Saving My Knees

How to avoid a total knee replacement

Find out if biologic solutions to rebuild your knee

can keep you active and help you avoid a total
knee replacement.
Contents
About The Stone Clinic 03
Meet Dr. Stone 03
Meniscus Transplant Center 03

Why rebuild a knee naturally? 04

Can I avoid total knee replacement? 04
Total knee replacement numbers are increasing 04
It doesn’t have to be this way 04
Small injuries can trigger big problems 05
Decades of pain is unacceptable 05

What is a BioKnee? 05
Articular cartilage regeneration 06
Meniscus repair or replacement 06
Ligament reconstruction 06

Is a BioKnee right for me? 07

Your injury history 07
Your current symptoms 08
Your goals 08
Your approach to recovery 09
Your attitude to treatment 09

If a BioKnee is not right for me,

what are my other options? 10
Partial knee replacement 10
Total knee replacement 10
Conclusion 11

02
About
The Stone Clinic
The Stone Clinic in San Francisco, California is at the We regenerate and rebuild, rather than replace with
forefront of orthopaedic surgery. Headed by world- metals and plastics, using innovative surgical interventions
renowned orthopaedic surgeon, Kevin R. Stone MD, we to preserve as much of the natural biology of the joint as
have spent 30 years pioneering and refining minimally- possible, often rebuilding with donor tissue to give our
invasive, biologic treatments to fulfill our mission of keeping patients natural-feeling, long-lasting outcomes that avoid
athletes active for life. or delay the need for joint replacement.

Every injury is different, every individual unique. We Our world-class physical therapy and rehabilitation team
see osteoarthritis not as an incurable disease but as a is onsite and will be with you every rep of your recovery,
fixable condition, which is why we design comprehensive, managing the pace and quality of your outcome with
customized treatment programs for each patient to stop supervision from the operating surgeon, to ensure you
the pain and return them to full activity. return to sports faster, fitter, and stronger than you were
before your injury.

Meet Dr. Stone The Meniscus

(Guide Author) Transplant Center

Kevin R. Stone, MD an orthopaedic surgeon at The Stone Dr. Stone is one of the world’s leading experts in
Clinic and also the Chairman of the Stone Research meniscus transplantation and a pioneer of biologic
Foundation. He is a pioneer of advanced orthopaedic orthopaedic techniques. For over 30 years, he and his
surgical and rehabilitation techniques to repair, regenerate, team have specialized in giving people back their vital
and replace damaged cartilage and ligaments and a leader meniscus shock absorbers, keeping the knee moving
in outpatient robotic surgery for partial and total knees. naturally and reducing the likelihood of a total knee
replacement.
Dr. Stone lectures around the world as an expert in
cartilage and meniscal growth, replacement, and repair and The Meniscus Transplant Center at The Stone Clinic is
holds over 50 U.S. patents on novel inventions to improve an international destination for meniscus transplantation,
healthcare. dedicated to the diagnosis, surgical implantation, and
rehabilitation of people in need of meniscus tissue.
Dr. Stone uses anabolic therapy and other biologic
techniques to work to preserve the natural biology of a
joint, helping people avoid or delay an artificial joint
replacement.

Learn more about

The Meniscus Transplantation Center

Call for an Appointment (415) 563-3110 Book a Complimentary Phone Consultation 03

Why rebuild a knee naturally?
Can I avoid total knee
replacement?
Total knee replacement numbers are increasing

As Baby Boomers stay active longer and young athletes push

themselves harder than ever, we’re becoming a nation of knee injuries.
We’re hard on our knees and we expect our joints to keep doing the
activities we’ve always done.

Not surprisingly, the past two decades have seen a sharp rise in the
number of total knee replacements performed in the USA. The latest
figures record six hundred thousand surgeries a year, with demand
projected to increase to three million by 2030.

