Tom Rowland Podcast Episode 1022 is a conversation with Dr. Kevin Stone, the San Francisco orthopedic surgeon behind The Stone Clinic, about biologic knee replacement — rebuilding a worn joint with donor meniscus cartilage and regrown articular cartilage instead of replacing it with metal. We also cover what “bone on bone” actually means, partial versus total knee replacement, robotic cementless implants, PRP and stem cell recruitment, the truth about BPC-157, and why he thinks most people told they need a total knee replacement do not.
Listen now: Apple Podcasts · Spotify · YouTube · Press play in the player above to watch.
A biologic knee replacement rebuilds a damaged knee with living tissue rather than metal and plastic. In Dr. Kevin Stone's description on Episode 1022, it means putting a donor meniscus cartilage back into the joint and regrowing the articular cartilage on the bone surfaces, so the knee keeps its own biology and its own capacity to heal. It is an option when a patient still has some joint space remaining. If the knee is truly bone on bone in that compartment, there is not enough room left to rebuild biologically, and a partial or total replacement becomes the realistic choice instead.
No. Dr. Stone's point on the episode is that the first question to ask is where the knee is bone on bone. Most people are bone on bone on only one side of the joint. Someone who is bow legged tends to wear out the inside compartment while the outside stays in reasonable shape. When only one compartment is worn, a partial replacement can resurface that side and leave the healthy ligaments, cartilage, and bone alone. A total replacement is the answer when the wear is tricompartmental — all three compartments, genuinely bone on bone.
A total knee replacement resurfaces the whole joint. A partial replacement resurfaces only the compartment that is worn out, which preserves the ligaments and the healthy bone around it. Dr. Stone compares it to capping a tooth instead of replacing the whole set of dentures. The partial procedure takes about an hour, is done robotically, and still uses cement because the implants are too small for bone to grow into. Patients frequently describe the result as a “forgotten knee” — three to four months out, they stop noticing it during a hike or a walk.
Dr. Stone's clinic actively pushes patients back to full sport. He explains that modern robotic surgery produces cuts precise enough that a total knee implant can be placed without cement, letting bone grow directly into the porous underside of the implant. Once that ingrowth happens — roughly six weeks — the implant is not going to work loose from skiing or running. He argues the old advice to go home and rest the joint caused the failures it was meant to prevent, because resting costs you muscle and bone. His instruction to patients is the opposite: you are condemned to exercise every day.
A meniscus transplant replaces the shock absorber that was removed or destroyed in an earlier surgery, using donor tissue from a tissue bank. Dr. Stone describes the classic case on the episode: a college athlete tears a meniscus, a surgeon takes it out, and ten or twenty years later that person has arthritis in the same knee. Putting a meniscus back in can head off some of that damage when the tissue is too damaged to repair. It is one half of the biologic joint replacement approach, paired with regrowing the articular cartilage.
PRP stands for platelet-rich plasma. Dr. Stone explains that platelets in your blood carry packets of growth factors and chemokines, and those growth factors send what he calls a siren song to your body's own stem cells, recruiting them to the site of injury. They are also anti-inflammatory, anti-fibrotic, and immune modulatory. His clinic combines PRP-derived growth factors with hyaluronic acid, the joint's natural lubricant. Hyaluronic acid alone typically gave about three months of relief; adding the anabolic component, he says, has pushed results out to a year and sometimes eighteen months.
Dr. Stone is openly cautious. He notes the FDA changed its regulation so compounding pharmacies can now prepare roughly twenty of these peptides when a physician orders them. His problem is the evidence: only a few peptides have genuinely good science behind them, mostly the GLP class. For BPC and thymosin-type peptides, he says there is no human clinical data telling anyone what the dose should be or how to use them properly, and most of the supply originates overseas. Many of his athletes use them independently. He will not counsel them on it, and he points to platelets and birth tissues as better-evidenced carriers.
Dr. Stone explains that thirst sensitivity declines with age. Older people simply do not register being dry the way a young athlete does, so they do not reach for water as often. He adds a set of behavioral barriers on top of the physiology: fear of getting up at night to urinate, and worry about being too full to eat. The consequence is measurable, because he maintains that people perform better at every age when they are well hydrated — brain, kidney, and heart function all included.
Episode 1022 is available on Apple Podcasts, Spotify, and YouTube, and it plays in the video player at the top of this page. Dr. Stone's first appearance on the show was in 2021, and this conversation picks up several threads directly from that one, including his research on humanized animal tissue.
I had Dr. Stone on in 2021 while I was staring down my own knee problem, wondering what the road ahead looked like. That is the honest reason. Almost everybody in my world — fishing, hunting, skiing, hiking — eventually hits the same wall in a hip or a knee and starts quietly wondering whether they get to keep doing the thing they built their life around. Five years later I wanted to know what had actually changed. The answer turned out to be a lot more than I expected.
The first thing out of his mouth was not surgical. He says everyone who gets hurt unexpectedly goes down one of two roads. You can be bummed and stay bummed, or you can treat the injury as the opening to get fitter, faster, and stronger than you have been in years. That sounds like a poster until he explains how the second path actually gets built, and who you have to recruit to build it. He makes the same case for chronic arthritis that he makes for an acute tear. Listen to the first five minutes and you will hear the whole framework.
I asked about diet expecting to hear about anti-inflammatory foods. He started somewhere else entirely: your weight, and the arithmetic underneath it. He walked me through the number of steps you take in a year and the multiple of body weight each one loads onto the joint, and the product of those two figures is genuinely hard to argue with. What surprised me is that he does not prescribe a target number on a chart. He asks a different question about where you actually feel and perform best. He lays out the math around the 3:05 mark.
This was the moment I stopped the conversation. I had never heard that thirst sensitivity fades as you get older, and once he said it I could not stop thinking about every older person I have taken out on the boat who barely touched their water. He tells you exactly what to look at to spot it in someone, and it is not a blood test. For anyone fishing the Keys in August, or hunting in heat, this section alone is worth the listen. It starts around 6:01.
An entire generation of athletes had torn meniscus cartilage removed rather than repaired, and Dr. Stone sees the bill for that arriving now, ten and twenty years later. His approach is to put tissue back in rather than take more out — donor meniscus from a tissue bank, and increasingly donor tissue for the ACL instead of harvesting a patient's own patellar tendon or hamstring. He is candid that there is real controversy in that choice and real data on the other side of it, and he tells you why he wants you to know your surgeon's bias before you agree to anything. That exchange begins at 13:46.
