I am an active 80 year old who does not want a knee replacement.

Ross A. Hauser, MD

I am an active 80-year-old who does not want a knee replacement.

This is a more typical email than you think. “I am (80) years old, I am still playing tennis and running but I have a lot of pain. The Medicare doctor says I have advanced arthritis, and I will need a knee replacement. My doctor told me there was nothing else to offer me except pain medications and pain management until I can no longer tolerate the pain or I become a fall risk. I can also wear a knee brace to help keep me stable. I do not know if there are alternatives for me, can you help?” Why would the doctor say there was nothing else but knee replacement? Because according to that particular doctor, there is nothing else.

Treatments that are useless for the elderly patient with degenerative knee disease.

We know, many 80-year-olds do not like to be spoken of as elderly, in the medical literature they are. Now, why would the doctor say there were no alternatives to our tennis player above? Because for those who resist the knee replacement option, the only other treatment suggestions are to therapies that are noted for their ability to ONLY prolong or delay the need to have a knee replacement. Not help avoid it.

These treatments include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, Hyaluronic Acid Injections.  Here is the big statement: These treatments are useless for the elderly patient. This is not just our opinion, it is the opinion of a team of researchers publishing in the medical journal American Health and Drug Benefits. (1)

These researchers insist:

• That there is only one realistic option for elderly or older patients with knee osteoarthritis, knee replacement.
• Delaying or prolonging the inevitable knee replacement is a waste of time, a waste of money, and a waste of health industry resources.
• The only people who should not get knee replacement are those with other health issues.
• The need for blood thinners to prevent blood clotting and possible prolonged recovery stay in a nursing home. Should be considered.

The very active elderly patient in the nursing home

There are likely not many active 70 and 80-year-olds who are ready for a nursing home, but why would an active 70 or 80-year-old need to be in a nursing home after knee replacement? The causes are many.

June 2016, published in the journal Anesthesia & Analgesia: “Elderly patients are at risk of increased length of hospital stay, postoperative complications, readmission, and discharge to destinations other than home (nursing homes) after elective total hip replacement and total knee replacement.”(2)

Knee replacement outcomes and complications in elderly patients

Six years later – this research was updated by a a June 2022 study from the University of South Australia, published in the journal Drug safety (9) which examined the mortality and complication rates in patients over the age of 80 AND patients over the age of 90 following a total hip and/or a total knee replacement. The study authors write: “Advancing age is a significant risk factor for the development of perioperative complications and mortality in patients undergoing total hip or knee replacement  due to their compromised health status and the associated medical comorbidities.” To demonstrate the risk factors between 80-somthing and 90-something year old patients, the researchers found: “Although nonagenarians (90 year olds) undergoing total hip or knee replacement can achieve the same clinical benefit as octogenarians (80 year olds), they have a higher risk of perioperative complications and one-year mortality.” The researchers suggest that a careful preoperative screening, proper patient selection and optimization of comorbidities are essential to minimize any postoperative side effects in patients over 90 years of age.

“These findings therefore refute the hypothesis that older patients receiving total knee replacement have similar outcomes to younger patients”

A November 2021 study published in the journal EFORT open reviews (11) agreed: “The most important findings of this systematic review are that older patients (those over 80 years old) receiving total knee replacement have higher rates of surgical and medical complications, as well as higher mortality, compared to younger patients (those less than 80 years). These findings therefore refute the hypothesis that older patients receiving total knee replacement have similar outcomes to younger patients. The literature also reports greater length-of-stay for older patients .” Further the researchers add that their findings “revealed that the older population is at a much greater risk of suffering postoperative cognitive dysfunction, such as confusion or delirium, in comparison to the younger population.”

“I had a knee replacement and it fractured my shin bone.”

A December 2021 study (10) from the University of Toledo Medical Center, Department of Orthopedic Surgery wrote about the various types if fractures caused by the knee replacement prosthetic. The study writes: “Periprosthetic tibia fractures following total knee arthroplasty remain a complex and uncommon complication. The patient cohort included in this study consisted of a population with a high prevalence of comorbidities and a well above average BMI (Body Mass Index > obesity) increasing the difficulty of management. Management of these fractures is highly variable, but union can be achieved through surgical means. With an average union of time of (48-282) days, surgical management provides satisfactory results for Periprosthetic tibia fractures. Of note, conservative treatment was attempted in four cases and included the lone malunion. A common complication associated with Periprosthetic tibia fractures in this case series was compartment syndrome which presented either before or after the surgery.”

