Alternatives to Knee Surgery and Knee Replacement
In this article Ross Hauser MD will discuss knee replacement research and alternatives. At Caring Medical Regenerative Medicine Clinics, we specialize in pain cures, not pain management. As such we always research, write our own research, and explore new methodologies to curing knee pain.
In this article we suggest:
- Surgery for many defects of the knee is not the first option we would choose.
- Stem Cell Therapy, Platelet Rich Plasma Therapy, Prolotherapy are viable alternatives to Knee Surgery and Knee Replacement
- As risk of complications rates from knee surgery rise, patients should be offered non-surgical options
Why Were You Recommended for Knee Replacement Surgery?
There are several reasons why your doctor may recommend knee replacement surgery. Recently, the American Academy of Orthopaedic Surgeons published general criteria which included the following reasons:
- Patients with bowed knees
- Patients in severe pain
- Patients with knee stiffness that limits everyday activities
- Patients with chronic knee inflammation and swelling that does not improve with rest or medications
- Patients who failed to have symptoms improve with anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy, or other surgeries.
From another perspective, when asked why they considered a total knee replacement, patients responded in survey research that they wanted an improvement in pain, a restoration of function, i.e., walking, stair climbing, and the ability to move without assistive devices.
Recently doctors tried to come up with a formula that would better allow them to predict who would have knee replacement and subsequent revision knee replacement surgery failure.
Who was most at risk?
- Patients who had tibial tuberosity osteotomy (bone realignment surgery)
- Patients with kidney faliure
- Patients with rheumatic diseases
- Patients who had Posterior-stabilized constrained total knee arthroplasty for complex primary cases
- Patients who had to have the revision surgery within 5 years of the first surgery
- Patients with septic loosening.1
At Caring Medical Regenerative Medicine Clinics we specialize in pain cures, not pain management. As such we always research, write our own research, and explore new methodologies to curing Knee Pain. Coming up on our twentieth year in practice, we can still safely say that surgery for many defects of the knee is not the first option we would choose. Why? Because we have found and shown in research that Prolotherapy is effective for curing knee pain.
Does Knee Replacement Meet Patient Expectations?
To be fair, we wanted to report on some positive outcomes and knee surgery success rates:
Arthroscopic joint debridement is a potential treatment for knee osteoarthritis. . . This procedure results in an excellent or good outcome in approximately 60 % of patients in approximately 5 years.2
Joint debridement is a sort of “power-washing” of the joint to wash away loose tissue and other loose bodies in the joint. Sixty percent patient satisfaction is good unless you are in the other 40%.
One Third of Knee Replacements Inappropriate
Over the years we have reported that we have seen many patients following knee replacement surgery who still had pain. After an examination we could clearly see that some of the patients did not need the surgery and that their doctors may have had an over zealousness to get them onto the operating table. That has been our opinion for years and many times we would get the casual email saying that we were off base to offer such an opinion.
On June 30, 2014, a press release was issued from the medical journal Arthritis & Rheumatology, in it doctors say that their research suggests that more than one third of total knee replacements in the U.S. were “inappropriate.” Using a patient classification system developed and validated in Spain the study highlights the need for consensus on patient selection criteria among U.S. medical professionals treating those with the potential need of knee replacement surgery.
The Agency for Healthcare Research and Quality reports:
- more than 600,000 knee replacements are performed in the U.S. each year.
- In the past 15 years, the use of total knee arthroplasty has grown significantly
- Some experts believe the growth is due to use of an effective procedure, while others contend there is over-use of the surgery that relies on subjective criteria.
The present study led by Dr. Daniel Riddle from the Department of Physical Therapy at Virginia Commonwealth University in Richmond, examined the criteria used to determine the appropriateness of total knee arthroplasties. “To my knowledge, ours is the first U.S. study to compare validated appropriateness criteria with actual cases of knee replacement surgery,” said Dr. Riddle.
“Our finding that one third of knee replacements were inappropriate was higher than expected and linked to variation in knee pain osteoarthritis severity and functional loss. These data highlight the need to develop patient selection criteria in the U.S.,” concludes Dr. Riddle.
In a related editorial, Dr. Jeffery Katz from the Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital in Boston, Mass., writes, “I agree with Riddle and colleagues, and with Escobar and colleagues, that we should be concerned about offering total knee replacements to subjects who endorse “none” or “mild” on all items of the pain and function scales.”
Pain After Total Knee Replacement
A main reason for knee pain after knee replacement is ligament instability. Ironically, the number one symptom that prolotherapy, platelet rich plasma, and stem cell therapy address in pre-surgery patients is ligament instability. This is the cause of pain that we point out to patients – knee ligament instability before and after total knee replacement. Perhaps the answer to their problem should have been to treat the ligaments! Not replace the knee!