In 2021 he told me about research on animal tissue engineered to work in a human joint. I asked how far it had come. The answer has a twist I did not see coming: the device was approved in Europe, a group of patients are still doing well on what they call their pig lig, and then it came off the market anyway. His explanation of why, and of what humanizing a tissue actually involves at the molecular level, is the most fascinating ten minutes in the episode. He gets into the chemistry at 15:09.
I have heard PRP mentioned in gyms and locker rooms for years without ever hearing anyone explain the mechanism. Dr. Stone does it with a bruise. He walks you through what those broken vessels under your skin are actually releasing, what the platelets do next, and why the signal they send matters more than the injection itself. That reframing changes how you should think about every stem cell clinic you have heard advertised — including the ones people used to fly overseas for. He explains the recruitment principle starting at 19:08.
I put the peptide question to him directly, because it is everywhere right now and the regulatory picture just shifted. He gave me the most useful kind of answer a physician can give: a clear account of what changed at the FDA, an honest map of where the science is strong and where it is absent, and a straight statement about what he will and will not counsel his own athletes on. He is not dismissive and he is not selling. His answer runs from 22:50.
Eighteen years ago he bought the first outpatient surgical robot in the United States, and he says it showed him how imprecise he had been. The precision gain led somewhere I would not have predicted — it let him stop using cement on nearly every total knee, because the cuts are clean enough for bone to grow into the implant itself. That single change is why his athletes go back to skiing and running on replaced knees. The section on what patients are told to do afterward turns the old advice completely upside down. It starts at 36:41.
Everyone in my life who has knee trouble has repeated the same sentence to me: the doc says it is bone on bone. Dr. Stone's response is that the sentence is incomplete, and he gives you the exact follow-up question to ask in the room. He also makes a claim about how many people are told they need a total replacement who actually need something smaller, and the number is high enough that I made him repeat it. Both of those moments land between 39:24 and 43:05.
I care about this one personally. Full range of motion — dropping into a deep squat, sitting back on your ankles — is what I was most worried about losing when I was looking down the road at a possible replacement. He does not oversell it. He gives different answers for a partial and a total, with actual degree ranges, and he explains whether the limitation comes from the implant design or from the body around it. If you are weighing a procedure right now, cue up 45:28 and listen twice.
I asked whether an artificial joint might someday beat the real thing outright. His answer was a firm no, for three specific reasons, and the third one is the one that stuck with me. He then used the 2026 London Marathon to make the broader case — a race where Sabastian Sawe and Yomif Kejelcha became the first athletes to run under two hours in official race conditions, and third place broke the old world record too. His read on what that says about human biology closes the episode at 47:21.
The line I keep coming back to is the simplest one he said all hour: do not live in pain. He wants you to drop dead at a hundred playing the sport you love, and he means it as a design specification rather than a sentiment. That is a very different message from the one a lot of people get, which is that if it hurts when you do that, stop doing that.
The other thing I did not expect was how much of this conversation was about your head rather than your knee. His view that the number one cause of injury is a mental error, and that almost every athlete knew a half second before it happened, has changed how I think about being present on the boat.
This is a conversation, not medical advice, and every knee is its own problem. If something here maps to yours, take it to a physician who will actually look at your imaging.
Press play in the player above, or grab Episode 1022 on Apple Podcasts or Spotify.
The Stone Clinic · Stone Research Foundation · Meniscus Transplant Center · U.S. Ski Team · Salt Lake City Olympics · ZLIG · PRP (platelet-rich plasma) · Hyaluronic acid · BPC-157 · TB-500 · GLP peptides · Lindsey Vonn · Conor McGregor · 2026 London Marathon · San Francisco, California
Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic in San Francisco and chairman of the Stone Research Foundation. He trained at Harvard University in internal medicine and orthopaedic surgery and at Stanford University in general surgery. He served as a physician for the U.S. Ski Team from 1988 through the 2002 Salt Lake City Olympics and has worked with the U.S. Pro Ski Tour, the United States Olympic Training Center, and several ballet companies including Smuin Ballet. He is a pioneer of biologic orthopaedic techniques and one of the leading practitioners of meniscus transplantation, and he runs the Meniscus Transplant Center at The Stone Clinic. He offers a complimentary virtual review of imaging for patients around the world through stoneclinic.com/consult.
Transcript
Tom Rowland Podcast — Episode 1022: Dr. Kevin Stone
In this episode: why an injury is an opportunity, losing your thirst sensitivity as you age, donor meniscus and the pig lig, what PRP actually does, the truth about BPC-157, cementless robotic knees, and why 80% of people told they need a total knee replacement do not — in the exact words spoken.
Dr. Kevin Stone: I'm Dr. Kevin Stone, orthopedic surgeon in San Francisco at the Stone Clinic. Happy to be here with you.
Tom Rowland: Great. Okay. Great. Dr. Stone, how are you? Fantastic. Are you busy?
Dr. Kevin Stone: Great, could be better. Always.
Tom Rowland: always there's there are always knee injuries knee issues that's why you're here well in my world of fishing outdoor pursuits everything for fishing hunting skiing hiking that seems to be the place where where people start to have problems in their hips and their knees and then tend to kinda wonder what's next are they gonna be able to keep doing what they're doing Are they going to be able, you know, are they going to have to have a replacement? What does it look like? Are they going to be able to keep fishing, hunting, hiking, skiing? And that's where you come in,
Dr. Kevin Stone: Well, that is where we come in. I'm thinking as I'm talking to you here that I'm wondering if many of your listeners see me as your speed detailer.
Tom Rowland: You could be the speed detailer right here, right? That's what we need, with your knee. How could you be the speed detailer with somebody's knee?
Dr. Kevin Stone: Well, you know, so many of the people we see have an injury that's unexpected and they can go down one of two paths. They can either be bummed and say, me my, or they can say, you know, I'm going to use this injury as an opportunity to get fitter, faster and stronger as we like to say, then they have been in years. And so if you can take on that mindset and recruit the resources around you, your physical fitness trainer, your physical therapist, orthopedic surgeon to fix the problem right away. and just set your mind towards coming back better than you've been in years, then you can have a great experience and use the injury as an opportunity. And that's true for acute injuries. It's also true for arthritis, the things that chronically bother people.
