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Regenerative Medicine Clinics


Chicagoland office
715 Lake Street, Suite 600
Oak Park, IL 60301
708.393.8266 Phone

Southwest Florida office
9738 Commerce
Center Court
Fort Myers, FL 33908
239.303.4069 Phone

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Research on Alternatives to Knee Replacement Surgery




Ross Hauser MD Alternatives to Knee Replacement SurgeryIn this article Ross Hauser MD discusses knee replacement research and knee surgery alternatives.

In a recent study, doctors suggested that given educational aids and time to think about total knee replacement, more patients (compared to a control group) opted out of getting a knee replacement.1

For many years, the undisputed primary treatment for advanced knee osteoarthritis was a total or partial knee replacement. Now, medicine is moving in a different direction. Over the past few years the medical community has initiated a shift away from surgery towards “biomedicine” and the use of patient’s stem cells and blood platelets as healing “medicines.”

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 explore all the new research and suggest:

  • Surgery for many knee pain, knee instability, and knee defects is not the automatic first option of treatment and researchers are telling doctors to STOP convincing patients it is.
  • Stem Cell Therapy, Platelet Rich Plasma Therapy, and 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.

Jump to


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, Hyaluronic Acid Injections and lubricating injections, physical therapy, or other arthroscopic knee 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.


Doctors say we are rushing too many patients to knee surgery


Doctors say we are rushing too many patients to knee surgery

Are doctors rushing patients too swiftly to surgery? Some studies are suggesting that they are. In a recent study, researchers assessed the screening process for surgical candidates with knee osteoarthritis.

They looked at 327 patients.

More than half – 172 of them – were referred to a surgeon and 76% of them went on to have total knee replacement. Rush to judgment? These researchers thought so and concluded

“Few conservative management options were tried before referral, indicating the need to enhance pre-surgical care for patients with knee osteoarthritis.”2


One Third of Knee Replacements Should Not Have Been Done


One Third of Knee Replacements Should Not Have Been Done
Over the years we have seen many patients who, following knee replacement surgery still had knee 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 overzealousness 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 statement was issued by the medical journal Arthritis & Rheumatology, in it doctors said that their research suggested more than one third of total knee replacements in the United States were the “inappropriate” treatment.

This research strongly suggested to doctors the need for a consensus on patient selection criteria. In other words making sure those who needed a knee replacement got one, and those who did not were offered other treatments.

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.

In other words a medical equation
knee osteoarthritis = knee replacement

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, “we should be concerned about offering total knee replacements to subjects who (have) “none” or “mild” on all items of the pain and function scales.” 3


Questioning Total Knee Replacement


Questioning Total Knee Replacement

Clearly doctors have started questioning knee replacement as THE primary treatment for knee osteoarthritis based on information like that above. Especially when the same information confirms patients being sent to surgery who exhibit NO or mild symptoms. This is why the “assured” and “safe” decision to have a total knee replacement is being replaced by the doctor’s desire to repair the natural knee.

Supporting this change in the doctor’s thinking is that knee replacement hardware will wear out and knee hardware failure are future problems that cannot be ignored. Patients are living longer. Further as discussed below, patients are being made wait until they are old enough for knee replacement.

Ethically this should be a problem to many. People forced to live in pain until they are of appropriate age to get a knee replacement.

In October 2015, an editorial appeared in the New England Journal of Medicine. In that editorial Jeffrey N. Katz, M.D., the same mentioned above, cites the arguments that randomized trials (any further research) of total joint replacement are senseless if they all confirm a rationale to use them. After all, joint replacements are among the most significant advances of the 20th century; don’t we already know they are successful? Yes, but maybe not as successful as we think they are.

