A discussion the surgical continuum for big toe joint arthritis.
Some injuries and conditions of the foot and ankle do not respond to our common treatment measures. Some of our most common treatments include custom foot orthotics, soft tissue massage to release tightness, physical therapy and cortisone injections. If these methods fail and we are trying to avoid surgery, we will often recommend a group of treatments that fall into the category called “regenerative medicine”. Regenerative medicine is a group of interventions that augment healing in your body in a way that your body can be more effective or more efficient in healing. Some patients will be recommended these regenerative medicine therapies on initial visit with us based on previous treatment history, type of injury or their level of activity. I frequently recommend regenerative medicine techniques for my high level athletes who need to be healed immediately.
As a homeowner with a lawn, I find many parallels between a healthy body and healthy lawn. Both require water and the correct nutrients, both don’t like when there are bugs that infect them, both can be injured and both have ways of fixing injuries. For this analogy, we’re going to compare a dead patch of lawn to an injury like achilles tendonitis. In some cases, a dead patch of lawn can be caused by too many people walking on it (an “overuse injury”) just like some achilles tendonitis injuries can be caused by too much running or walking. In a perfectly healthy lawn, the neighboring grass plants will help restore the dead patch of grass by gradually filling in the dead spot to “heal it”. A healthy lawn should be able to do this. A lawn that is stressed by lack of water or certain nutrients may not be able to fill in the dead spot. For an achilles injury, a normal person should be able to heal with physical therapy, rest and some of our other standard treatments like foam rolling.
But what happens if the lawn can’t fill it in/what happens if the injury lingers or is particularly severe?
This is where regenerative medicine comes in. We’ll discuss 3 regenerative medicine options and how they compare, rather loosely, to how a lawn can be repaired. Keep in mind, I’m a foot surgeon not a landscape architect. DO NOT take lawn care advice from me.
Shockwave Therapy (aka Extracorporeal Shockwave therapy [ESWT]/Extracorporeal Pulse Activation Technology [EPAT])- If the dead patch of lawn has healthy nearby plants, sometimes we can stimulate those healthy plants to fill in. We get them to work a little harder and they’ll take care of it. You can do that with some extra watering, raking up the dead patch, aerating. These are techniques you do locally/directly to the dead patch but they recruit the healthy lawn to fix it. Similarly, shockwave therapy is applied locally and recruits the healthy tissues to fix an injury. I’ve written about shockwave before (Check that out here.) but it is basically a handheld jackhammer that stimulates a localized immune response from your body to heal an injury. It can be used on both chronic and acute injuries. It increases the correct type of inflammation to trigger the normal healing response chain of events and it also increases blood flow to the injured tissue. But just like the local treatments for a lawn, it requires a generally healthy environment to do its job. Sometimes shockwave won’t work as well as we want because the injury is so severe (too big of a dead patch), the injury is too old (the local environment is not conducive for a healthy lawn anymore), the patient isn’t healthy enough (the lawn doesn’t have the right water, nutrients or sunlight). In the realm of regenerative medicine, it is fairly cheap. We will use the Google style cost rating of $.
Platelet Rich Plasma therapy (aka PRP)- Another way to address a dead patch in your lawn is to transplant a patch of healthy grass from somewhere else onto the dead spot. Primarily, this assumes that there is good grass somewhere in your lawn. It also assumes that the dead spot can be prepared well enough to accept the new grass. It still also needs the correct nutrients and sunlight. Lastly, it needs to be placed in the correct location. Otherwise it won’t work well. With PRP, we draw some of your blood, spin it through a centrifuge to separate the different types of cells, then inject those cells that are best for healing directly into your injury under ultrasound guidance. It’s basically a “good cells” transplant into the injury. The same issues affect this as a “good grass” transplant; you need to have those good cells somewhere, we need to draw them in your blood, the injury has to be ready to accept those new cells and they need to be placed in the correct spot. There is probably a role for PRP, however, the scientific literature is very unclear about how well it works. This is probably partially due to few doctors using ultrasound (they don’t transplant it into the injured tissue/putting the patch of new grass in the wrong spot) and that there are MANY different companies and protocols (which type of cells do you want to inject/picking the best patch of grass to transplant). Lastly, and this is my own personal opinion, is that shockwave uses inherent pathways in your body that have developed over 100,000’s of years and are similar across almost all vertebrates. If you have the right stuff, shockwave should be able to trigger it. My ego is not so big as to think that I am better at getting those cells to the injury than evolution. Google rating of $$
Amniotic Tissue Injections (aka Amnio)- The last way to fix that dead spot in your lawn is to do everything with the top notch seeds, fertilizer and local treatment. Some of the grass seeds out now are designed for areas that get barely any sunlight or water. Also imagine taking the best bag of Miracle Gro ®, getting an irrigation system installed and using the best designer grass seed available. Now imagine planting those seeds one by one in the best possible pattern to allow them to grow where the dead grass is, rather than dropping them from 5 feet up in the air. Amniotic tissue injections are derived from placental tissue from screened donors. They contain large quantities of the materials that help with healing (growth factors, interleukins, collagen, etc). This is the medical equivalent to the perfectly engineered fertilizer. We take this high quality material and inject it directly into the injury with ultrasound guidance for precision. As an aside, performing amniotic tissue injections without ultrasound guidance can cause you to miss the injured tissue all together (picture shaking the grass seeds from on top of a ladder, rather than placing them right at the surface). If, for whatever reason, your body does not have the right materials to heal an injury, sometimes it is best to supplement your healing with precise injection of these materials directly into the injury that we can identify on ultrasound examination. Google rating of $$$-$$$$
Regenerative medicine is an evolving field. While the science at times is confusing, the use of ultrasound for guidance has been shown to increase the precision of the application and should improve the overall result as those precious materials are applied to the most injured tissue. If a person is young and healthy, they may have the ability to heal with the materials that are circulating in their body. We can call those materials to an injury with shockwave, or directly inject those materials with PRP. With age, those necessary materials for healing diminish. If the materials just aren’t there, we sometimes will use that Miracle Gro ® for healing that is amniotic tissue allograft injections. I tend to recommend a step-wise approach to these, starting first with shockwave since it is very effective and pretty cheap. In my practice, I tend to bypass PRP and go straight to amniotic tissue, but both have their role. Oftentimes, I will do amniotic tissue injections AND shockwave concurrently. While using these does not guarantee an injury will heal, it really does improve your chances on a cellular level. For some injuries, surgery is necessary and may be a shorter path to healing. I have had conversations in both directions; recommending surgery instead of regenerative medicine and vice versa. Ultimately, our role as physicians is to provide all of the information and allow our patients to choose their path.
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