Tom Rowland: And so with that mindset of coming back fitter faster and stronger that goes certainly into training it certainly goes into into your just your mindset but also probably your diet too. How much how much do you coach people on anti-inflammatory diets and what that and how what you eat affects the way that you're feeling especially in your joints?
Dr. Kevin Stone: in multiple ways. We start out by optimizing your weight. So what's the right weight for your body frame and your sport and your mentality and where do you feel great? And so some people feel great, know, heavier than they should be. Other people feel great, lighter than they should be. You've got to just listen to your body and listen to yourself, know where you perform the best and then optimize your diet and stay there and to be the best person you can. from a weight point of view. And why is weight so important? Well, you take two to three million steps per year in normal walking, and that's up to five times your body weight. So if it's a high step or you're running or impacting, well, a 10 pound weight loss, five times your body weight, so 50 pounds potentially, two to three million times per year off your joints, it's just an enormous difference. So the first thing to think about in terms of diet is really optimizing your weight. How do you get to where you want to be? How do you get to the state that you feel fittest in and best and can perform the best? That's number one. And number two, what are you putting into your body? And I think we've all learned that if you can avoid processed foods, if you can eat things that come from the ground, grow in the ground, you're in general, if you use that principle. you'll probably be on the right track. And we've all learned that hydration matters. We all seem to function better when we're better hydrated. So having that tall glass of water on your desk, as I always have on my desk, and drinking it all the time. and often trying to finish the glass when you pick it up, if you can, so that you really hydrate with water as your primary beverage. And then all the other beverages you like to take in life, whether they're coffee or beer or whatever it is, you know, makes you happy. That's great. As long as you've hydrated well with water first, you'll tend to be well satiated. You'll be well hydrated. And we just know that the brain cells work better. Your kidney cells work better. Your heart works better. when you're better hydrated than when you are dehydrated and you just feel better. if we, and unfortunately what happens with aging is that people tend to lose their thirst sensitivity. So they don't appreciate so much when they're dry. And so they don't reach for that glass of water as frequently as does the young athlete. And so being sensitive to where you are and your Aging and your fitness will determine a lot of what you're going to reach for to put in your body. And so if you use those principles about hydrating, eating what grows in the ground, optimizing your weight, you'll probably do great.
Tom Rowland: Wow. i have never heard that you lose your thirst sensitivity as you age that's it's near and and so that that's common i'd i guess when i think about it like we're not when i take older people on the boat some people don't as much water is younger people i guess but i've never i've never heard that before that that that's something that is kind of common to lose that
Dr. Kevin Stone: You really do. Look at all the old people you know in your life. They tend to be a little dry. Look at their tongue, look at their membranes, look at their behavior pattern during the day. Do they have a big glass of water on their desk? Are they frequently going to drink? In general, they're not. In part, there's fear about getting up at night too often to pee, or fear about not eating enough if they've drunk too many fluids, or all the other things that
Tom Rowland: you Mm-hmm.
Dr. Kevin Stone: are barriers to staying well hydrated. And yet if they're better hydrated, they perform better at every age.
Tom Rowland: One thing about drinking a lot of water is that especially when we're out in South Florida fishing, we have to drink a lot of water just to stay hydrated, but then you're also sweating a ton, you're losing a ton of electrolytes. And that has become really, really something that I've paid way more attention to is what my electrolyte intake is in addition to just plain water. And I'm doing that with an electrolyte mix or like sea salt rather than gatorade or some kind of power aid or something like that does that have anything to do with your with your joints your your electrolyte balance does that affect your joints at all or just everything else in your body
Dr. Kevin Stone: We're sure that it does. How we correlate it, I don't know. Except for the most common thing I hear from patients is that when they are well hydrated, often when they use glucosamine as a supplement, they feel less stiff.
Tom Rowland: Mm. Hmm. Yeah, well, I would think that certainly for hydration, you feel better. But electrolytes, man, I'll tell you what, if you've ever been really low in electrolytes and then you get some, it's better than a cup of coffee. It's better than anything else. Nothing. I don't know if there's anything else that makes you feel better faster than electrolytes when you are literally tapped out. That makes you feel so much better.
Dr. Kevin Stone: That is exactly the reason why the rehydration clinics, the IV clinics are popping up all over America and all over the world. And if you've had a big night out dancing or you've been working at night all along or you've had a big endurance event or you've been out on the water on your boat in the sunshine all day, if you get an IV filled with electrolytes, you immediately, just as you're saying, feel so much better. And how can you avoid having to go get that IV?
Tom Rowland: Mm-hmm. Right.
Dr. Kevin Stone: It's making sure that the beverages you're drinking are balanced reasonably and you're staying hydrated. So the first step is you get tend to get dehydrated and tend not to drink the right things. The second thing is what are you replenishing with? So if you're in the replenishment stage, meaning you got down, just as you're saying, look at the beverage that you're about to replenish with. And the object is not to get down. So if you're using water first before coffees and alcohol and other things that tend to dehydrate you, that's a good way to try to balance that off. If you're gonna have, your beverage for the day to take out on the boat, picking ones that are well balanced with electrolytes makes a lot of sense.
Tom Rowland: now agree with that in your bio i was reading that you were the you were or are the the team physician for the u.s. ski team are you still doing that
Dr. Kevin Stone: I did that from 1988 to 2002, the Salt Lake City Olympics, and after that I moved on and took care of a host of other events, ski events around the world. And now I mostly take care of skiers who come see me from around the world and ballet dancers and other athletes.
Tom Rowland: Yeah, well I would imagine that skiers, I don't know, I mean I'm sure there's plenty of ways to mess up your knee but you know the one in recent memory that is was so visible and public was Lindsey Vonn having her wreck in the Olympics and she had already recovered from several other knee injuries. I don't know if you ever were able to to see her or not but when somebody has an injury you know like something like that and that could be you know she's going super fast and she's a very very accomplished skier one of the best in the world obviously but anyone could have an accident kind of like that where you get twisted and you come down what like in when when people come to see you like that that have had a an injury like what's the what's your protocol to determine whether surgery is necessary or what the next steps are.
