May 22, 2003

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Knee1: Dr. Sklar is a partner at New England Orthopedic Surgeons, where he specializes in sports medicine and knee arthroscopy.

Knee1: Welcome to today's discussion with Dr. Kevin Stone.

Knee1: Dr. Kevin Stone is an orthopedic surgeon specializing in sports injuries, particularly those of the knee and shoulder. He is recognized internationally as an authority on cartilage growth, replacement, and repair. He is a founder and chairman of the Stone Foundation for Sports Medicine and Arthritis Research, a leading center for treatment of athletes with joint injuries.

Knee1: From 1988 until 2000, Dr. Stone was a physician for the U.S. Ski Team and the World Professional Ski Tour. He has also been the physician for the U.S. Olympic Training Center, The U.S. Olympic Festival, the International Winter Special Olympics, the Smuin Ballet and other numerous sports and dance organizations.

Knee1: Dr. Stone received an A.B. from Harvard College and an M.D. from the University of North Carolina School of Medicine. He completed his internship in internal medicine at Harvard's Beth Israel Hospital, a general surgery residency year at Stanford University Hospital and orthopedic residency at the combined Orthopedic Residency Program at Harvard.

Knee1: Welcome, Dr. Stone, and thank you for joining us. Users, we welcome your questions!

Knee1: Dr. Stone, why don't we start by having you tell us how you got started in orthopedics?

Dr. Kevin Stone: I injured my knee playing soccer at Harvard tearing my medial meniscus cartilage. I was inspired by the surgeon who operated on me.

LGKeys: Is there anything else along with PT you can do for stiffness and limited range of motion in the knee after total knee replacement? Are there any medications you can take such as muscle relaxer to help eliminate muscle stiffness after surgery.

Dr. Kevin Stone: All PT is not PT. Our form of PT involves a tremendous amount of manual therapy, massage therapy, tissue mobilization, functional exercises and gait training. Each session lasts one hour with at least 30-40 minutes of actual hands on work. This is the most successful way to mobilize a joint. If stiffness is a result of inflammation, we find early use of cortisone and anti-inflammatories to be helpful. Glucosamine is also quite helpful.

judy: Doctor Stone, I've been told there is little that can be done to improve my knee condition. But I'm not ready to give up. I have severe patellofemoral mal-alignment with patellofemoral arthritis and subluxion bilaterally. Twenty years ago, I went through the typical series of surgeries to correct alignment--- lateral releases and tibial tubercle transfers with a few further corrections. Last year tried a microfracture surgery, which did not succeed. Currently gathering second, third, fourth through 20th opinions. Do you have any suggestions or recommendations? Thank you.

Dr. Kevin Stone: I would need to see your films, exam and gait to advise you properly. In general if the biomechanics are still bad then any biologic solution is compromised. At some point joint replacement is better than living with pain.

Lynne: Hi Dr. Stone, I have had several knee surgeries, from release, maquet procedure, clean outs and torn meniscus; also had infection, which is gone now. My problem is that I still having tremendous pain in my knee. I had an MRI, which shows tear of the undersurface involving the body and posterior horn of the medial meniscus, and also sigmal heterogeneity within the cartilage of the lateral compartment and patellar cartilage; also surface irregularity and subchondral edema. There is alot more, but my question is whether or not you think I should get a new knee, or if surgery would correct these problems; I've been battling this for 7 years and tired of being in so much pain

Dr. Kevin Stone: As with the previous answer I would need to examine you and review your films to advise you properly. Each of us views problems with in the knee according to our experience, education and bias. There are certain difficult problems we have had success with by performing cartilage transplantation (meniscus and articular cartilage) that others would not have tried. However there are risks, especially the possibility of making the knee worse. A superb rehabilitation program should precede further surgery whenever possible.

Billyv: What would be the benefits of cutting out the torn portion of the medial meniscus?

Dr. Kevin Stone: Pain relief is usually the reason to do it. Whenever possible we prefer to repair the meniscus cartilage if we can get a stable repair in healthy tissue.

coolmom: I had arthroscopic surgery on my L. knee in June 2002. The Postoperative findings were Grade IV Chondromalacia of the femoral condyle. When the pain did not improve by November 2002, my physician informed me that I would have to live with the pain. The pain continued to get worse, so in February 2003, I consulted another physician, who scoped it again, and found only a few pieces of cartilage. He now suspects that the pain involves nerve compression, and has suggested exploratory peroneal surgery, with probable nerve decompression. My question is: Does this sound reasonable? I thought maybe the pain was due to the cartilage damage, but he said no, because the pain I have is on the outside line of the back of my knee, and the cartilage damage is on the INSIDE part of the femoral condyle. Thank you for addressing this question.

Dr. Kevin Stone: Nerve compromise can usually be proven by a nerve conduction study performed by a neurologist. Pain from a cartilage lesion can usually be proven by an MRI with STIR or fat suppression sequences.

Lynne: When there is a tear in the undersurface involving the body and posterior horn of the medial meniscus, does that require surgery?

Dr. Kevin Stone: Usually it does and often it can be repaired if the tissue is healthy. Leaving these tears alone usually results in symptoms of pain or swelling and leads to further tearing (making a repairable meniscus un-repairable.)

vhib: Why is it so difficult to straighten the knee after ACL reconstruction? I had surgery 7 months ago and still have to work hard to get the knee as straight as the other. I also feel some pain in the joint near the screw. Is this scar tissue?

