Ross Hauser, MD; Danielle R. Steilen-Matias, MMS, PA-C.
Many people are faced with a decision when they go to their “final,” all conservative treatments have failed visit to their orthopedist surgeon. The decision they need to make is what do I do next?
So here you are, likely at the end of years of conservative treatments that have included everything from physical therapy, weight management, anti-inflammatory medications, knee braces, cortisone injections, hyaluronic injections, and all sorts of remedies that you bought online and you still have a painful, swollen knee that will make you wince in pain when you try to walk steps, get out of bed, or try to do your physically demanding job.
You are sitting in the examination room of your orthopedist surgeon and he or she will walk in with your latest MRI and tell you that you are “bone on bone.” You should get a knee replacement. You can either manage your knee as you have been doing, which is not really an option anymore because your knee is getting worse or worse, or you can move forward with a total knee replacement.
You start thinking about knee replacement because others have had it, you started doing your research online and you see people playing tennis and you are not sleeping at night.
For some people, where there is a degenerative deformity of the knee and the knee bends inwards to create a “knocked knee,” look or it is bowed outward to create a bowlegged appearance, or if your knee does not bend because it is now encased and locked in place by bone spurs, knee replacement will likely be the only option.
But if you can still work, your knee still bends, you are still walking a golf course, there can be alternatives to knee replacement that you have not tried yet, and that will be explained below.
Being forced to wait for knee replacement. Treatment options to help avoid knee surgery
This article gives options for patients in pain who have been told that their knee replacement cannot be performed for them at this time.
In our nearly three decades of proving alternatives to surgery and our nearly 25 years of being an online presence, we have constantly updated our articles to provide our readers with the latest in research and clinical observations. In 2020 we added a new list of impacts to include COVID.
Your ability to get a knee replacement may have been greatly impacted. You have been told to wait, elective surgeries have now been delayed. You have to go back to the very treatments that were not helping you and may have accelerated your need for knee replacement. But you understand as well as other people waiting for knee replacement.
Here are some observations on patient reaction to this delay from Emory University School of Medicine researchers publishing in the HSS Journal: The Musculoskeletal Journal of Hospital for Special Surgery, November 2020 (1)
In this study, 111 patients who experienced COVID-19-driven delays to scheduled total hip or knee replacements were asked a series of questions regarding this delay to get a surgery
90% said that the surgical delay was in their best interest;
68% reported emotional distress from the delay, but 45% reported a desire to wait longer for the pandemic to subside.
Lower joint-function scores,
higher pain levels,
higher pain catastrophizing scores,
and longer latency (delay) from personally deciding to pursue surgery were associated with the reported need for immediate surgery. (The longer the wait, the greater the patient’s felt a need to get the surgery as soon as they could.
Conclusion: “Overall, patients reported that they understood the need for elective surgical delays during the COVID-19 pandemic. However, the psychological implications they reported were not negligible (should not be ignored). Patient preference for immediate re-engagement with the healthcare system was dichotomous (divided, wait for surgery, need surgery now), with many patients favoring precautionarily furthering the delay.
You probably do not need to be told what these researchers have confirmed:
Patients who are waiting months until their doctor can be available for the surgery suffer from severe and accelerated knee instability, difficulty walking, and pain. Perhaps like yourself, most of these patients rely on painkillers and cortisone to get them through until surgery. Perhaps like yourself, these people as they become more disabled, take excessive medication to possibly include anti-depressants to help deal with the depression and isolation that comes with battling chronic knee pain.
However, this does not have to be the fate of all patients who were told they need to wait to get a knee/joint replacement. In many cases, the ideal intervention is actually not surgery but regenerative options that can repair the joint non-surgically.
What happens when you are waiting for a knee replacement?
So what happens to your knee while you are waiting for a knee replacement?
In one study, doctors from Laval University in Quebec wrote in the medical journal, Rheumatology(2) about 153 patients who had been given a date far in advance for their total knee replacement. What the doctors wanted to study were the patient’s changes in pain, function, and quality of life and the possible burden excessive wait times had on these 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.”
The problem is compounded because one of the factors that will give a patient pain after knee replacement, is the poor management of their pain before the surgery.
It gets worse for obese and depressed patients.
Researchers at the University of Kentucky and Harvard Medical School (3) wrote: “The combination of inferior knee pain, physical function, and significantly greater increases in biomarkers of cartilage degradation (Cartilage loss) and bony remodeling (bone spurs) suggest a more rapid progression for obese osteoarthritis patients with comorbid depression.”
Patient education – the longer you wait for knee replacement the less likely you will want it.
Here is an example of someone who contacted us and their reasoning for not going forward with a knee replacement.
I have been avoiding knee replacement for years now. I was told years ago that knee replacement was my only option. I have been functioning with pain that has gotten progressively worse but I have survived it. I am now being told to get an MRI so a stronger recommendation can be made to get a knee replacement now. No other treatments have been offered to me, it is almost like “it is knee replacement or the highway.” I cannot take the time off from work, I am the only means of support for an extended family.
Researchers from four universities including the University of Ottawa, the University of Montreal, the University of Toronto, and the University of Chicago, published research in the medical journal Osteoarthritis and Cartilage. In this study, the researchers say more patients, when given educational aids and time to think about the benefits and side effects and complications of knee replacement, opted out of getting the knee replacement (compared to a control group).