Dr. Kevin Stone: Well, the first thing, especially in an injury like that is to make sure the athlete's safe. So as she correctly pointed out to her own physicians, know, am I at risk of getting a compartment syndrome? Am I at risk of losing my leg? Am I at risk of bleeding more? Am I all the things that are, you know, truly tragic and devastating for the athlete? step one is to make sure the athlete's safe. and make sure that they're not doing more damage or some events going on that's going to do more damage. Step two is to sit down with the athlete and say, okay, what's your goal? And let's design the surgery and the rehabilitation program and the fitness program to meet your goal. And so if your goal is to train and play at a very high level, then we want to use that time while the leg might be healing. to being optimizing your core program, your upper body strength, your cardiovascular program. put you on a bike, a well-legged bike where you're spinning on one side. that whole program, we put a lot of thought into optimizing, not just for the world-class athlete, but for the weekend warrior as well, and for anybody who wants to come back better than they were before. So that program starts on day one, the first conversation of how do we design? the entire program. How do we repair the tissues that are broken in a way that they can come back? And then how do we design the entire fitness program? So it helps if you're, if you are in that situation, seek out a doc who, who has the tools to put the tissues back together or put the tissues back in and has the mentality to help you get better than you were. And unfortunately throughout history, there've been a lot of examples where torn meniscus cartilages were taken out or ACLs weren't repaired well or broken bones weren't perfectly put back together. And those things matter a ton. And so there are people like me and others around the world who specialize in these sorts of things and putting tissues back in and biologic reconstructions for athletes. it's a fantastic time to be involved in this field because not only are we good at the tissues going back in, We now have a host of injection tools that we can augment that healing with.
Tom Rowland: I'd love to talk about that. first of all, putting tissues back in and like, can you explain that a little bit? Like are there different options or some tissues like from a cadaver and some tissues are from something else? Like what are your what are the options that you have when you when you're talking about putting tissues back in?
Dr. Kevin Stone: of most common tissues that we put back in are the meniscus cartilage, meaning athlete says, hey, I was playing college ball, tore my knee joint, meniscus, doc took it out, I'm now 10 years, 20 years later, I've got knee arthritis. So we know that we can prevent some of that by putting the meniscus right back in if it's too damaged to repair. And that's a human donor meniscus that we get from a tissue bank. Same on the ACL, you know, we've shifted our thinking. We used to always
Tom Rowland: Okay.
Dr. Kevin Stone: take apart one part of the patient's knee, the patellar tendon or hamstrings to rebuild another. And now we much more commonly will take a donor tissue to rebuild that broken part, broken tissue in their joint. And there's controversy about that. There are some data to say that donor tissue may rupture more frequently than your own tissue, but there are a host of ways of diminishing that rupture right now. We can talk about that in detail. So our bias, you always need to know the bias of your surgeon. So I'm biased to putting tissues back in when they're torn or devastated and in general using tissues from donors, young, healthy donors, then taking your own. By the way, I have an enormous research program going on around using pig tissues that we've studied how to humanize them. It's not on the market now, but it will come back as we're pushing forward the research.
Tom Rowland: Well, in 2021, when we did our first podcast, you were working on that already. And so how far along have you come with that?
Dr. Kevin Stone: Yeah, and it can't. Yeah, good. Good memory. So that first project, first version did pretty well. It got approved in Europe as an ACL device. It was called the ZLIG and we have a number of patients who are doing very well still with their pig lig as they call it. However, it could have been made a little bit better. And so it came off the market and we're now in the research lab optimizing how to make that even better. It will come back.
Tom Rowland: you
Dr. Kevin Stone: So just hold your breath on that one. So for right now, it's still a human donor tissue. It will come back as pig tissue later on. So I can get young, healthy, strong pig tissue every time. And we've learned how to humanize that tissue now. And so hold your breath.
Tom Rowland: What does that mean to humanize that tissue?
Dr. Kevin Stone: So animal tissue has a specific carbohydrate on it called the galactoseal epitope. And it also has a number of what we call non-gal epitopes. And what we did back in the mid late 1990s, early 2000s is we designed a technique to enzymatically strip or wash those animal tissues to strip that specific carbohydrate. Now what we've done is we've improved that so we can strip not just that carbohydrate but a host of the other animal antigens that cause a mild rejection response or a bigger rejection response. So when we come to the human implantation, that tissue will have been stripped, essentially humanized, and then the body can remodel it as it would normally. So we're very excited about that research. It'll come back as ligaments and meniscus and articular cartilage and bone screws. It's a hot space right now. The other thing that's happened in that space is we now, as everybody knows, can add anabolic. This is an era of I call the anabolic era of orthopedics. So you've heard about PRP and stem cells and growth factors and lubrication. And we have a fair amount of research on how to optimize what we now call the cocktail of combining these together to help people heal faster, reduce inflammation, reduce scarring. So whenever we're doing any of these surgical procedures for our athletes now, we're always augmenting that procedure with these growth factors and other techniques. Yeah.
Tom Rowland: And these, quickly like compared to, you go back to the, you know, I don't know what would be a fair comparison because so many things have changed, but without those, how much better or faster are you healing?
Dr. Kevin Stone: So you're probably seeing Achilles tendon ruptures now in athletes and basketball players, and they're coming back at six months to a year, where in the past it was easily a year or more. All of my patients ask, hey doc, why does it take a year to come back from an ACL injury? And we believe we can speed that up quite a bit now in getting people back in around usually the six month mark, depending on how. aggressive and they are and how good they are at their rehabilitation program. So this isn't solid data yet and clearly varies based on the drive of the patient and the application of various growth factors and the surgical technique and the tissue used. of factors go in here, but this whole frustration about taking so long for collagen to mature, we're in this wonderful era of learning how to speed that up now.
