Research on Alternatives to Knee Replacement Surgery
If you are researching Stem Cell Therapy as an alternative please review this article:
Stem Cell Therapy for Knee Osteoarthritis and Cartilage Regeneration
If you are researching at PRP Therapy as an alternative please review this article: Platelet Rich Plasma Therapy for Knee Osteoarthritis
If you are researching Prolotherapy as an alternative please review this article: Prolotherapy for Knee Osteoarthritis
This article is part of our multi-article series on Knee Replacement Alternatives. Other articles include:
- When knee replacement is the wrong operation
- Why patients in pain are made to wait for knee replacement
- Pain after knee replacement
Educating patients on knee replacement
In a recent study, doctors suggested that given educational aids and time to think about knee replacement, more patients (compared to a control group) opted out of getting the knee replacement.1
For many years, the undisputed primary treatment for advanced knee osteoarthritis was a total or partial knee replacement. With patients as those mentioned in the above study questioning whether a total joint replacement is the way for them to go, medicine is moving towards providing alternatives to knee replacement. This is a shift away from surgery towards “biomedicine” and the use of patient’s own stem cells and blood platelets as healing “medicines,” is occurring.
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.
- As risk of complications rates from knee surgery rise, patients should be offered non-surgical options.
- Doctors say we are rushing too many patients to knee surgery
- One Third of Knee Replacements Should Not Have Been Done
- Why shouldn’t I get a knee replacement?
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.
You will also be a candidate for knee replacement these treatments failed to improve your condition:
- anti-inflammatory medications,
- cortisone injections,
- Hyaluronic Acid Injections and lubricating injections,
- physical therapy,
- or other arthroscopic knee surgeries.
From the patient’s 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.
Patient expectations not met
For many patients these simple expectations turnout to be unrealistic expectations as witnessed by research that suggested that people who receive knee replacements expect to have greater independence immediately following the surgery.
Overlooked but certainly one of the most important reasons many patients give for getting a knee replacement is that they need to be able to care for a family member.
From the research: “Transformation from a person with osteoarthritis to someone recovering from a surgical intervention can lead to alterations in the source, type and level of support people receive from others, and can also change the assistance that they themselves are able to offer.
Findings highlight the value of the concept of interdependence to our understanding of participants’ experiences.”2
Conversely, the pressure to help the knee replacement patient recover fails mainly on the spouse and this may be a job that the spouse will need a lot of help doing. Here is the research from a team of leading Swedish and Finnish researchers::
“(The spouse is) considered to be the primary caregivers. . . the spouses’ emotional state played an important role in the patients’ quality of recovery , with uncertainty and depressive state as the main predictors (of not meeting the patient’s or spouse’s expectations of a successful knee replacement).3
The problem is clearly the patients think they can do more after knee replacement and they are not forewarned to reduce their expectations.
Doctors at Australia’s leading medical universities combined to produce this opinion:
“Walking ability and speed are important to the total knee replacement patient and are representative of their pain and function.”4 Important functions to the patients such as how fast they can walk are typically not measured in determining patient outcome scores, compromising true patient outcome surveys.
The rising number of unmet patient expectations is why some doctors believe we are rushing too many people to surgery.
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.”5
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.”6
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:
- 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. 7,8
The video below will demonstrate on of the treatment options, Platelet Rich Plasma Therapy or PRP.
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.9
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.10
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.11
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.”12
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.
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.”19
You may be at high risk for these 22 different risks associated with total knee replacement
The 22 complications and adverse events include:
• 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)
• deep joint infection, (see below)
• 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,
• implant loosening,
• implant fracture/tibial insert dissociation,
• need for revision surgery,
• need for readmission to hospital,
• and death. 20
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.21
You may be at risk for cobalt sensitivity, please see my article on cobalt poisoning in knee replacements.
Are you a candidate for our non-surgical treatments? Ask of specialists:
- Ross Hauser MD – Danielle Steilen, MMS, PA-C – Tim Speciale, DO
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