In a previous study published in the journal BioMed Central musculoskeletal disorders (3), surgeons wrote: “Periprosthetic tibial fractures predominantly affect elderly patients with a reduced bone quality and reveal a high complication rate. Careful operative planning with individual solutions respecting the individual patient condition is crucial.”

• “I developed blood clots.”
  • Blood clots – Venous thromboembolism is an important complication to monitor following total knee replacement. (Published BioMed Central musculoskeletal disorders September 2018) (4)
• “I lost too much blood during the procedure”
  • Blood management after a joint replacement has become a serious problem. (Published in the journal Medicine September 2018) (5)

We did not mention infection or malpositioning of the new knee or the many other complications a more mature patient may face because we cover this is our article Problems after knee replacement | Finding help for prolonged pain 

Research then has been somewhat shocking in its recommendations that aging or elderly patients proceed directly to total knee replacement. Why not find a non-surgical alternative especially now that the science of joint repair focuses on healing the elderly patient with biomedicine, namely those components of stem cells, blood platelets, and comprehensive Prolotherapy

“I researched stem cells – I went to a seminar at a hotel. They gave me lunch”

For those who did not trust that joint replacement was their only option, alternatives including stem cell therapy were explored.

Here is another typical email: “I researched stem cells, I did a lot of reading. I went to a seminar at a hotel. They gave me lunch. The presenters, I am not sure if they were doctors, told me that my stem cells were too old and weak to help fix my knee, I needed to explore amniotic, placenta, or umbilical cord stem cell therapy.”

Understandably – the science surrounding stem cells for the treatment of osteoarthritis in the elderly is still somewhat in its infancy, as such researchers are still questioning the potential of the elderly stem cell to provide a healing response. This is the argument supported by advocates of allogenic stem cells (from donors) or those who endorse culturing stem cells in overseas clinics, or from those who suggest amniotic/placenta stem cell treatments are needed in the elderly.

In stem cell therapy practiced in the United States, a patient’s stem cells are taken from bone marrow or from the fat from their abdominal area as in a liposuction procedure. The stem cells are then reintroduced into the damaged joint to create a healing environment from a diseased joint environment. They are not cultured or expanded.

In amniotic/placenta/umbilical cord blood treatments there are NO STEM CELLS, only stem cell activators that activate your stem cells. For these “stem cell therapies” to work you need your own stem cells to be very active and very potent.

Question: Is there enough of my own stem cells, are they vital enough? Answer: Look at the synovial fluid, you will find a high presence of native active stem cells in your knee

Doctors at Tokyo Medical and Dental University published their research in the Journal of Orthopaedic research. In it, they looked at patients with mild to severe knee osteoarthritis, obvious problems found in the elderly. They took some of the synovial fluid from the knee joint and found there was a high presence of stem cells in those knees. The researchers speculated that the stem cells were responding to a diseased joint environment and that doctors should investigate what are they doing there and can they be harnessed or signaled action.(6)

In another supportive study published in the World Journal of Stem Cells researchers also found viability and potency even in stem cells from patients with advanced osteoarthritis and agreed that diseased and damaged cartilage has a high number of repair cells, that could also be exploited.(7)

The researchers here are saying that there is a potential to use these extra/native stem cells to heal the knee and doctors need to be aware of how to use them. One method is through Signalling – where stem cells tell other stem cells to “wake up and go to work.” – please see our article on Avoiding knee replacement | Effectiveness of stem cell therapy and bone repair in knee osteoarthritis.

In signaling, doctors believe that the numerous stem cells present in the aging joint are confused and have lost their healing instructions. The introduction of stem cells from the pelvic bone or patient’s fat “reboot” these stem cells to start healing again.

Can stem cell injection therapy in ultra-octogenarians stimulate self-repair? Elderly stem cells should not be dismissed as having limited potency

Doctors have presented research in the medical journal Current Opinion in Rheumatology that stem cell injection therapy in ultra-octogenarians can stimulated to self-repair in Degenerative Joint Disease.