Tom Rowland: that's very interesting cuz i mean you you have professional athletes and and they are obviously need to get back so they can continue with their career you have regular people who are wanting to get back so they're not in pain anymore they can continue to do what they want i'm sure both are are utilizing these this cocktail can you tell us what some of that what some of those are that are so effective
Dr. Kevin Stone: Sure, the most common one that almost everybody hears about is called PRP. that's the, in your blood, there are platelets and within those platelets, there are packets of growth factors and what we call chemokines. These are little peptides and proteins that attract other substances within your body. And so let me explain, if you have an injury, let's just say you have a bruise. those broken vessels under your skin that you see turning your skin black and blue, those things are releasing blood, releasing platelets into the tissue. The platelets release their growth factors in packets and those growth factors send out a siren song to your body's own stem cells. Hey, come here, help repair this broken tissue. Amongst other things, they also are anti-inflammatory. They're anti- fibrotic, meaning they diminish scarring. They're anabolic, which means they stimulate the cells that are local to produce more fluid or more lubrication. They're immune modulatory, which means they shut down some of the inflammation. And they are recruitment factors in that they recruit your body's own stem cells. So today we combine the growth factors in the platelets from the PRP. with HA, the natural lubricant of the joint. You've heard about hyaluronic acid that many people have injected in their joints or their faces and other parts of their body. And that usually worked pretty well for about three months. We now know that when we add an anabolic to it, these PRP-derived growth factors and others, we can get those results to be out to a year and 18 months sometimes. So it's a more potent way of using a joint injection.
Tom Rowland: You
Dr. Kevin Stone: And then it brings up this whole other space, which are both birth tissues and exosomes and other factors that we are looking at the data on and using in the clinic to see if we can make these injections work better. And let me explain the science about why they might. So as you're sitting there, you have billions of stem cells in your body. They're called pericytes. They live on the walls of vessels. And yes, when you're younger, you have more billions than you do when you're older, but you wouldn't be sitting there talking to me unless you didn't have billions of these things in your body to keep you healthy. So our job when we do an injection is not just to stimulate the local environment, but to recruit some of those billions of cells in your body to that site of injury to direct the healing response. The better we are at recruiting them, the more effective the injection will be. So you probably remember lots of athletes traveling to Europe or the Caymans or Mexico to get stem cell injections. Well, patients don't ever need to do that anymore because those cells generally didn't last very long at the injection site or died or didn't have the effect that we really wanted. It were just, too few to make the real impact. What you really want is the most powerful recruitment factor to recruit your body's own cells. And that's
Tom Rowland: Mm-hmm.
Dr. Kevin Stone: the work that we're doing and others are doing on how to make those injections work better.
Tom Rowland: And there's been so much lately also on peptides and healing peptides like BPC 157 and TB 500. BPC 157 I think was just made legal, I think, at least in some states. Is that something that you use at all in your practice, these other type of peptides like that?
Dr. Kevin Stone: So let's describe what happened there. So first of all, the FDA made a change in their regulation where it was illegal for compounding pharmacies to put these compounds together for doctors to then prescribe for patients. And they changed that regulation for about 20 of these peptides to make it possible for compounding pharmacies to put them together if a physician orders them. The big problem for us is that for only a few of these peptides is there really good science. And the few are the GLP peptides that you hear for weight loss and also athletes are using for body sculpting. Once we get into the BPC peptides, which are peptides that come from the gastric juice of the stomach or the thymusin type peptides, the TB peptides that you hear about. Then we are outside of any normal sourcing. Most of these are coming from China and we have no human clinical data or research studies to know what the dose should be, how to use them properly. So many of my athletes of course are using them on their own, but we just can't counsel them on what makes real sense in that environment. That said, we do have potent carriers of almost all the peptides you need in your own blood and platelets. in birth tissues and other ways that we can augment your healing response. So I would tell you as a physician, I'm still waiting and cautious. developing data on the ones that we can and have been legally allowed to use over years now. And the other peptides that you get in the gym and get from your local compounding agency or pharmacy are tricky to figure out how to use safely.
Tom Rowland: when you have somebody that comes in i'm sure that you have people that are injured you have people that had previous injuries i'm sure you can also have people that are coming in with previous surgeries that just it just never never went as well as they hope to i know someone like that that's close to me and they used her quad tendon to repair her acl does that sound right
Dr. Kevin Stone: Yes.
Tom Rowland: And she's just never been able to get back to where she thought that she could be. And in a situation like that, where you're looking at a surgery that might have been 10 years ago or 15 years ago or something, and now you have all these other tools at your disposal, you know so much more, all doctors know so much more today than they did back then, what kind of
Dr. Kevin Stone: Yes.
Tom Rowland: and i'm sure that there's tons of people that are are like that like they just had this knee replacement or knee that just has never quite gotten back to where they wanted to what kind of advice do you have for somebody like that do they need to do it over again or can they work with what they have
Dr. Kevin Stone: Well, first of all, getting good data first before giving advice is always a good idea. So we really encourage people to come in, we're going to do careful physical exam, our fitness team can assess them, we can get x-ray, MRI, can understand the athlete, where are they, what are their goals, what's holding them back. So before I give advice, I really like to have that combination of data if I can. We see people from all over the world and so in this virtual era that we're in,
Tom Rowland: Mm-hmm.
Dr. Kevin Stone: Many of our patients go to our website and go to stoneclinic.com slash consult. They upload their X-ray and MRI, and then I can get on a Zoom call with them and talk with them about what the issues are that I can see missing the physical exam, which I love to have, but at least I can give them some guidance based on data. So we do that as a complimentary service to our athletes around the world. And then if we can help them, we're happy to help them.
Tom Rowland: That's cool.
Dr. Kevin Stone: Bottom line, to answer your question though, there's so many of the things that are holding people back from an old injury or from a surgery that didn't work out as well as they wanted it to, can be improved. We've got the tools to do that. It doesn't always involve surgery. If it does, then it involves both surgery and all these new factors. But, and sometimes it just involves injections and rehab. So that range of tools for a physician now is so much greater than it ever used to be. that the message and the answer to your question is don't live in pain. Life's short. You never know how many years you get. We want you to drop dead at age 100, play in the sport that you love, but at least play all the way up until that age if you can.