It doesn’t have to be this way

Eighty percent (80%) of people told they need a knee replace-
ment don’t need one. Even when there is bone-on-bone arthritis, KNEE ANATOMY
most of the damage is in one part of the knee, and that part can be
treated, resurfaced, or replaced alone. A partial knee replacement The knee is a remarkable construction. It extends,
flexes, and rotates in a complex, coordinated
preserves more of the knee anatomy and feels more normal than a
fashion. It can bear forces up to five times your
total knee replacement.
bodyweight. It’s the largest joint in your body,
connecting the femur (thighbone), tibia (shinbone),
In cases where the bone is not resting on the bone, there are great
and the patella (kneecap). Four major ligaments
alternatives that can help delay or avoid an artificial knee replacement. attach bone to bone while the tendons attach the
Operative solutions include replacing the meniscus cartilage, paste muscles to the bones.
grafting the damaged articular cartilage, and reconstructing the
ligaments called the BioKnee program. There are two types of cartilage in your knee; the
first is a fibrocartilage called the menisci (there are
Non-operative solutions include injection of bioactive factors, two, the lateral on the outside and the medial on the
growth factors, lubricating hyaluronic acid, often with the addition of inside) which act as shock absorbers (or more
platelet-rich plasma to reduce inflammation and recruit stem-derived accurately force diffusers) between the tibia and the

cells to the site of injury. We have an ongoing research interest and femur. Once torn, or if partially removed, the forces
of walking and running are concentrated in a smaller
clinical program evaluating amniotic fluid as a rich source of active
area on the tibia and thus lead to wearing of the
growth factors that potently reduce inflammation, reduce scarring,
articular cartilage down to the bone.
and may accelerate healing.
The second type of cartilage is articular cartilage,
which covers and protects the ends of your bones
allowing them to move smoothly. The articular
cartilage is five times as slick as ice on ice as long
as it is not injured.

04
 Patient Spotlights
Small injuries can trigger big problems Top athletes are unique people with drive to
recover that inspires all of us. They push
We have learned that if injuries to the meniscus, articular cartilage, boundaries and teach us to reconsider what is
and ligaments are not repaired quickly, lead to arthritis. Joints general- possible.
ly do not wear out, even with extensive running, unless there is an
injury. We believe that it is far better to repair, regenerate, or replace
these injured tissues as soon as they are injured to prevent arthritis, to
reduce the pain, and, hopefully, prevent the progression of arthritis.

Decades of pain is unacceptable

Most patients diagnosed with arthritis are told that it can’t be repaired.
They are told to take pain medication and anti-inflammatory drugs,
lose weight, cut back on their activities, and essentially wait until the Tracy Porter,
arthritis is bad enough to warrant a knee replacement. Although a Super Bowl-winning Football Player
knee replacement can be a godsend after years of agony, they are not
perfect and cannot be easily revised if they fail. Every decade is Treatment: Bioknee - Meniscus transplant
precious and we believe that there is no reason to live in pain when and articular cartilage paste graft
repair options exist. Most patients told they need a total knee
Tracy etched his name in Super Bowl history intercepting
replacement have excellent alternative treatment options such as a a pass from the legendary Peyton Manning and returning
partial knee replacement, a biologic knee replacement, or a it 74-yards for a touchdown–bringing the first-ever Super
combination of anabolic injections plus physical therapy and fitness Bowl trophy to New Orleans.
training
The demands of the sport caught up with Tracy in 2011.
Under the care of another surgeon, Tracy received a

What is a BioKnee? microfracture surgery and a meniscectomy commonly

used in athletes with injured joints. While short-term
results for these techniques often look promising,
A BioKnee is an alternative to an artificial knee replacement. It outcomes often tend to deteriorate over time, ultimately
combines three key procedures that rebuild, regenerate, or biologically leading to bone-on-bone arthritis.