Here is what the literature says:
- “Instability is one of the most common causes of failure of total knee arthroplasty (TKA)…Acute instability is related to intraoperative injuries or excessive release of important coronal stabilizers such as the medial collateral ligament in extension or the posterolateral corner in flexion.” (Note – the surgery itself caused instability!)3
- “In 32.6 % of all cases [requiring a revision surgery], ligament instability was the primary reason for revision. In another 21.6%, ligament instability was identified as a secondary reason for revision. Analysis of the different instability forms showed combined instability in extension and flexion as the most common cause, followed by isolated instability in flexion (31.8%) and isolated instability in extension (9.1%).4 The high correlation between instability and malpositioning of the prostheses was obvious.”
Please see the companion article treating patients with pain after knee replacement surgery on our site.
Minimally Invasive Knee Replacement Surgery
There recently has been increased interest in soft-tissue sparing total knee arthroplasty (TKA). Reports have advocated reduction in the size of the incision, disruption to the joint and relative preservation of the quadriceps tendon. Some studies have even suggested decreased blood loss, transfusion rates, and hospital length of stay using these techniques. However, enthusiasm for the potential advantages of this approach is tempered by the possibility of increased complication rates.5
This study was conducted in 2008, certainly things have changed with the upgrades in technique and technology to assist the surgeon. BUT maybe not – In July 2013 published research – listen to what these researchers said: even after the surgeon completed a substantial number of cases before the commencement of this study, using computer-assisted navigation to preserve the quadriceps tendon gave inferior results (documented on MRI) and longer operating time.6
Let’s point out here that this technique is designed to spare the quadricep muscles and tendons from damage and destruction caused by the surgery, not the injury itself!
Bone surgery for the knee
As the knee degenerates, it changes in shape. A popular treatment involves restoring the shape by bone surgery to alleviate pressure and pain. Osteotomy is a surgery that the researchers say, “should always be performed if possible.”7
When a surgeon recommends an osteotomy for the knee the goal is that they can change the shape or slope or angle of the bone to realign the knee to relieve pressure on the pain causing part of the knee by distributing your weight to a sturdier part of your knee. The hope of course is to extend the life of your real knee and delay knee replacement surgery. Surgery to avoid surgery!
Problem is -
1) You are removing anatomy, as we like to say, if you didn’t need it, it wouldn’t be there in the first place.
2) Extended recovery time and immobility.
3) If the Osteotomy does not work, a knee replacement is next and unfortunately, total knee replacement is a much more complicated surgery with some bone missing or altered. This complication is why knee replacement is usually called for from the start.
So why always perform this surgery if possible? Because there is a chance by altering the knee that knee cartilage can regenerate! In fact it has been reported in 60% of cases following high tibial osteotomy that there has been some degree of cartilage regeneration.
Alternatives to Knee Surgery and Knee Replacement
For a patient researching alternative treatments for knee surgery, especially a patient who has had many failed treatments and procedures, the one new thing that will keep coming to the top of their search is stem cell treatments, specifically bone marrow-derived mesenchymal stem cells.
Mesenchymal stem cells represent one of the new technologies in medicine, so much so that many different treatment modality specialists want to incorporate their usage into their scope. Surgeons want it, synvisc doctors want it, Prolotherapy doctors want it. Why? Read the research on stem cells, osteoarthritis and cartilage regeneration:
Osteoarthritis (OA) is a degenerative disease of the connective tissue and progresses with age in the older population or develops in young athletes following sports-related injury.
The articular cartilage is especially vulnerable to damage and has poor potential for regeneration because cartilage has a poor blood supply and therefore poor healing abilities. Although surgical and pharmaceutical interventions are currently available for treating osteoarthritis, restoration of normal cartilage function has been difficult to achieve. [In other words surgery and pharmaceuticals are not working]. . . . Bone marrow-derived ‘mesenchymal stem cells’ with inherent chondrogenic differentiation potential [Stem cells can morph into cartilage cells] appear to be ideally suited for therapeutic use in cartilage regeneration. [Stem cells can morph into cartilage cell].”8
Stem Cell Therapy for Articular Cartilage Regeneration
This regeneration potential is why the Prolotherapy doctors want to use stem cells. In Prolotherapy, ligaments and tendons are treated to stabilize the knee joint and prevent excessive movement that could cause pain in the bone on bone situation. If you add stem cells to the treatment protocol you are not only repairing the ligaments and tendons, but also the cartilage in a non-surgical manner.
Stem Cell Therapy
The results have been very promising, so much so that the other orthopedic specialties have noticed that the introduction of stem cells seem to make their procedures go a little better. Even the surgeons have joined in:
In surgery, the stem cell technique require some form of scaffolds (a patch) and two separate surgical procedures. One research paper was happy to announce that they did not need acartilage patch and eliminated one of the surgeries.9 It is interesting to note that a high advance would be the scaffold-less approach – in other words – a piece of tissue from healthy cartilage transported to the site of the damaged cartilage. In Bone Marrow Prolotherapy the scaffold-less approach is how it is done! In this study success was cited as only a single operation as opposed to two and they even speculate that stem cells would be superior to autologous chondrocyte implantation (ACI) and aid in Hyaluronic Acid effectiveness. The question has to be asked, why have the surgery, why have the autologous chondrocyte implantation, why have the Synvisc, if the stem cells are working well on their own? The one treatment that researchers are showing stem cells work well with is in a combined application with Platelet Rich Plasma Therapy.
