State of the Art management of knee osteoarthritis?
In February 2015, a new research paper called: “State-of-the-Art management of knee osteoarthritis” outlined treatment strategies for knee osteoarthritis. Here are the summary highlights with treatment suggestions:
- Patients with knee osteoarthritis should be educated on weight loss, strengthening programs, and addressing biomechanical issues with bracing or foot orthoses.
- Patients should be advised that painkillers and anti-inflammatories that while commonly used for managing knee osteoarthritis, can be effective in the short-term but are less effective for long-term management. Additionally, more prolonged use significantly increases the risk of serious associated side effects that are not too uncommon.
- Disease-modifying osteoarthritis drugs need to be further investigated for their effectiveness.
- Patients should be educated on intra-articular injectables to include cortisone, hyaluronic acid, platelet-rich plasma therapy and stem cell therapy.
The goal of developing new treatment strategies for knee osteoarthritis is to prolong the need for total knee replacement which should be utilized only if other strategies have failed.
High tibial osteotomy (cutting and reshaping of the bone) and unicompartmental knee arthroplasty (partial knee replacement) are potential alternatives if only a single compartment is involved with more data supporting unicompartmental knee arthroplasty as a good treatment option in this scenario.
Arthroscopy has been commonly used for many years to treat knee knee osteoarthritis to address degenerative articular cartilage and meniscus, however, several high-quality studies have shown that it is not a very effective treatment for the majority of cases and should generally not be considered when managing knee osteoarthritis. From “State-of-the-Art management of knee osteoarthritis”
One Third of Knee Replacements NOT NECESSARY
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 reported
- Some experts believe the growth of number of knee replacements 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 who said: “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.”
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 endorse “none” or “mild” on all items of the pain and function scales.”
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 replacement2. 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.
While women should take this information into account, any Prolotherapist would argue that all knee osteoarthritis patients should seek a second opinion from a Prolotherapist to see if they can avoid surgery and its potential adverse outcomes.
At Caring Medical and Rehabilitation Services, (CMRS), we have found and shown in research that Prolotherapy is effective for curing knee pain.2
Knee replacement given to patients with low back and hip pain
Recently we wrote about a study that said knee replacement given to patients with low back and hip pain. That sounds inappropriate, does it not? In that study, investigators advised doctors that they must recognize hip disease before giving a recommendation for back and knee surgery because doctors may be performing the wrong procedures. Writing in the medical journal Modern Rheumatology, they say: “We suggest that rheumatologists be aware of hip disease masquerading as knee pain or low back pain.”3
They noted various ways hip pain distributes itself:
Distribution of pain originating in the hip was:
- 89 % to the groin
- 38 % to the buttock
- 33 % to the anterior thigh
- 29 % to the knee
- 27 % to the greater trochanter
- 17 % to the low back
- 8 % to the lower leg
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. Let’s take a look at some recent research.
Positive outcomes and knee surgery success rates
“Arthroscopic joint debridement is a potential and sufficient treatment for knee osteoarthritis in a middle-term time interval. This procedure results in an excellent or good outcome in approximately 60 % of patients in approximately 5 years.”4 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%.5
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.” 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!
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. (See cartilage repair).
One study identifies 22 different risks associated with total knee arthroplasty
Here is what the authors had to say:
“The 22 TKA complications and adverse events include:
- wound complication,
- thromboembolic disease,
- neural deficit,
- vascular injury,
- medial collateral ligament injury,
- deep joint infection,
- extensor mechanism disruption,
- patellofemoral dislocation,
- tibiofemoral dislocation,
- bearing surface wear,
- implant loosening,
- implant fracture/tibial insert dissociation,
- and death.”6
Another surgical complication involves difficulty in performing secondary surgery. In another study, researchers looked at patients who had a prior procedures including bone procedures, high tibial osteotomy, tibial plateau fracture, patellar realignment, and arthroscopy. They discovered that prior knee surgery could be considered a clinical condition that predisposes a patient to postoperative complications with a total knee replacement. After analyzing three groups of patients they found that patients who underwent arthroscopy and meniscectomy had a higher rate of postoperative local complications than patients with no prior surgery or procedures. Further, they found that patients with prior bone procedures showed the poorest postoperative abilities in knee flexion and showed the greatest need for extended surgical approach.7
Prior procedures that damaged the knee
The saline used in many medical procedures actually damages articular cartilage. “Normal saline, the most commonly used irrigation fluid, may have an inhibitory effect on proteoglycan metabolism in articular cartilage. Additional studies are required to assess the potential damage to cartilage from normal saline in the clinical setting.”8
This medical research paper was published in December 2012. Interestingly ,way back in 1991, similar concerns were noted: “[It is suggested] that meniscal damage may occur as a direct result of using normal saline for irrigation during knee arthroscopy.”9
Problem 2: Loss of knee fluid
Remarkably, about twenty years later, one paper noted: “The short-term recovery period post-arthroscopic meniscectomy is characterized by pain and impaired function most likely related to the irrigation of synovial fluid from the knee intraoperatively. Consequently, along with removal of harmful debris, the irrigation fluid dilutes the hyaluronic acid layer covering the joint tissues. Hyaluronic acid contributes to the homeostasis of the joint environment and is an important component of synovial fluid and cartilage matrix. Hence, the instillation of hyaluronic acid after the procedure may relieve symptom. “10
In concept, replacing hyaluronic acid makes sense. If the surgery is causing loss of natural hyaluronic acid, then replacing it after surgery should help. For some it reduced pain ,but it did NOT improve knee function for all. As a side note – which patients were excluded from the study? “Patients with ligamentous injuries or severe chondral damage were excluded.”11 These patients are those who seemingly would benefit the most from Comprehensive Prolotherapy.