replace the damaged parts of the knee using donor tissues, a

Tracy chose The Stone Clinic to repair his joint in 2017
patient’s own stem cells, and growth factors. This regenerative
after hearing Dr. Stone’s game plan for naturally
approach, harnessing the body’s natural ability to heal itself, is regenerating and rebuilding his knee. After a successful
the new frontier in modern medicine. The BioKnee has various outcome with the BioKnee surgery including meniscus
combinations of meniscus repair with sutures, regeneration with a transplantation and extensive articular cartilage paste
scaffold called a collagen meniscus implant (CMI) or replacement grafting, Tracy dedicated himself to rebuilding his knee
strength and mobility under the guidance of The Stone
with a donor meniscus, articular cartilage paste graft repair, and
Clinic physical therapy team. He is now living pain-free
ligament repair or reconstruction often with donor ligaments.
and performing at an intense level of physical activity not
possible before.
All of these procedures can be performed at one time. Some patients
need all the tissues rebuilt and others are just missing one or two. As
long as there is some joint space available our bias is to rebuild joints
biologically before proceeding to a bionic or artificial implant solution.

Watch Tracy's Story

Call for an Appointment (415) 563-3110 05 Book a Complimentary Phone Consultation

Articular cartilage regeneration

With a BioKnee, we first repair the articular cartilage, the white shiny
surface that covers the ends of the bone. We’ve been doing this for
over 25 years with a technique called Articular Cartilage Paste
Grafting, which promotes the regrowth of cartilage inside the knee.
In a single-step procedure, we take stem cells from your own bone
marrow and mix them with harvested cartilage cells to form a paste.
When the paste is packed into the damaged area of the joint, it is able
Emily S,
to regrow cartilage repair tissue (lab data shows the formation of the
Ironman Triathlete
paste increases the cellular activity of the cartilage cells to ramp up
their healing ability. The cells dramatically increase the production of Treatment: BioKnee - Meniscus transplant
extracellular matrix. Clinical data and multiple biopsies show excellent and articular cartilage paste graft (2010)
repair tissue and improvement in pain and function lasting on average
17 years in over 80% of cases so far.) Emily is an Ironman distance triathlete and a lifetime
ski-racer. Years of activity had destroyed her meniscus
cartilage, and since the injured meniscus had not been
repaired, it also resulted in articular cartilage damage.
Emily had a BioKnee replacement consisting of a
Meniscus repair, regeneration or replacement meniscus transplant and an articular cartilage paste
graft in 2010. Within a year of the surgery, she trained
for and completed her fourth Ironman and did the whole
Another BioKnee procedure repairs, regenerates, or replaces the
race only eight minutes slower than her previous
meniscus, the shock absorber in the knee joint. A damaged or
pre-surgery time.
missing meniscus leads to increased forces across the knee and
causes arthritis. We have developed new techniques to repair the By 2012 Emily also completed two double-century bike
meniscus, bringing in new blood supply to the torn tissue and often rides. Emily says “Dr. Stone’s surgery has been a
adding growth factors, recruiting stem-derived cells, and adding revelation to me, it’s totally enabled me to continue
being who I am which is way more than just the sports
blood clots to augment healing––even in older people.
that I do It’s part of my personality and I’m thrilled.”

When only a portion of the meniscus is missing, we add a collagen We have followed Emily’s progress over the years as
meniscus implant (CMI) (which Dr. Stone invented in 1989) to act as a part of our outcome study on meniscus transplants in
regeneration template for meniscus regrowth. When we can’t repair or athletes. Since her surgery, she has completed 6 Iron
regenerate the meniscus, we replace it with a donor meniscus. We Man races, Heliskies, and skies powder regularly. Her
last Iron Man finish was in September, 2019.
now have over 500 meniscus transplants in patients since 1995.

“This was my fourth IM finish since surgery, bringing

me to 7 finishes. I have also done several half iron
Ligament reconstruction races, half marathons, two double century rides and
enjoyed several ski trips back to my Mecca of
Another BioKnee replacement solution is to fix damaged ligaments in Jackson Hole. At risk of sounding trite, I thank Dr.
order to properly stabilize the knee. We are able to repair, reconstruct, Stone after every good run (skiing AND running). This
ride I've been on is miraculous”
or replace these ligaments often using donor tissue. For people who
have had a failed ACL reconstruction, we often notice that the corners
of the knee joint are loose.