Tom Rowland: right what a great message because it doesn't seem like that's always the message that you get sometimes there they say well does it hurt when you do that will don't do that again or don't do that anymore cycle that's when i live for like it might be pickleball skiing or fishing or hiking or and it's like to imagine a life without doing that for someone is not at all what they're asking for like yeah sure if i don't play pickleball my knee doesn't hurt but I love playing pickleball and that's what I want to do right like and and having a doctor who is like okay well if that's your goal this is what it's going to take to get there and you have to determine if you're willing to put in the work which I'm sure in in a lot of cases there's a tremendous amount of work that goes into recovery but also finding the right doctor who can put you on that path I think is is really really big and that's what you're what you're doing right
Dr. Kevin Stone: your doctor at your fitness team too. So treat yourself like a pro athlete would. And a pro athlete who comes in says, hey doc, you know, how do I get back to a better level for next season than I was just before I got hurt? So we lay out a whole program for them, but involves physical therapists, athletic trainers, nutrition council, sports psychology, daily attention to the whole fitness program. And so you can do that no matter where you are, no matter what your resources, you don't have to spend as much money or, or have all the dedication or all the hours in every day that a pro athlete does. But you can take little bits of all of those things yourself. You can optimize your nutrition program. You can find a athletic trainer in the local gym who will work with you. Find an orthopedic surgeon who will guide you and counsel you, you know, put the team together, optimize your nutrition and your hydration. As we started out talking. These are things that are available to everyone. with the tools on the web now, and certainly with the AI tools, you can really pick a program that fits for you in a way that you've never had a chance to do in the past.
Tom Rowland: and the the pro athletes and i see take like a it's not an injury but when connor mcgregor broke his leg i mean he was planning on coming back very very quickly and you see other athletes that that have these these injuries were career-ending not long ago and they're back in six months eight months a year and they're doing things that it looks like they never missed a step it's incredible And so a lot of that are these injections and doing what you're talking about earlier,
Dr. Kevin Stone: But the most important part of that though, that you just said is that they're not just back. They're back better than they were before. They're a smarter athlete. They avoided the mental error that led to the injury in the first place. They're building on, they've optimized part of their fitness program that they didn't have time to do before they were injured. Now they've spent time thinking about. They've used the time to take every part of the program and make it better. And all of us can do that.
Tom Rowland: that's super interesting that you look at it that way that like an injury is an opportunity not everybody does i mean a lot of people think an injury is a setback but you're looking at it completely differently you're looking at it as an injury is an opportunity to reassess so many things and take a step back when you look at so many athletes that have really achieved true greatness some of them have black marks on their name but they they have taken time off away from the sport either for an injury or for something else and taken some time away from it and then come back and been better than they have ever been before and a lot of that is because of an injury and that's a that's a very cool way to to look at that that that that is that is an opportunity do you think that if somebody goes their whole career without ever having an injury achieves a great career. When you think about it like you just said, would that athlete have been better if they had somehow sustained an injury that would have put them, made them reassess their training? It's an interesting thing to think about.
Dr. Kevin Stone: That athlete's a unicorn. So in ski racing, for instance, you have a 300% chance of a near career ending injury if you start out as a youth and go all the way to the World Cup, meaning three significant injuries that could potentially end your career. And so if you're an athlete that's been lucky enough to make it all the way through without visiting your local orthopedic surgeon, you probably are number one extremely lucky.
Tom Rowland: Yeah
Dr. Kevin Stone: but you've also had mental injuries. You you've had times when you were down or times when you were bummed about something or times when, you know, your mind kept you from performing at the level that you thought you could or should. And so there's all kinds of injuries out there that you can use this philosophy for, you know, bummer that something happened to you. How do you think it through so that you can be smarter mentally, intellectually and come back better? Most, the number one reason we see as a cause of injury is a mental error. So you were going a little too fast, you knew it just before you caught that edge or missed the turn or stuck your leg out or just did something. Almost every athlete I asked, just before that injury happened, did you know? Did you have a premonition? Did you realize you're going too fast or you had the wrong angle or you were on the wrong line? And they almost always kind of knew. And so if you can train your mind to be in the game, when you're out on your boat, you're there fishing, you're not on your cell phone, you're in the game, you're mentally there, you're aware, you're attuned, then you're gonna do so much better performance wise and from every other point of view. And if you have times in your life when you have that downer, that mental injury, not the orthopedic surgeon version of it, and you can think through why am I in this space, what got me here? what made me a great athlete before, how do I get out of it, then you'll use the same philosophy of coming back better than you've ever been and the next time you'll be more aware.
Tom Rowland: how much do you suggest or see these certainly the professional athletes are consulting sports psychologists to to help them through these these tough times but like what about regular people is there is there the equivalent of a sports psychologist that a regular person that sustained a knee injury and wants to get back to to doing what they want to do i mean that's not a regular therapist like a sports psychologist is is there to teach you like the mindset of how to win and how to how to focus on what's important for winning and that's not necessarily like a psychiatrist or a psychologist
Dr. Kevin Stone: What you're describing is the definition of every great teacher and every great coach. Everybody who's gone into teaching, everybody who's gone into coaching does exactly what you just said. They're thinking about their athlete. How do I help that athlete do better? And yes, part of it is technique and training and fitness, but a big part of it is how do get that athlete to bring their A game every time?
Tom Rowland: Mm-hmm. And so what about for a regular person? Is there somebody that exists like that? I mean, is that a job, a profession to help people make it through? Of course, tough times, but athletically tough times. You just blew your knee out, and you're going to go through this whole thing. And you kind of need a coach. Who is that?
Dr. Kevin Stone: You need a coach, a coach. So look at your sport and look at whether that's coaches in your sport or not in your sport, but somebody available to you or your kids coach, your school coach, your old coach you had from a former team that you were on. You'd be surprised if you pick up the phone and call them and say, Hey coach, I need your help. I'm just not performing at the level I was back then, or something's getting in the way. Would you spend a little time talking me through it? And I've never met a coach who wouldn't love that phone call.
Tom Rowland: Mm-hmm. because that's what they do. what they, yeah, that a former student would call them back. Now, what about in your bio also, it talks about robotic surgery. And so you're doing a lot of these virtual kind of calls with MRIs, x-rays, talking to people and kind of talking them through it. But when you find somebody that's in a different place and they need
Dr. Kevin Stone: That's their dream.