In this editorial, the readers of one of the most prestigious medical journals in the world learned that total knee replacement poses the following risks:

  • About 0.5 to 1% of patients die during the 90-day postoperative period.
  • The procedure is not universally successful; approximately 20% of patients who undergo total knee replacement have residual pain 6 or more months after the procedure.
  • Third, there are alternatives. Clinical trials have shown that physical therapy (including exercises and manual therapies) can diminish pain and improve functional status in patients with advanced knee osteoarthritis.
  • Finally, an ideal treatment for one patient may not be right for the next. Patients with knee osteoarthritis differ in the importance they attach to pain relief, functional improvement, and risk of complications. Therefore, treatment decisions should be shared between patients and their clinicians and anchored by the probabilities of pain relief and complications and the importance patients attach to these outcomes.

In a randomized, controlled trial, involving 100 patients with symptomatic knee osteoarthritis, patients were assigned to undergo total knee replacement followed by a rigorous 12-week nonsurgical-treatment regimen (total-knee-replacement group) or to receive only the nonsurgical treatment (nonsurgical-treatment group), which consisted of supervised:

  • exercise,
  • education, patient information
  • dietary advice,
  • use of insoles,
  • and pain medication.

Total knee replacement proved markedly superior to nonsurgical treatment alone in terms of pain relief and functional improvement. However, it is noteworthy that more than two thirds of the patients in the nonsurgical-treatment group had clinically meaningful improvements in the pain score and that this group had a lower risk of complications. 4,5

In the research above, Prolotherapy, Platelet Rich Plasma Therapy, and Stem Cell Therapy were not included in the study. The interventions were pain medications, exercise, education and use of insoles. These three important options will be discussed later.

The video below will demonstrate on of the treatment options, Platelet Rich Plasma Therapy or PRP.



Why shouldn’t I get a knee replacement?


Why shouldn’t I get a knee replacement?

The internet has provided patients with unlimited access to answers, good and bad, about their health conditions. It has also allowed them to participate in the health decisions as an informed participant.
Patients are seeking their own information because they are not getting all the information they could from their doctor. This has been verified in the research that suggests despite the availability of evidence-based guidelines for conservative treatment of osteoarthritis, management is often confined mainly to the use of painkillers and waiting for eventual total joint replacement.6

Which confirms what we have been hearing from patients for decades, “Why have I never heard of Prolotherapy before?”

Sometimes the doctors will expand knowledge of conservative management beyond painkillers to
1. nonsteroidal anti-inflammatory drugs (NSAIDs)
2. corticosteroid injections
3. Hyaluronic Acid Injections

Independent research has shown: These “conservative” treatments serve as the standard of care and this care has been found lacking.7

In regard to the use of these treatments as a means to delay inevitable knee replacement two recent major studies offer contradictory information – one study on the benefits of Hyaluronic Acid Injections says that these injections can delay total knee replacement for more than a year and in some patients up to 3.5 years.

Another study says patients should not delay total knee replacement and go right for it, Hyaluronic Acid Injections are not providing the patients with a quality choice.

In the first study on the benefits of delaying surgery with Hyaluronic Acid Injections doctors found:
Patients who had one course of Hyaluronic Acid Injections, knee replacement was able to be delayed an average of 1.4 years.

Patients who received more than 5 courses of Hyaluronic Acid Injections delayed Knee Replacement by 3.6 years.8

HOWEVER, the second in the journal American Health and Drug Benefits suggest that patients over the age of 70 should proceed to total knee replacement as opposed to delaying the knee replacement with steroids or hyaluronic acid to save on national health care costs.

This is from the study: “findings indicate that members without significant comorbid (other health problems) conditions who underwent knee or hip replacement procedure had a greater decrease in osteoarthritis-related healthcare resource utilization and costs after they recovered from surgery, compared with pre-surgery, and compared with the members who received intraarticular injections of (steroid and hyaluronic acid ).”

These results also suggest that, although initially generating lower cost, treatment with steroid and viscosupplementation injection may result in increased spending and cost over time.