Watch Emily's story

06
Combining posterolateral corner reconstruction with ACL revision
surgery has saved many a loose knee. MCL or LCL ligaments are less
frequently in need of repair or reconstruction; however, the techniques
for doing so have improved dramatically over the last few years.

Is a BioKnee right for me?

We will be able to assess your personal treatment options by taking a
detailed history of your injury and symptoms, examining you carefully, Jen Hudak,
and analyzing your recent (within 1 year) MRIs and x-rays. However, it Professional Skier
may be helpful for you to know what comes into play when deciding
whether a biologic or bionic solution is right for you. Here’s what we Treatment: BioKnee - ACL replacements,
consider: articular cartilage, paste graft, posterolateral
corner repair, meniscus repair
1 Your injury history
In 2009, professional freestyle skier, Jen Hudak,
Damage to the articular cartilage (the soft surface protecting the ends suffered a devastating left knee injury that threatened to
cut short her athletic career. Dr. Stone used an articular
of your bones) or acute tears of either the ligaments (which connect
cartilage stem cell paste graft to repair her articular
the bones) or the meniscus (the knee’s shock absorber) often occurs cartilage and rebuilt the back corner of her knee with a
when the knee is suddenly twisted, the person hears a “pop” and the posterolateral corner reconstruction. Within six months
knee swells. she was back on the slopes winning X-Games Gold in
the superpipe and every major national and
These acute injuries can most commonly be repaired or the tissue international competition the subsequent year.

can be replaced. The patient can then return to full activities after
In a new injury in 2012, Jen ruptured her right knee
appropriate rehabilitation is complete. We have learned that the ACL, tore the posterolateral corner of the knee, the
success rates of primary repair increase when the injury is treated medial meniscus, and damaged the articular cartilage
promptly. on the end of the lateral femoral condyle. Each of these
was repaired by Dr. Stone using the BioKnee
If your knee injury occurred years or even decades ago, and you have techniques of donor ligament reconstruction, paste
grafting, meniscus repair, and posterolateral corner
lived with the pain, or have had multiple previous surgical interventions
reconstruction.
attempting to repair or resect the damaged tissues of the joint, you
may need a more complex BioKnee procedure such as articular In 2013 Jen then re-injured her left knee’s ACL. Dr.
cartilage paste grafting combined with a meniscus allograft Stone reconstructed those ligaments with sterilized
replacement or ligament reconstruction. bone-patellar-bone grafts from a donor, repaired a
new articular cartilage injury with a paste graft, and
performed a complex meniscus reconstruction
2 Your current symptoms successfully returning Jen to full competitive form
the following seasons so well that she competed
A common scenario for our patients is that they injured their knee successfully in 2018 taking third place in The Amazing
playing high school or college sports, had some tissues taken out Race. She bikes, hikes, and skis like a professional
or a ligament reconstructed, and then over the years developed athlete to this day.
progressive knee pain.

Watch Jen's story

Call for an Appointment (415) 563-3110 07 Book a Complimentary Phone Consultation

Their symptoms are often intermittent pain, swelling, giving way or
buckling, achiness after walking, and sometimes limitation of knee
range of motion.

X-rays and MRI’s are particularly helpful to determine whether or not

the damage inside the knee is in one portion of the knee or extensive
throughout the knee. BioKnee procedures such as cartilage
replacements can often be performed as long as there is space
available, meaning that the joint is not completely bone-on-bone.
Andrew H,
Patients who are candidates for a BioKnee often have symptoms World Champion Sailor
associated with pain isolated primarily to one side of the joint and do
Treatment: Patellar tendon repair
not have underlying inflammatory arthritis such as rheumatoid arthritis
which differs from injury-caused post-traumatic or osteoarthritis. Andrew is a world-class sailor, Melges 32 world
champion, and match racing champion who developed
Ideally, their range of motion is not too severely limited and their legs
severe elbow pain (lateral epicondylitis) from sailing in
are not too badly bowed inside or curved outside (i.e. less than 10
2016 and chronic patellar tendon pain in 2018 from
degrees of angulation). squatting and hiking out in his sailboat and from training
hard on his mountain bike.