Dr. Kevin Stone: Failure to gain full motion can be due to ligament position, tension, scar tissue formation, or failure of rehabilitation. We believe it is crucial to obtain full motion, equal to the opposite normal side, and that all efforts to do so should be pursued.

judy: Thank you Dr. Stone. I understand my knee condition is too complex to address online. Generally speaking, would patellofemoral alignment issues be correctable, or improved, along with total knee arthroplasty?

Dr. Kevin Stone: Yes they often can be. One must be sure that the symptoms are actually coming from the mal-alignment and not from a treatable cartilage lesion.

almayor: I have gone through 3 surgeries for my torn ligaments (ACL,PCL,MCL). My last surgery was last Dec. and every now and then, I get a pain right on my shin. Is this normal? I have never experienced this pain from the previous surgeries. How long do you think recovery is from this? I still walk with a limp and my leg is still swollen...

Dr. Kevin Stone: Limping and swelling must be addressed first with good rehabilitation, soft tissue massage, and functional exercises before full recovery can take place. Continued pain and swelling is cause for concern and should be evaluated by your surgeon.

Knee1: Dr. Stone, a lot of our users ask about the side effects of knee replacement, both positive and negative. Do you have any comments regarding this?

Dr. Kevin Stone: Artificial Knee replacement can be a great benefit to people with severe arthritis in all three compartments of the knee. People can return to many sports after the procedure including skiing, hiking, bicycling, etc. usually without pain. However the range of motion is usually not normal and the lifespan of the joint varies. Whenever possible we try a biologic joint replacement first (treating the cartilage, replacing the meniscus if necessary, etc) or perform a unicondylar joint replacement. These procedures generally lead to a more normal feeling knee and permit a greater activity level. More specific information about them is found at www.stoneclinic.com

Lynne: Also, Dr. Stone, my medial and lateral patellar plica are quite large; what is to be done about that? Thank you for your help.

Dr. Kevin Stone: If they are painful then sometimes soft tissue massage can reduce the symptoms, sometimes a cortisone injection can shrink the tissue, or lastly arthroscopic excision can remove them.

Jon Jarvis: What is your estimate for when we will be able to grow hyaline cartilage or produce a satisfactory biocompatible material for meniscal replacements? I'm living with knee pain and don't want to go the route of a couple of TKR's.

Dr. Kevin Stone: We have performed about 80 meniscal cartilage transplantations in arthritic knees and about 180 articular cartilage paste graftings. The articular cartilage grows a repair tissue that functions fairly well over the last 12 years that we have been doing them, returning many of the patients to sports. Normal cartilage regeneration is still a ways off but there is no reason to live with pain and wait for it.

Vic: Is it worth going in for Knee replacement for my mother who is 63 yrs old and is in good health otherwise? Problem is strictly w/ knee joints, creating walking problems and standing in one position for more then 5 mins. at a time.

Dr. Kevin Stone: Only if she needs it. Many people with these complaints have arthritis in only one part of the knee that can be treated with an arthroscopic procedure or a partial (unicompartmental) knee replacement.

Lynne: Dr. Stone, could you explain degenerative geodes identified below the tibial spines with tibial spurring?

Dr. Kevin Stone: Bone formation that is usually benign and only require treatment if they are in the joint. Spurring is reflective of an arthritic process.

juliekane: I had a patella tendon transfer in the summer of 1999. Now when I put in a good walk I get pain on the outside and below the knee. Sometimes I get tightness on the outside of my shin. Are there any stretches or any type of relief I could try???

Dr. Kevin Stone: Yes. First start with soft tissue massage to this area. If done well the massage can stretch the tight fascia and muscle tissues. A good PT can examine your gait and determine if improvements in gait, footwear, orthotics etc might help. Glucosamine also helps.

EBishop@chillc.com: Hi, My Doctor is going to perform the OATS procedure to repair a patellar lesion, but will be using a new "machine" to aid in the drilling of the plugs. Have you heard of this?

Dr. Kevin Stone: I have not seen any successful results from OATS procedures performed on the patella. Would carefully explore with your doctor his results and follow his rehabilitation program.

tdenk312@comcast.net: I have had 3 arthroscopies and I am 7 months post and have returned to a 7-9 pain level. After further x-rays it was determined that a osteotomy was next in my cards. I feel uncomfortable with this somewhat radical surgery at 42 yrs old. I currently am very confused and depressed. Any suggestions?

Dr. Kevin Stone: Need to see your films and arthroscopy pictures to advise you properly. As always, optimize your rehabilitation program before surgery.

kkw0614: I had a Fulkerson osteotomy in January. My Dr's PA-C Said I could have my left one done sometime this summer. The problem is that I am in so much pain now. I have tried Tylenol Arthritis. Is there anything you can suggest? I am 28yrs old with OA of both knees. Before the surgery I tried an anti-inflammatory and cortisone shot. They are skipping this in my left knee because it didn't work on my right one. My psychiatrist doesn't want me on pain meds. Please help! Thank you.

Dr. Kevin Stone: As you can tell from many of the questions, patella femoral problems are very difficult without great solutions sometimes. If the procedure hasn't worked on one side I would not perform it on the other.

Knee1: It's just about time to wrap up. Users, thank you for your questions, and Dr. Stone, thank you for your time!

Knee1: Stay tuned for future Knee1 discussions and thank you for joining us today!