These results are consistent with the American Academy of Orthopaedic Surgeons’ recent change in evidence-based guidelines for viscosupplementation for symptomatic osteoarthritis pain of the knee, from “inconclusive” to “recommend against.”9

Clearly these papers indicate that steroids and Hyaluronic Acid Injections do not rebuild or restore knee function – they can only reduce symptoms until it is time to get the knee replacement.


The Pain of Waiting for the Total Knee Replacement Surgery Date


As we spoke above, researchers have noted that patients on a waiting list for knee replacement surgery suffer from severe symptoms and the waiting list delay can be considered a major reason that patients seek alternatives.

In one study, doctors followed 153 patients who had been given a date for their total knee replacement. What the doctors wanted to study was changes in pain, function and quality of life and the burden excessive wait times had on the patients.

Here is what they published: “Overall, subjects suffered a significant deterioration of their condition while waiting, in terms of knee pain, contralateral knee pain, functional limitations and quality of life.10


How is a knee replacement priority list compiled?


Patient concerns and doctor concerns differ

Researchers wanted to know what influenced surgeons in determining the order in which patients are scheduled for surgery. In the study, they asked a group of surgeons to assess patient profiles of 80 patients. They also asked a group of non-medical personal (lay people) to assess the patient profiles for their “lay” recommendation.

  • Both groups determined that the patient’s pain was the number one concern.
  • For the surgeons, the other determining factors were physical limitations and other medical factors.
  • The lay people saw it a little differently. While agreeing on the physical limitation part, they were concerned with the patient’s socio-economic situation and the stress a prolonged wait would bring on the patient’s ability to make a living as well as the psychological distress that may bring.11

While the surgeons did not consider socio-economic factors in determining priority in patients wait time to surgery, it is clear that for the lay person, the delay to surgery, the surgery, and the recovery time from a total knee replacement are important factors.

One of the reasons the surgeons may not have prioritized this factor may be found in the literature.
“There is little in the literature to guide clinicians in advising patients regarding their return to work following a primary total knee (replacement). In (our) study, we aimed to identify which factors are important in estimating a patient’s time to return to work. . .how long patients can anticipate being off from work, and the types of jobs to which patients are able to return following primary total knee arthroplasty.”12

Information for patients to assess from the study scores were:

  • The average time to return to work after the surgery was nine weeks.
  • Patients who reported a sense of urgency about returning to work were found to return in half the time taken by other employees
  • Other preoperative factors associated with a faster return to work included being female, self-employment, higher mental health scores, higher physical function scores, higher Functional Comorbidity, and a handicap accessible workplace.
  • A slower return to work was associated with having less pain preoperatively, having a more physically demanding job, and receiving Workers’ Compensation

Insurance Coverage and Surgery Availability


Researchers in the Journal of Arthroplasty wanted to know if insurance coverage was a determining factor FOR THE DOCTOR, as a deciding factor for who would be prioritized to replacement surgery:

“Our objective was to compare the availability of hip and knee arthroplasty (replacement) to an adult insured by Medicaid and by private insurance.

All orthopedic surgeons’ offices in a South Florida county were contacted by telephone and presented with a hypothetical patient that needed either a hip or a knee arthroplasty for end stage arthritis.”

Two scenarios were presented.
The hypothetical patient was presented as either having private insurance or Medicaid.
14.3% of all offices contacted offered an appointment to patients with Medicaid coverage for hip and knee arthroplasty, respectively. All offices offered an appointment to patients with private insurance.

“The mean time until appointment was longer for patients with Medicaid when compared with private insurance. Adults insured with Medicaid currently have limited access to total joint arthroplasty within the studied community.”13

In another study, researchers noted:
“A total of 1120 consecutive patients were asked what they believed a surgeon should be paid for performing hip and knee replacement surgeries….Most of the patients stated that Medicare reimbursement was “much lower” than what it should be. Many patients commented that given this discrepancy, surgeons may drop Medicare, which may decrease access to quality hip and knee arthroplasties.”14

Patient out-of-pocket costs
Total Knee Replacement procedures can cost an uninsured patient in the tens of thousands of dollars, for the Medicare patient out of pocket costs may reach into the hundreds of dollars, for the privately insured patient the out-of-pocket costs depends on your insurance coverage and can range from the thousands to tens of thousands. Patients are always recommended to check with their insurance carrier prior to surgery to get estimated out-of-pocket expense.