Tom Rowland: your services are you able like explain how you're using robotic surgery and what what you're capable of doing these days with robotic surgery
Dr. Kevin Stone: Sure, so robotic surgery is all local now, so meaning I'm holding the robotic arm in my hand. I can't do it virtually or remote, in part because there's technologies in there, but also in part because there's a million decisions that the surgeon has to make in addition to the precision of the robotic arm. So let me give you an example. So the first half of my career, when I was doing partial or total knee replacements, I was using the standard guides and standard instruments and implants, and I thought I was pretty good at it. until I bought the first outpatient robot in the United States about 18 years ago now. And then I realized how much more precise I could be. We would do a CT scan now with robotics, build a 3D model, put the implants on the model before we ever touched the patient. And then at surgery, we could just take away just the amount of bone needed to put the new implant in. And we could adjust everything at surgery to match that patient's anatomy and their ligament laxity and their alignment. and their goals. so robotics has made the surgeon much more precise. And then the next thing it did from our patients who needed a full knee replacement, it helped us get rid of the cement. And so in the old days, we'd cement in total knees. Now we don't have to use cement at all for almost any of them because the cuts are so precise that the bone can grow into the porous undersurface of the implant. So for my athletes who going back to ski and run on their total knee replacements, we don't have to worry about them knocking them loose. They're never going to knock them loose unless they break their leg. So because the bone has grown into the implant. So it completely changed our precision, our ability to get rid of cement, our ability to help patients who need a partial or total knee replacement go back to full sports. It helped us shift in so many ways. And so no, I can't do it remotely. I can. usually tell the patient whether or not they need one remotely, but all the surgery has to happen in the operating room.
Tom Rowland: Mm-hmm. Wow. the cement, like how much, like when you're not cementing in these fixtures and you go to what you just talked about. I mean, it's gonna be more durable, but it's also, are you gonna heal faster? Like everything's faster too?
Dr. Kevin Stone: sure everything's faster because the incisions are smaller, the dissection smaller, the bone grows in by six weeks, they're fully grown ends, the patients can weight bear immediately after surgery, but can return to sport so much earlier. Everything about it has gotten better.
Tom Rowland: In the weight bearing immediately after surgery, are you encouraging people after they have a total knee replacement, are they up and walking that day? As quickly as possible.
Dr. Kevin Stone: Yes, we want them up on it. Yeah, as quickly as possible. We want them to weight bear immediately. And we guide the whole, they're in with our rehab team the next day after surgery. Surgery takes two hours. They're here the next day, fully awake, alert, working with the rehab team, working on range of motion first, because we want to get full range of motion whenever possible and then progressing. And so these have been godsends to our patients who have true severe arthritis. Now all the levels before that, we can do either a partial knee replacement, which we're very biased about just doing the part of the knee that's worn out. And the reason for partial replacements are that the knee feels much more normal than it does with a full replacement. Many people can qualify for a partial knee replacement where in the past they were told they couldn't. And so it's an enormous advantage to surgery. only takes an hour. It's robotic. that does use cement still because the implants are so small that there's not enough area for the bone to grow into. So that's been an enormous part of our practice. I would say 80% of the people who are told they need a total knee replacement don't. They could either have a partial replacement or they could have a biologic joint replacement, which is where we put the meniscus cartilage back in and regrow their articular cartilage. And that's true if they have still joint space remaining. If it's bone on bone, then there's not enough space to do a biologic replacement there. We'll do a partial if we can or a full if it's really tricompartmental bone on bone.
Tom Rowland: So that's what people hear so much. Like you'll hear somebody and they're like, my knee hurts. Doc says it's bone on bone. I hear that all the time. And so you're saying when it does get to that point that you're not able to open it back up and put something in between there.
Dr. Kevin Stone: So when they say to you it's bone on bone, your next question is where is it bone on bone? Because most people are only bone on bone on one side of their knee. If they're bow legged, they tend to be bone on bone on the inside. And so if the outside is still in reasonably good shape, don't touch it, it's our bias. Again, you need to know the bias of your surgeon. And in that bone on bone on one side, I can put in a partial replacement. The knee will feel much more normal. By three to four months, 98% of the patients say,
Tom Rowland: or Mm-hmm. Mm-hmm. Right, yeah.
Dr. Kevin Stone: It's a forgotten knee, meaning they went out for a hike, they went out for a walk, they forgot about the fact that they had knee partial replacement. If it's not bone on bone, if they have arthritis, but it's not bone on bone, then they have options. And the options are an injection and rehab alone, a biologic replacement where we put the meniscus back in and regrow the cartilage or a partial replacement where we just resurface one part of the knee.
Tom Rowland: Mm. Wow.
Dr. Kevin Stone: And many patients will say, doc, if you just resurface one part of the knee, will I be back to get the rest of the knee done? does that commit me to having a full knee replacement later on? And the fact is it does not commit you. I can do a partial replacement on the other side of the knee if you ever develop it, but it's really quite uncommon that people do that.
Tom Rowland: So resurfacing the knee, that sounds like it's not a big deal, but it sounds like it might be a little bit bigger deal. Like what's the process of resurfacing the inside or outside of a knee that can make somebody have a, I think that the way that you described that, a forgotten knee, like a knee that's been bothering somebody for 10 years and all of sudden they just, they went through the whole day and they don't think about it, that's a dream come true for anyone.
Dr. Kevin Stone: Right. So think about it as if you've only worn out one side of your knee, if we cap the tooth rather than replacing the whole dentures, that's a good way to think about it. And what's happened with these partial replacements and with the total replacements, the new implants are so much less than what the old ones were. The old ones had huge stems. lost a lot of bone. they were just a much, they were cemented in place. The new stuff is much more like capping the end of the bone. You remove lot less bone, there's less metal, the bone grows into the metal. So it's really a new era in robotics and precision and return to sport. So let me explain the return to sport part and why this is so important for your listeners to understand as well and for everybody. As you age, you're losing muscle and bone. That's natural as you age. And so in the old days, when you told a patient, go home and rest your knee, your total knee, you don't want to wear it out. Well, you lost more muscle and more bone and that's why these things tended to fail. So we, for 30 years here, have been telling patients, go home and you're condemned to exercise every day. And the more resistance exercise you do, the more you're going to build bone, the more you're going to build muscle, the less likely you are to wear out your joint or knock it loose. And so that's been our experience. That's what our data shows. So we really strongly encourage our patients to get back to full sports and the more active they are, the much better they're gonna do.