Prolotherapy to the knee
Prolotherapy for knee pain
Comprehensive Prolotherapy injections, whether dextrose, Platelet Rich Plasma Therapy, Stem Cell Injection Therapy for Knee Osteoarthritis, or other growth factors is a less complicated, less risky, and less invasive procedure. As we have reported in previous articles, we have documented articular cartilage regeneration in the Journal of Prolotherapy. Here is our summation:
“Prolotherapy improved the pain and function in five knees with osteoarthritis. All five degenerated knees showed evidence of articular cartilage regeneration in their standard weight-bearing X-rays after Prolotherapy. It is suggested that before and after X-ray studies can be used to document the response of degenerated joints to Prolotherapy.”
Prolotherapy is the only treatment found to stimulate cartilage repair and regeneration, as is shown by the X-rays. Furthermore, Prolotherapy offers the most curative results in treating chronic pain. It effectively eliminates pain because it attacks the source: the fibro-osseous junction, an area rich in sensory nerves. This improved tissue strength creates long term pain relief.
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.
2. Judge A, Arden NK, Cooper C, Kassim Javaid M, Carr AJ, Field RE, Dieppe PA. Predictors of outcomes of total knee replacement surgery.Int Orthop. 2014 Feb;38(2):429-35. doi: 10.1007/s00264-013-2268-8. Epub 2014 Jan 9.
3. Nakamura J, Oinuma K, Ohtori S, et al. Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip. Mod Rheumatol. 2012 Apr 11. [Epub ahead of print]
4. 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.
5. 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.
6. Healy WL, Della Valle CJ, Iorio R, Berend KR, Cushner FD, Dalury DF, Lonner JH. Complications of Total Knee Arthroplasty: Standardized List and Definitions of The Knee Society. Clin Orthop Relat Res. 2012 Jul 19. [Epub ahead of print]
7. Piedade SR, Pinaroli A, Servien E, Neyret P.KA outcomes after prior bone and soft tissue knee surgery. Knee Surg Sports Traumatol Arthrosc. 2012 Jul 25.
8. Gulihar A, Bryson DJ, Taylor GJ. Effect of Different Irrigation Fluids on Human Articular Cartilage: An In Vitro Study. Arthroscopy. 2012 Dec 19. pii: S0749-8063(12)01654-4. doi: 10.1016/j.arthro.2012.07.013. [Epub ahead of print]
9. Mah ET, Lee WK, Southwood RT, Carbone A, Leppard PJ. Effects of irrigation fluid on human menisci: an experimental comparison of water, normal saline, and glycine. Effects of irrigation fluid on human menisci: an experimental comparison of water, normal saline, and glycine. Arthroscopy. 1991;7(1):24-32.
10. Thein R, Haviv B, Kidron A, Bronak S. Intra-articular injection of hyaluronic acid following arthroscopic partial meniscectomy of the knee. Orthopedics. 2010 Oct 11;33(10):724. doi: 10.3928/01477447-20100826-11.
11. Hauser R, Phillips HJ, Maddela HS. The Case for Utilizing Prolotherapy as First-Line Treatment for Meniscal Pathology: A Retrospective Study Shows Prolotherapy is Effective in the Treatment of MRI-Documented Meniscal Tears and Degeneration. Journal of Prolotherapy. 2010;2(3):416-437.