With all of these considerations, it is no wonder a patient may search for an alternative to surgery. Not to mention the knee replacement failures and other complications associated with any type of surgery. For these reasons we recommend any joint replacement candidate to seek the second opinion of an experienced Prolotherapist before undergoing surgery.15


Why Were You NOT Recommended for Knee Replacement Surgery?


Knee Replacement – How old is too young? Is it 55?
Here is research suggesting that in patients age 55 or younger, knee replacement should not be recommended unless the case presents special situations:

“In the short-term follow-up the relatively young age of 55 years or less was associated with a higher risk of revision, especially for aseptic failure (infection). The underlying mechanisms require further investigation, but current knowledge indicates that in patients who are less than 55 years old, total knee replacement should only be used in selected cases when there are no other satisfactory means of giving relief from pain and dysfunction.”16

You may be at high risk for these 22 different risks associated with total knee replacement
The 22 complications and adverse events include:
• bleeding,
• wound complication,
• thromboembolic disease, (surgery caused blood clots)
• neural deficit, (nerve damage)
• vascular injury,
• medial collateral ligament injury, (surgery caused knee instability by damaging ligaments)
• instability,
• malalignment,
• stiffness,
• deep joint infection, (see below)
• fracture,
• extensor mechanism disruption, (damage to ligaments and tendons in the knee cap region and disruption of quadriceps)
patellofemoral dislocation, (knee cap is not sitting properly)
• tibiofemoral dislocation,
• bearing surface wear,
• osteolysis,
• implant loosening,
• implant fracture/tibial insert dissociation,
• reoperation,
• need for revision surgery,
• need for readmission to hospital,
• and death. 17

You may be at high risk for post-surgical heart attack

Doctors at Harvard Medical School released their study in October 2015 that showed risk of heart attack was significantly higher during the first postoperative month in those who had knee replacement surgery and that venous thromboembolism was a significant risk during the first month and over time for those having total knee or total hip arthroplasty as well.18


Pain after knee replacement


Post operative infection

Post operative infection has rightfully been called the most dreaded post surgery complication. Current treatment procedures include one-stage or two-stage revision total knee replacement. These procedures replace part or all of the original your previous knee prosthetic with a new prosthesis.

If the periprosthetic infection is no longer controllable after several revision total knee arthroplasties, many surgeons regard knee arthrodesis (a big nail) to be a possible solution. In the research cited here – this procedure Intramedullary nailing following septic failure of revision total knee arthroplasty must be regarded with skepticism, and (the researchers) cannot recommend it. Repeat revision total knee arthroplasty or amputation should be considered as an alternative in such difficult cases.19

Neuropathic knee pain after surgery

One study suggests that it is neuropathic pain that cause problems after knee replacement. That is damage to the nerves that usually occurs in surgery.20 Neuropathic pain is an underestimated problem in patients with pain after total knee replacement. It peaks at between six weeks and three-months post-Contact us about Alternatives to Knee Replacement Surgeryoperatively. Currently best choice recommendations for neuropathic knee pain is pharmacologic management.

Waiting too long for a knee replacement causes pain after knee replacement

This is from research: Pre-operative pain in the knee predisposes to central sensitization (catastrophizing thoughts). Pain due to osteoarthritis of the knee may also trigger neuropathic pain and may be associated with chronic medication like opioids, leading to a state of nociceptive sensitisation called ‘opioid-induced hyperalgesia’ painkillers increase chronic pain.21 

Catastrophizing thoughts

Researchers in Canada have released findings that suggests that  one of the reasons patients continue to have chronic pain after total knee replacement is catastrophizing thoughts.