Tom Rowland: Mm-hmm. Mm-hmm. Mm-hmm. and do you feel like people can get full range of motion i mean that's been one of the things i have had issues with my knee a couple times gone in i mean that's one of the reasons why i wanted to have you on in the very beginning because i was looking at this road ahead what am i going to do luckily i don't have any problem anymore like it's it's a forgotten it's a forgotten thing but one of the things that I was very concerned about was full range of motion. So all the way down into a complete squat or be able to sit on my ankles. I can easily do that now with a replacement. Are they to the point right now, whether it's a partial or full, that it has the same range of motion as a natural human knee?
Dr. Kevin Stone: The answer is with a partial knee, they're highly likely to be able to get their full range of motion. With a total knee, they're not. They're usually can get full extension, but bending usually ends up in the 120 to 135 range, not that 150 where you can touch your heel to your butt. And it really depends on how flexible the patient is, how much they work at it in PT right away, host of factors like that.
Tom Rowland: Mm-hmm. But you're saying, is the, is the, like there's a mechanism, right? So it's a, it's a unnatural manmade mechanism, the new knee, right? And you're saying that is it capable of going to 150, but when you put it into the body, then there's some resistance and very few people can get it to that point, or is the, is the knee itself capable of going that distance?
Dr. Kevin Stone: It is capable, however, the shapes and designs usually don't tolerate range of motion past about 130, 135. Just the way the anatomy is and the way the implants are designed, most people don't get there. There's not a physical block to getting there.
Tom Rowland: Do you see that, with in the last, I don't know, even since 2021 when we talked before, it seems like you've come a long way with a lot of different things that can happen. Do you see in the future with AI and everything else and all these different things that we're using and the different peptides that we're learning about and the different, all these different things and things that we don't even know about. Would there ever be a day do you think that that an artificial joint would be a significant advantage over a regular human joint?
Dr. Kevin Stone: The reason why a regular human joint has an advantage is number one, it's got several hundred million years of evolution behind it. Number two, it's a dynamic environment, meaning as you load the joint, fluid goes in and fluid goes out in that viscoelastic combination of hydrodynamic force distribution. And number three, when you injure the knee, has the capacity capacity to heal. So when you injure tissue, can heal. It can be stimulated to heal by a surgeon or physician or it can heal on its own. And those three things make a artificial component or a man-made component very, very difficult to reproduce at the level of a normal human joint. Your joint will last you a lifetime if you don't injure it, including running for lifetime. It's only the injury that then changes the biomechanics and the biology of the joint that causes it to go downhill. Now, there are also other injuries such as genetic injuries, meaning you picked your parents poorly, or some inflammatory arthritis, you got an infection or you had rheumatoid arthritis, some other agents that caused your joint to degrade. But if your joint is a healthy joint when you start out, if you don't injure it, you get it for a lifetime.
Tom Rowland: But you don't think that maybe 20 years in the future they might say there's a division for artificial joints and there's a division for natural human joints just like we have with drug testing and like we're do you not see that we could get there like could a
Dr. Kevin Stone: Yep, you definitely will get there on robots. As you saw the robots running in the races this past week. So the joints and those robots are getting better and better and better as they can tolerate a marathon at speed. And so yes, joints are getting better and better. So robots will get better and better. When you put artificial materials into a biologic system though, that dance between biology and artificial material. is always going to be challenged because one has the capacity to heal and one doesn't.
Tom Rowland: I know, just saw that. That's very interesting. Then you see like in the military they're trying these exoskeleton type things where you'll have you know basically a knee brace that can now tolerate ten times what a normal, I don't know, ten times. I don't know how many times. It's just I understand that you could lift more, you could possibly run faster, you could certainly climb up a hill better with this exoskeleton I just kinda wonder and I can see that how it could you could maintain your normal human joint but then you have it some kinda amplifier of sorts
Dr. Kevin Stone: But here's an example of why it's far better to spend your thought time and body time and brain and money time on your own body. Last weekend at the London Marathon, three people broke the world record for the marathon and two of them did it in sub two hours. So that progression of human performance, human anatomy, human nutrition, human drive, which we all thought might not be breakable in our lifetime. is in fact broken and that's a testimony to how much we can continue to improve in the biologic systems we're all born with. So I would strongly encourage all of your listeners focus on yourself and optimize what you've been given and you can you got a long way to go.
Tom Rowland: Right. I know. did you pay any attention to how fast those robots ran the the marathon
Dr. Kevin Stone: I just saw they finished and I saw the times look pretty good. I didn't really focus on their performance. No, I don't think so. I didn't really focus on it.
Tom Rowland: It wasn't below two hours though. but i i i saw the winner of the marathon that you just reference under two hours but i didn't realize that the second place was also under two hours that's incredible
Dr. Kevin Stone: And third place broke the world record, even though he wasn't under two hours. You know, had he run that race with those two guys ahead of him, he would have been the world record holder. So it's a stunning example that it's just not one or two guys in the field is moving forward. And that's human biology. Yeah, the shoes are better. Yes, there may be a little spring component to those frames, but at a carbon inserts, but in general, it's human physiology and it's mental toughness. You've got to have the mental ability to focus and survive the pain and use that pain to your advantage to be able to excel.
Tom Rowland: That's incredible. Well, I love your mindset about injury and the ability to recover from injury. I'm sure that's going to be a breath of fresh air for a lot of people that are currently going through injuries or have had them for a long time. If they want to get in touch with you and discuss their own knee, are you all knee or what else do you do?
Dr. Kevin Stone: It's knee, shoulder, and ankle. see damaged ankles from around the world where people are told their only choice is a fusion or ankle replacement. And we've developed a biologic approach towards these arthritic ankles. It seems to be working out quite well. And then we see the normal shoulder injuries in our athletes of dislocations and cuff tears.
Tom Rowland: and might be sending my buddy who he's got the worst shoulders i've ever seen in my life and he's been told over and over and over again to get a shoulder replacement but i'd be interested to see what you what you have to say he basically has nothing and it's very very painful for him but maybe i'll send him your way so how do people like for for him or somebody else how do they how do they get in touch with you and have you look at their stuff
Dr. Kevin Stone: Go to stoneclinic.com slash consult and all the information's right there. I'm happy to help. That's what we love to do. It's why we're so committed to this and driven to see if we can make these things better and better.
Tom Rowland: Well, you're doing a great job for a lot of people. really appreciate it. I appreciate you coming on the podcast again and wish you all the best. All right. Thank you. See ya.
Dr. Kevin Stone: Take care. Bye bye.
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