Caring Medical - Where the world comes for ProlotherapyResearch on Alternatives to Knee Replacement Surgery

Research on Alternatives to Knee Replacement Surgery

Ross Hauser, MD

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:


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:

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:

You will also be a candidate for knee replacement these treatments failed to improve your condition:

From the patient’s perspective, when asked why they considered a total knee replacement, patients responded in survey research that they wanted:


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.” 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.


Doctors say we are rushing too many patients to knee surgery


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


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.”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:

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:

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 complications7,8

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



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.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:
• 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. 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:

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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. [Pubmed]

2. Johnson EC, Horwood J, Gooberman-Hill R. Trajectories of need: understanding patients’ use of support during the journey through knee replacement. Disabil Rehabil. 2016 Dec;38(26):2550-63.  [Pubmed]

3. Stark ÅJ, Salanterä S, Sigurdardottir AK, Valkeapää K, Bachrach-Lindström M. Spouse-related factors associated with quality of recovery of patients after hip or knee replacement – a Nordic perspective. Int J Orthop Trauma Nurs. 2016 Nov;23:32-46. [Pubmed]

4. Graff C, Hohmann E, Bryant AL, Tetsworth K. Subjective and objective outcome measures after total knee replacement: is there a correlation? ANZ J Surg. 2016 Nov;86(11):921-925. [Pubmed]

5. 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. [Pubmed]

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

7. 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 [New England Journal of Medicine]

8. 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 [New England Journal of Medicine]

9. 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.

10. 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.

11. 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.

12. 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.

13. 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

14. 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.

15. 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.

16. 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.

17. 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.

18. 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]

19. 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.

20. 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.

21. 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.

22. 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.

23. 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

24. 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.

25. Burns LC, Ritvo SE, Ferguson MK, Clarke H, Seltzer Z, Katz J. Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review. J Pain Res. 2015 Jan 5;8:21-32. doi: 10.2147/JPR.S64730. eCollection 2015.

26. 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.

27. 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.

28. Jackson G, et al. Complications Following Quadriceps-sparing Total Knee Arthroplasty. Orthopedics. June 2008 – Volume 31 · Issue 6

29. Al-Hadithy N, Rozati H, Sewell MD, Dodds AL, Brooks P, Chatoo M. Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies? Int Orthop. 2012 Jan 11.

30.  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.

31. T Ibrahim T, et al. Temporal trends in primary total hip and knee arthroplasty surgery: results from a UK regional joint register, 1991–2004 Ann R Coll Surg Engl. 2010 Apr; 92(3): 231–235.

32. Nakamura J, Oinuma K, Ohtori S, Watanabe A, Shigemura T, Sasho T, Saito M, Suzuki M, Takahashi K, Kishida S. Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip. Mod Rheumatol. 2013 Jan;23(1):119-24. doi: 10.1007/s10165-012-0638-5.

33. Lau RL, Perruccio AV, Gandhi R, Mahomed NN. The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature.BMC Musculoskeletal Disorders. 2012;13:250.

34. Maratt JD, Lee YY, Lyman S, Westrich GH4. Predictors of Satisfaction Following Total Knee Arthroplasty. J Arthroplasty. 2015 Jan 30. pii: S0883-5403(15)00062-5. doi: 10.1016/j.arth.2015.01.039. [Epub ahead of print]

35. Ben-Galim P1, Steinberg EL, Amir H, Ash N, Dekel S, Arbel R. Accuracy of magnetic resonance imaging of the knee and unjustified surgery. Clin Orthop Relat Res. 2006 Jun;447:100-4.

37. 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.

38. Dy CJ, Marx RG, Ghomrawi HM, The potential influence of regionalization strategies on delivery of care for elective total joint arthroplasty. J Arthroplasty. 2015 Jan;30(1):1-6. doi: 10.1016/j.arth.2014.08.017. Epub 2014 Sep 6.

39. Hodges A, Harmer AR, Dennis S, Nairn L, March L, Crosbie J, Crawford R, Parker D, Fransen M. Prevalence and Determinants of Fatigue Following Total Knee Replacement: A Longitudinal Cohort Study. Arthritis Care Res (Hoboken). 2016 Oct;68(10):1434-42. doi: 10.1002/acr.22861.

40. Howells N, Murray J, Wylde V, Dieppe P, Blom A. Persistent pain after knee replacement: do factors associated with pain vary with degree of patient dissatisfaction? Osteoarthritis Cartilage. 2016 Aug 9.

41. Vina ER, Ran D, Ashbeck EL, Kaur M, Kwoh CK. Relationship Between Knee Pain and Patient Preferences for Joint Replacement: Healthcare Access Matters. Arthritis Care Res (Hoboken). 2016 Sep 16.

42. Gottfriedsen TB1, Schrøder HM, Odgaard A. Transfemoral Amputation After Failure of Knee Arthroplasty: A Nationwide Register-Based Study. J Bone Joint Surg Am. 2016 Dec 7;98(23):1962-1969.


BW 10/28/2016

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