Pain catastrophizing reflects a patient’s anxious preoccupation with pain, inability to inhibit pain-related fears, amplification of the significance of pain and a sense of helplessness regarding pain.22

Clearly a patient who exhibits catastrophizing thought behavior should be screened for a very invasive surgery with its expected pain during recovery. In many cases knee replacement may be considered inappropriate for these patients.


Ligaments as a cause of pain after Total Knee Replacement


A main reason for knee pain after knee replacement is ligament instability. Ironically, the number one symptom that Prolotherapy, Stem Cell Therapy and Platelet Rich Plasma Injections 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!)23
  • “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%).24 The high correlation between instability and malpositioning of the prostheses was obvious.”

Remarkably, doctors have made a discovery – saving the knee ligaments in total knee replacement is good.

The surgery itself caused more complications and ligament damage and instability. As cited above, most of the pain after knee replacement relates to the structures around the joint. Besides the ligaments, the pes anserina tendons can be problematic as they too are stretched during the surgery. Often as a person rehabs after a knee replacement these tendons and their muscles are not addressed as a pain risk factor.25


Pain Caused By Wrong Diagnosis?


Doctors warn that in the case of chronic knee pain, a thorough examination is imperative in identifying the correct diagnosis. That sounds like common sense, but the truth is that the source of pain is often missed and treatment then will present a significant challenge with less than desired results.

One study sought to understand why up to 20 percent of patients who undergo total knee replacement still have persistent pain and why secondary surgery rates are on the rise.26 Forty-five patients were studied. What the researchers found was somewhat shocking. The pain was not originating in the knee – here is what they said:

“Patients may still be undergoing knee (replacement) arthroplasty for degenerative lumbar spine and hip osteoarthritis. . . We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.”

In other words, patients received a knee replacement when the cause of pain came from the hip and spine.


Masked Hip Pain


Other researchers also cautioned doctors to be on the look out for “hip disease masquerading as knee pain or low back pain.”They noted various ways hip pain distributes itself including as groin, buttock and hip pain. 27

For women and older patients, the chances of a successful knee replacement are lower

In a study out of London, researchers sought to uncover various predictors of a successful (or unsuccessful) outcome in a total knee replacement. Looking at 1,991 total knee replacement patients over a three-year period, they discovered various predictors of poor outcomes. Among the findings were that females and older people had worse functional outcomes following the replacement surgery.28


Another side effect – you may get the wrong operation or at the wrong hospital or the surgery did not address the true cause of pain


Knee replacement given to patients with low back and hip pain

In a recent study, investigators advised doctors that they must recognize hip disease “masquerading as knee pain or low back pain” before giving a recommendation for back and knee surgery because doctors may be performing the wrong procedures.29

In the case of chronic joint pain, a thorough examination is imperative in identifying the correct diagnosis. That sounds like common sense, but the sad truth is that the source of pain is often missed because of misinterpretation of MRI and other imaging scans. Please see our article on MRI accuracy.

Recently doctors warned patients not to go to low-volume knee replacement hospitals because the risk of complication was greater due to lack of expertise. (Yes we say the same thing about Prolotherapy – go to a high volume Prolotherapy practice).

Despite this warning about knee replacement complication risks being higher when performed at local low-volume hospitals – patients still choose the local – higher risk option. In fact the researchers called these patients the “vulnerable group.”30

As noted above one in three knee replacements are unjustified and inappropriate. Was this the reason many patients suffered from pain after joint replacement?

Further, researchers note that despite the success of total knee replacements as a procedure, “numerous studies report that nearly one in five patients who underwent total knee replacement were unsatisfied with their outcome.”31

One in three should not have been done, one in 5 not satisfied. These finding are confirming what doctors have been discovering – joint replacement surgery should only be the last option – not the first option to degenerative joint disease.