In the elbow, he responded brilliantly to injections of

3 Your goals amniotic fluid with high levels of growth factors
combined with direct soft-tissue massage physical
Your goals play a vital role in determining which procedures should therapy at The Stone Clinic.
be performed. Ideal candidates for biologic repair and replacement of
acutely injured tissues are people who would like to get back to For the patella tendon, he required a percutaneous
debridement followed by injections of growth factors to
sports and who can take the time to do the appropriate rehabilitation.
recruit stem-derived cells to the site of his injury. He has
We find that people whose goals are to stay active into their old age returned to his previous level of racing glory and checks
are motivated to prevent future osteoarthritis by stabilizing the knee in for fitness training when he is sailing in San Francisco.
and repairing the injured tissues.
“After Knee Surgery and Elbow Stem Cell injections, I
In particular, for athletes who wish to continue impact sports, run was wondering if my athletic life was coming to an end!
With all the rehab and PT lessons on how to get fit and
hundred-kilometer races, or even run every day of the week, we
strong again, I have been able to win the Laser masters
recommend that they delay an artificial knee replacement by opting USA National Championships, North American
for biologic repair to keep the knee moving naturally. Championships, Pacific Coast Championships and
come 4th in the World Championships.
We push the limits for biologic replacements in order to help delay the
time in which an artificial component is placed for our high-impact All the best Andrew”

athletes. With that said, many patients can perform at high levels of
athletics with artificial components. However, our preference is to
replace the biologic tissues whenever possible.

Watch Andrew's story

08
 4 Your approach to recovery

The accuracy of the surgical procedure is extremely important to a

successful outcome, but equally important, is your personal
commitment to the rehabilitation program. Most patients who have
had arthritic knees or loss of cartilage over the years have favored
their knee, have decreased range of motion, and have developed
weakness in their quadriceps, core, and gluteal muscles due to an
abnormal gait pattern that occurs from trying to avoid the pain. A
Natalya V., Ballet Dancer
successful replacement of cartilage is only as good as the ability to
rehabilitate the entire body so that we normalize gait patterns and
Treatment: ACL reconstruction
muscle strength returns. Without this, abnormal forces will continue to
(BTB allograft)
wear on the cartilage replacement and the life span of the cartilage
replacement will be diminished. Ballet dancer patient, Natalya tore her ACL during a
rehearsal. She did not want to use her hamstring to
We ask our patients to dedicate at least one hour a day to their repair her ACL. She came to The Stone Clinic where
Dr. Stone reconstructed the injury using donor
physical therapy and rehabilitation programs until they have regained
bone-patellar tendon-bone tissue.
full motion and strength. We also encourage them to spend at least
one hour a day focusing on a safe strength training and fitness Dancers cannot afford to lose a portion of their
program for the rest of their life. Our goal is to help you play sports patella tendon or their hamstrings. So, when the
until the end of your lifespan. Most often patients stay at our clinic at ACL is completely ruptured, Dr. Stone reconstructs it
least one week after their surgery; some stay as long as two to three with a donor bone-patellar tendon-bone graft, often
pre-loaded with the patient’s own growth factors
months working with our physical therapy team everyday (often for
stem cells. During surgery, the graft is placed so as
two hours a day for both rehabilitation and fitness training). Our goal is
to permit the knee to extend equally to the opposite
to return you to sports fitter, faster, and stronger than you have been knee—which, for many dancers, actually means
in years. hyperextension. Traditional graft placements often
did not allow this extra motion. Without it, though,
the dancer would never be the same.
5 Your attitude to treatment
With this type of repair, Natalya was able to return to
We cannot make a promise or guarantee your outcome but we can professional performance level and now dances five
times a week, teaching other dancers as an
tell you that the majority of patients do extremely well. Those that have
instructor: "I am awesome, back to 100%,
a complication, problem, or failure have been returned to a successful performing better by focusing on form."
outcome after the failure has been treated. We have learned that the
happiness and motivation of the patient who enters into the clinic
environment and into the operating room affect the whole team and
the outcome. We encourage you to bring your positive attitude and
watch how it influences your outcome.