Stem cell therapy to repair damaged knee cartilage
Further, “Despite its remarkable ability to resist mechanical loading, articular cartilage is not capable of mounting a useful reparative reaction in response to damage caused by trauma or disease. As a result numerous surgical and medical approaches have been developed to aid the healing of articular cartilage. Despite the success of surgical techniques such as microfracture, recently attentions have been turned to cell based therapies such as autologous chondrocyte implantation (ACI).”10
Despite the remarkable success the surgeons want something better than microfracture – perhaps the success was not as remarkable as they hoped. Back to autologous chondrocyte implantation (ACI) – “ACI has produced encouraging results, however better results may be achievable through an evolution of this surgical approach.” That would be the introduction of stem cells – and in agreement with the previous cited study about perhaps stem cells being more effcetive than ACI.8
In these cited studies, stem cells are looked upon to enhance surgical procedure and have been shown effective. In Bone Marrow Prolotherapy we like to show that the stem cells are effective enough that the surgery is not necessary. Like all injectable solutions used with Prolotherapy, Stem cells are used as an aid in healing and an alternative to surgery. The injections are designed to stimulate the repair of injured tissues. This is achieved through the rebuilding of the components of the ligaments, tendons, and cartilage in knees with moderate and advanced osteoarthritis. Would you like help finding a Prolotherapy doctor who uses Stem Cells?
Alternatives to Knee Surgery and Knee Replacement
In our experience, even if a person has already had a surgical evaluation, it is well worth consulting a Prolotherapy and/or Platelet Rich Plasma Therapy and/or stem cell therapy. At Caring Medical, we specialize in Physical Medicine and Rehabilitation and has seen and treated thousands of patients who were on the path to surgery before avoiding it because of Prolotherapy, an injection technique that stimulates the body to repair the painful area.
For more information on Prolotherapy, Stem Cell Therapy, and Platelet Rich Plasma Therapy for the regrowth of knee articular cartilage and meniscus tissue, please refer to our article stem cell treatment for meniscus repair.
1. Luque R, Rizo B, Urda A, Garcia-Crespo R, Moro E, Marco F, López-Duran L. Predictive factors for failure after total knee replacement revision. Int Orthop. 2014 Jan 9. [Epub ahead of print]
2. Spahn G, Hofmann GO, Klinger HM. The effects of arthroscopic joint debridement in the knee osteoarthritis: results of a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2012 Aug 15. [Epub ahead of print]
3. Spahn G, Klinger HM, Harth P, Hofmann GO. [Cartilage regeneration after high tibial osteotomy. Results of an arthroscopic study]. Z Orthop Unfall. 2012 Jun;150(3):272-9. Epub 2012 Jun 22.
4. Del Gaizo DJ, Della Valle CJ. Instability in primary total knee arthroplasty. Orthopedics. 2011 Sep 9;34(9):e519-21. doi: 10.3928/01477447-20110714-46.. 2011 Sep 9;34(9):e519-21. doi: 10.3928/01477447-20110714-46.
5. Jackson G, et al. Complications Following Quadriceps-sparing Total Knee Arthroplasty. Orthopedics. June 2008 – Volume 31 · Issue 6
6. Lin SY, Chen CH, Fu YC, Huang PJ, Lu CC, Su JY, Chang JK, Huang HT. Comparison of the clinical and radiological outcomes of three minimally invasive techniques for total knee replacement at two years. Bone Joint J. 2013 Jul;95-B(7):906-10. doi: 10.1302/0301-620X.95B7.29694.
7. Graichen H, Strauch M, Katzhammer T, Zichner L, von Eisenhart-Rothe R. Ligament instability in total knee arthroplasty–causal analysis. Orthopade. 2007 Jul;36(7):650, 652-6.
8. Gupta PK, Das AK, Chullikana A, Majumdar AS. Mesenchymal stem cells for cartilage repair in osteoarthritis.Stem Cell Res Ther. 2012 Jul 9;3(4):25. [Epub ahead of print]
9. Lee KB, Wang VT, Chan YH, Hui JH. A novel, minimally-invasive technique of cartilage repair in the human knee using arthroscopic microfracture and injections of mesenchymal stem cells and hyaluronic Acid-a prospective comparative study on safety and short-term efficacy. Ann Acad Med Singapore. 2012 Nov;41(11):511-7.
10 Gardner OF, Archer CW, Alini M, Stoddart MJ.Chondrogenesis of mesenchymal stem cells for cartilage tissue engineering. Histol Histopathol. 2013 Jan;28(1):23-42.
11. Hauser R. Prolotherapy just makes more sense for cartilage injuries than accelerating arthritis with arthroscopy. Journal of Prolotherapy. 2009;1(1):6-7.
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