Back in 2006, the rate of knee replacement failures caused some concern that maybe everyone is NOT a candidate for joint replacement. Findings at that time suggested 37% operations supported by a significant disorder on magnetic resonance imaging were unjustified.32

In 2013 a study came out that said only half of people with arthritis who had a hip or knee replacement reported a significant improvement in pain and mobility after surgery. From the press release issued by Women’s College Hospital:

“Patients may need subsequent surgeries to maximize the benefits of joint replacement”

“Many patients with hip and knee arthritis have the condition in more than one of their hip or knee joints,” said the study’s lead author Dr. Gillian Hawker. “So it’s not surprising that replacing a single joint doesn’t alleviate all their pain and disability — patients may need subsequent surgeries to maximize the benefits of joint replacement.”

The study, published in the journal Arthritis & Rheumatism (April 2013), followed a group of patients with osteoarthritis and inflammatory arthritis. Only half reported a meaningful improvement in their overall hip and knee pain and disability one to two years after surgery. What’s more, researchers found the patients who had the worse knee or hip pain to begin with but fewer general health problems and no arthritis outside of the replaced joint were more likely to report benefits.

According to the study authors, nearly 83 per cent of study participants had at least two troublesome hips and or knees.

In general, an estimated 25 per cent of patients who undergo a single joint replacement will have another joint replacement — usually the other hip or knee — within two years.

“While demand for joint replacement surgery has increased as our population ages, physicians lack a set of established criteria to help determine what patients will benefit from surgery and at what point during the course of the disease,” said Dr. Hawker, physician-in-chief at Women’s College Hospital and a senior scientist at ICES. “As physicians, we need to do a better job of targeting treatments to the right patient at the right time by the right provider.”

This may lessen the concern over patient expectations not being met.33


Recommendation to Minimally Invasive Knee Replacement Surgery


There recently has been increased interest in soft-tissue sparing total knee replacement. 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.33


Continuing your research on the alterntives to knee replacement
Stem Cell Therapy for Knee Osteoarthritis and Cartilage Regeneration 

and Platelet Rich Plasma Therapy for Knee Osteoarthritis

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1. Stacey D, et al. Impact of patient decision aids on appropriate and timely access to hip or knee arthroplasty for osteoarthritis: A randomized controlled trial. Osteoarthritis Cartilage. 2015 Aug 4. pii: S1063-4584(15)01267-4. doi: 10.1016/j.joca.2015.07.024. [Epub ahead of print]

2. Klett MJ, Frankovich R, Dervin GF, Stacey D. Impact of a surgical screening clinic for patients with knee osteoarthritis: a descriptive study. Clin J Sport Med. 2012 May;22(3):274-7.

3. http://www.wiley.com/WileyCDA/PressRelease/pressReleaseId-111028.html)

4. Skou ST, et al. A Randomized, Controlled Trial of Total Knee Replacement N Engl J Med 2015; 373:1597-1606October 22, 2015DOI: 10.1056/NEJMoa1505467

5. Parachutes and Preferences — A Trial of Knee Replacement. Jeffrey N. Katz, M.D. N Engl J Med 2015; 373:1668-1669October 22, 2015DOI: 10.1056/NEJMe1510312

6. Umapathy H, Bennell K, Dickson C, Dobson F, Fransen M, Jones G, Hunter DJ. The Web-Based Osteoarthritis Management Resource My Joint Pain Improves Quality of Care: A Quasi-Experimental Study. J Med Internet Res. 2015 Jul 7;17(7):e167. doi: 10.2196/jmir.4376.

7. Van Manen MD, Nace J, Mont MA. Management of primary knee osteoarthritis and indications for total knee arthroplasty for general practitioners. J Am Osteopath Assoc. 2012 Nov;112(11):709-15.

8. Altman R, Lim S, Steen RG, Dasa V. Hyaluronic Acid Injections Are Associated with Delay of Total Knee Replacement Surgery in Patients with Knee Osteoarthritis: Evidence from a Large U.S. Health Claims Database. PLoS One. 2015 Dec 22;10(12):e0145776. doi: 10.1371/journal.pone.0145776. eCollection 2015.

