINT: IT is a prominent joint which is visibly seen  and made up of urn collar bone (clavicle) and acromion a part of the scapula the shoulder blade bone, it’s a prominence in front of the shoulder when you trace urn collar bone.

What is AC joint separation or shoulder separation.

It is a very frequent injury among athletes , physically active individuals , in this the collar bone (clavicle) separates form the scapula (shoulder blade), cause is due to a fall, a direct impact injury mainly seen in cyclist, runners, football players or contact sports.

There are different types of AC joint separations:

Grade 1 AC joint Separation:  Grade 1 is a mild form of displacement, this is where AC ligament may become partially torn or merely stretched, usually the symptoms are mild pain, tenderness on touch and some difficulty and pain when moving the shoulder, Grade 1 AC joint separation treatment is usually conservative , includes physical therapy along with use guided injections of super concentrated prep into the ligaments, it maintains the integrity of the ligament.

Grade 2 AC joint separation: In this there is partial joint dislocation with the acromioclavicular ligament being torn completely, though the coracoclavicular ligament is still intact, in this the patient may experience moderate to severe pains around the shoulder, some visible swelling  and also the movement of clavicle is more pronounced as the ligament which supports the clavicle acromial joint is torn, Grade 2 AC joint separation treatment is again focused on minimally invasive interventions including using your own concentrated cell therapy with high concentrated PRP, these regenerative medicine protocols and orthobiologics help in preventing further damage, maintains the integrity and with a good physical therapy protocol over time  most of the function is restored and pain is completely under control.

Grade 3 AC joint separation: in this there is complete tear of both the ligaments supporting the AC joint, the acromioclavicular and coracoclavicular are both torn, there is instability and also a visible bump on the shoulder, patients present with severe pain, popping sound, a visible deformity is appreciated in the shoulder region, the person needs support his arm by the elbow and will need a sling to avoid more movement.

The treatment of grade 3 AC joint separation is usually surgery, but with growing evidence pouring in a meta-analysis, researchers found out that a fusion surgery for high grade separation does not make any major significant difference in comparison to the group of other patients which same issues who were not offered any surgery, the group who dihttps://journals.lww.com/jorthotrauma/Abstract/2018/01000/Operative_Versus_Nonoperative_Management_of_Acute.2.aspxd not undergo surgery returned to work faster and had fewer complications too in the long run

So a good approach for treatment of AC joint separation is using a combination of interventions like PRP ( super concentrated platelets) cell therapy and physical therapy which yields better results and is more effective with less down time.

Osteoarthritis in young adults, why is it happening so soon and how to prevent?

Osteoarthritis is a progressive disease of the joints in which the cartilage which cushions the bones and absorbs the shock wears down, causing pain, stiffness and swelling around the knee joint, in over period we see a bone on bone phenomenon.

According to Indian data millions of patients are suffering from OA knee with a prevalence rate of 25 to 35% of which women are more common than men(C p PAL IJO 2016, 10.4103/0019-5413.189608)

Making it one of the most common arthritis in India, though it is age relegated but nearly 18to20% of arthritis is from injury to abjoint or posttraumatic arthritis and this is not only restricted to athletes layman and general public are also not spared the trauma of it which happens due to repetitive stress injury, over weight and genetics.

We need to understand that our knee is just not bone and cartilage but a complex structure formed of ligaments, soft tissue, tendons, nerves and fat and any event which can destabilize or injure any one of the structure can lead to early arthritis in the younger age group the main components which trigger these events are.

A. Injury to the ligaments

B. Injury or damage to the cartilage

C. Meniscal tear or tear of the labrum

D. early arthroscopy procedures in the young adults which increases risk of OA manifold.

Recent paper in Journal of Athletics Training highlights how small injures to the joints can get blown up into full arthritis over the period, eg a small rent in cartilage or meniscus can lead to bone swelling and can in turn put more pressure on the spot leading to multiple rents in cartilage and end up damaging the surrounding ligaments and joint structure, the single biggest issue which we can fix and can prevent early arthritis in knee is instability, which is easily diagnosed on dynamic use scanning and education of few points.

The person suffering from popping sensation and cracking in knee sounds but no pain is a potential arthritic patient in long run and should be evaluated by a regenerative and musculoskeletal physician who understands instability of joints better.

We see a lot of patients with these instability issue and opt for stress mask USG to identify the instability and the loose ligaments, if you had some knee injury in recent times and suffering from such issues we opt for PRP for ligaments to strengthen and tighten the ligaments and cartilage to provide better stability to the joint in order to prevent OA later stages.