The beauty of biologic joint reconstruction procedures is that should

one of the procedures fail or tear earlier than expected, in most cases,
it can be fixed, repaired, or replaced as needed. The attitude of the
patient plays a large role in the speed of their recovery. Patients who
keep their head in a good place and have a good spirit about it, tend
to do the best.

Watch Natalya's story

Call for an Appointment (415) 563-3110 09 Book a Complimentary Phone Consultation

If a BioKnee is not right for me,
what are my other options?
For patients who are not candidates for a biologic knee replacement,
because the degeneration has progressed to the point of being
bone-on-bone, we have a number of options.projected to increase to
three million by 2030.

Scott Endsley,
Partial knee replacement Triathlete age 62

Treatment: MAKO Robotic-assisted Partial

If the cartilage damage is extensive but limited to just one or two parts Knee Replacement
of the knee, we have had tremendous success resurfacing only the
worn-out portion of the joint (either the inside, outside or kneecap) Scott is a world-class triathlete who presented to us in
leaving the rest of the joint alone. 2014 after having nine right knee surgeries beginning in
1974. He had an arthritic knee with a poor range of
motion and stiffness, however, not much pain. His left
For unparalleled accuracy in placement, we use the MAKO Surgical
knee had articular cartilage loss, meniscus tears, loss of
Robotic Arm Interactive Orthopaedic System. The MAKO robot is the motion, and pain.
most accurate and sophisticated joint replacement system in the
world. The system robotically guides the surgeon to precisely replace Scott underwent a partial knee replacement for his left
the joint, resulting in better alignment and reducing the risk of early knee. He then completed the Wildflower Triathlon two
wear. months after his partial knee replacement, as well as a
second triathlon the day after.

This is an outpatient procedure, after which the patients can Five months post-surgery, he completed the San
weight-bear on the implant immediately, leading to a remarkably rapid Francisco triathlon where he came in second place.
recovery. The majority of patients who are referred to us for a total Nine months later, he reported his knee was “perfect”
knee replacement find that only one part of the joint is worn out. and he qualified for the World Championships in
More than 80% of these patients have been candidates for a partial multisports in Canada. In 2018, he reported no issues
with his knee.
knee replacement rather than a total knee replacement.

Total knee replacement

Sometimes a total knee replacement is the best option. When

multiple parts of the joint are worn out and a total knee replacement
is indicated, we have found that by using the MAKO Surgical Robotic
Arm we have been able to avoid the use of bone cement, securing
the implant to your knee joint with a perfectly placed, uncemented
bony ingrowth implant. The absence of cement gives us and our
patients confidence that when they return to full sports they are
unlikely to loosen the implant.

Watch Scott's story

10
Many of our patients a return to skiing, climbing, and hiking on their
joint replacements. Exercising daily makes stronger bones and
muscles and simultaneously diminishes the most common causes
of failure of joint replacement, which is weakening of the bone
leading to loosening of components.

In thirty years of partial and total knee replacements, we have only

seen one perfectly placed component wear out from activities.
The treatment was the replacement of the plastic insert. Accuracy
of placement is the key to reducing wear over time and
computer-assisted robotic surgery has increased the accuracy of
placement in our hands.

Conclusion
To keep you active playing sports and enjoying the activities you
love until you are 100 years old we need to keep your joints
moving. Using biologic and selected bionic replacement solutions
combined with dedicated rehabilitation and fitness programs is the
way forward.

If you can see yourself as an athlete in training and not a patient in

rehab we can achieve the goal to return you to a fitter, faster,
stronger version of you.

Connect with Dr. Stone to find out more

about your treatment options

Book An Appointment

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