9. Pasquale MK, Louder AM, Cheung RY, Reiners AT, Mardekian J, Sanchez RJ, Goli V. Healthcare Utilization and Costs of Knee or Hip Replacements versus Pain-Relief Injections. Am Health Drug Benefits. 2015 Oct;8(7):384-94.

10. Desmeules F. The burden of wait for knee replacement surgery: effects on pain, function and health-related quality of life at the time of surgery. Rheumatology (2010) 49 (5): 945-954. doi: 10.1093/rheumatology/kep469 First published online: February 8, 2010

11. Styron JF, Barsoum WK, Smyth KA, Singer ME. Preoperative predictors of returning to work following primary total knee arthroplasty. J Bone Joint Surg Am. 2011 Jan 5;93(1):2-10.

12. Styron JF, Barsoum WK, Smyth KA, Singer ME. Preoperative predictors of returning to work following primary total knee arthroplasty. J Bone Joint Surg Am. 2011 Jan 5;93(1):2-10. doi: 10.2106/JBJS.I.01317.

13. Lavernia CJ, Contreras JS, Alcerro JC. Access to arthroplasty in South Florida. J Arthroplasty. 2012 Oct;27(9):1585-8. doi: 10.1016/j.arth.2012.03.014. Epub 2012 May 2.

14. Foran JR, Sheth NP, Ward SR, Della Valle CJ, Levine BR, Sporer SM, Paprosky WG. Patient perception of physician reimbursement in elective total hip and knee arthroplasty. J Arthroplasty. 2012 May;27(5):703-9. doi: 10.1016/j.arth.2011.10.007. Epub 2012 Jan 14.

15. Perruccio A, Power J, Evans H, Mahomed S, Gandhi R, Mahomed N, Davis A. Multiple joint involvement in total knee replacement for osteoarthritis – effects on patient-reported outcomes.Arthritis Care Res (Hoboken). 2012 May 8. doi: 10.1002/acr.21629. [Epub ahead of print]

16. Julin J, Jämsen E, Puolakka T, Konttinen YT, Moilanen T. Younger age increases the risk of early prosthesis failure following primary total knee replacement for osteoarthritis. A follow-up study of 32,019 total knee replacements in the Finnish Arthroplasty Register. Acta Orthop. 2010;81(4):413–419.

17. Healy WL, Della Valle CJ, Iorio R, et al. Complications of Total Knee Arthroplasty: Standardized List and Definitions of The Knee Society. Clinical Orthopaedics and Related Research. 2013;471(1):215-220. doi:10.1007/s11999-012-2489-y.

18. Lu N, Misra D, Neogi T, Choi HK, Zhang Y. Total Joint Arthroplasty and the Risk of Myocardial Infarction: A General Population, Propensity Score-Matched Cohort Study. Arthritis Rheumatol. 2015 Oct;67(10):2771-9. doi: 10.1002/art.39246.2. Complications of Total Knee Arthroplasty: Standardized List and Definitions of The Knee Society.

19. Drexler M, Dwyer T, Chakravertty R, Farno A, Backstein D.  Assuring the happy total knee replacement patient. Bone Joint J. 2013 Nov;95-B(11 Suppl A):120-3.

20. J. R. A. Phillips, B. Hopwood, C. Arthur, R. Stroud, A. D Toms  The natural history of pain and neuropathic pain after knee replacement a prospective cohort study of the point prevalence of pain and neuropathic pain to a minimum three-year follow-up. DOI: 10.1302/0301-620X.96B9.33756 Published 2 September 2014

21. Lavand’homme P, Thienpont E. Pain after total knee arthroplasty: a narrative review focusing on the stratification of patients at risk for persistent pain. Bone Joint J. 2015 Oct;97-B(10 Suppl A):45-8. doi: 10.1302/0301-620X.97B10.36524.

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