This study says elderly stem cells should not be dismissed as having limited potency, “Mesenchymal stem cells (MSCs) from elderly patients with osteoarthritis may still display significant chondrogenic potential…”(8)

Caring Medical’s Published Research starts with a young man of 63 and continues on with a young woman of 76 years of age

In our own research that we published in the Clinical Medicine Insights Arthritis and Musculoskeletal Disorders, we documented 7 patient outcomes using bone marrow Prolotherapy / stem cell therapy.

• The patients included a 69-year old male with knee pain,
• a 69-year old female with knee pain,
• a 76-year old female with pain in both hips, and
• a 63-year old man with pain in the hips – you can read about their case histories in our article Bone Marrow Stem Cell Prolotherapy.

While we are always hesitant to define anyone as elderly especially patients in their 60’s and 70’s, the research we spoke about earlier in this article set the line of knee replacement at age 70. Once you get to 70, it should only be knee replacement according to that research. But as we have found, 70 is too young NOT to explore stem cell therapy.

The determination of the effectiveness of stem cell therapy in the elderly needs to be made during a consultation. As mentioned above if determined that success will be good, stem cell therapy may be utilized on its own or within the comprehensive prolotherapy program.

If you have questions about stem cell therapy, You can get help and information from our Caring Medical staff

1. 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. American health & drug benefits. 2015 Oct;8(7):384. [Google Scholar]
2. Pitter FT, Jørgensen CC, Lindberg-Larsen M, Kehlet H; Lundbeck Foundation Center for Fast-track Hip and Knee Replacement Collaborative Group. Postoperative Morbidity and Discharge Destinations After Fast-Track Hip and Knee Arthroplasty in Patients Older Than 85 Years. Anesthesia & Analgesia. 2016 Jun 1;122(6):1807-15. [Google Scholar]
3 Schreiner AJ, Schmidutz F, Ateschrang A, et al. Periprosthetic tibial fractures in total knee arthroplasty – an outcome analysis of a challenging and underreported surgical issue. BMC Musculoskeletal Disorders. 2018;19:323. doi:10.1186/s12891-018-2250-0. [Google Scholar]
4 Lu X, Lin J. Low molecular weight heparin versus other anti-thrombotic agents for prevention of venous thromboembolic events after total hip or total knee replacement surgery: a systematic review and meta-analysis. BMC musculoskeletal disorders. 2018 Dec;19(1):322. [Google Scholar]
5 Wang F, Zhao K-C, Zhao M-M, Zhao D-X. The efficacy of oral versus intravenous tranexamic acid in reducing blood loss after primary total knee and hip arthroplasty: A meta-analysis. Palazón-Bru. A, ed. Medicine. 2018;97(36):e12270. doi:10.1097/MD.0000000000012270.  [Google Scholar]
6. Sekiya I, Ojima M, Suzuki S, Yamaga M, Horie M, Koga H, Tsuji K, Miyaguchi K, Ogishima S, Tanaka H, Muneta T. Human mesenchymal stem cells in synovial fluid increase in the knee with degenerated cartilage and osteoarthritis. J Orthop Res. 2012 Jun;30(6):943-9. doi: 10.1002/jor.22029. Epub 2011 Dec 6. [Google Scholar]
7 Eslaminejad MB, Poor EM. Mesenchymal stem cells as a potent cell source for articular cartilage regeneration. World journal of stem cells. 2014 Jul 26;6(3):344. [Google Scholar]
8  Diekman BO, Guilak F. Stem cell-based therapies for osteoarthritis: Challenges and opportunities. Current opinion in rheumatology. 2013;25(1):119-126.  doi:10.1097/BOR.0b013e32835aa28d.[Google Scholar]
9 Kassie GM, Roughead EE, Nguyen TA, Pratt NL, Kalisch Ellett LM. The Risk of Preoperative Central Nervous System-Acting Medications on Delirium Following Hip or Knee Surgery: A Matched Case-Control Study. Drug Safety. 2022 Jan;45(1):75-82. [Google Scholar]
10 Varghese PP, Chen C, Gordon AM, Magruder ML, Vakharia RM, Erez O, Razi AE. Complications, readmission rates, and in-hospital lengths-of-stay in octogenarian vs. non-octogenarians following total knee arthroplasty: An analysis of over 1.7 million patients. The Knee. 2022 Mar 1;35:213-9. [Google Scholar]

• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.