When people come into our office looking for an alternative for knee replacement, they come in with a new understanding of how knee replacement will impact their lives. Some NOT in a good way.
We often see the older patient with knee pain who cannot even think about a knee replacement because he or she needs to care for a husband or wife who has their own health issues. As we will see in this article one unforeseen circumstance of knee replacement is that the person recovering from knee replacement can no longer offer the assistance that they provide their spouse on a daily basis. Now, this couple needs to consider assisted living or in-home care providers.
Another reason we see many patients looking for alternatives is that they cannot take the possibility of 6 to 9 months off from work necessary for recovery. Especially contractors, landscapers, and those with physically demanding jobs. Many of these people have simply assumed that they can get back to work fast after knee replacement. Many do not return to work. The sobering research can be found here: How fast can I return to work after knee replacement? 15 to 30% of patients do not return to work.
In this article we will:
Provide information to the person who has been told that knee replacement now or later will be their only option to repair their knee.
Show research that many patients were not aware of what knee replacement would mean as far as expectation of success.
Then we will explore research on alternatives to knee replacement that do not prolong need or delay knee replacement but seeks to provide an option to avoid knee replacement.
Lastly, we will explore how these non-surgical options address the problems of degenerative knee disease and joint destruction by re-building the cartilage and ligaments of the knee.
Patients are seeking their own information on an alternative to knee replacements because they are not getting all the information they could from their doctor.
This is alluded to in numerous research studies which suggest that if given educational tools and time to think about it, many patients opt out of knee replacement.
Examples of this research include a paper from four universities including the University of Ottawa, the University of Montreal, the University of Toronto, and the University of Chicago, published research in the medical journal Osteoarthritis and Cartilage. (4) In this study, the researchers say more patients, when given educational aids and time to think about the benefits and side effects and complications of knee replacement, opted out of getting the knee replacement (compared to a control group).
Unchanged or worse pain and physical function 1 year after knee replacement surgery
In September 2020, a multi-national research team including orthopedic surgeons suggested that 20% of patients do not have favorable outcomes following knee replacement surgery and the mechanism for screening outpatients who are at high risk for surgical failure is outdated. Here is exactly what they said in the prestigious medical journal BMJ Open(5):
“One in five patients undergoing total knee arthroplasty (replacement) experience unchanged or worse pain and physical function 1 year after surgery. Identifying risk factors for unfavorable outcomes is necessary to develop tailored interventions to minimize risk. There is a need to review more current literature with an updated methodology that addresses the limitations of earlier systematic reviews and meta-analyses.”
There is a need, according to this paper, to minimalize the risks of failed knee replacement surgery in one out of 5 patients. Simply said.
Let’s again stress that 4 out of 5 people have successful surgeries and are very happy with their decision. This article is again for those people who are in the 20%. This is what we hear:
Is there help for me, I would up with severe pain after knee replacement and now I have to use a walker. The knee is also very stiff but I have been told it is not a hardware problem and physical therapy would help me. I have had physical therapy and it is not helping me. I cannot find any solutions to my knee problem.
People who used opioids prior to surgery and more often to help them manage their pain prior to surgery were at greater risk for failed knee replacement.
Is it far-fetched to imagine that people who are waiting for knee replacement surgery or putting it off without treatments that are helping them are more prone to taking opioids and other medications to help them manage their pain?
In December 2020, researchers writing in the European Journal of Pain (6) again touched on a common theme among surgeons, that “One in five patients experiences chronic pain 12 months following total knee arthroplasty (replacement),” and again looked for those pre-operative reasons for what would put a patient at risk for a poorer outcome. Here is how this research team conducted their study and sought to help isolate those risk factors. What did they find? More medication usage.
“On the day before (knee replacement) surgery, 202 patients completed questionnaires that assessed pain, interference with functioning, fatigue, anxiety, depression, and illness perceptions.”
Patients without that much pre-surgical pain or who had “lower than average” and “lower than average worst” pain scores had moderate preoperative pain scores that decreased over the nine months following total knee replacement.
Patients in the “higher than average” and “higher than worst” pain classes had relatively higher preoperative pain scores that increased during the first three months and then decreased slightly over the remaining 9 months. Patients in the higher pain classes had higher interference with function scores; used opioids prior to surgery more often, were more likely to receive a continuous nerve block and ketamine (a pain killer that is seen as a better alternative to stronger pain medications); had higher preoperative fatigue severity and interference scores, and had worse perceptions of illness than patients in the lower pain classes.
Patients should be more well educated on the realistic expectation of knee replacement of what the surgery can actually do for them
In February 2019, researchers opened a study to see if patients were being well informed about the appropriateness of their knee replacement recommendation. Publishing in the journal BioMed Central Musculoskeletal Disorders,(7) the research team wrote: “While the rates of total knee replacement continue to rise worldwide, there are concerns about whether all surgeries are appropriate. Guidelines for appropriateness suggest that patients should have realistic expectations for total knee replacement and that the patient and their surgeon should agree that the potential benefits outweigh the potential harms.”
The team then designed various education aids that they are testing to investigate whether the self-reported outcomes of patients who previously underwent total knee replacement can be used to improve decision quality about the appropriate use of total knee replacement They note that many health systems have been routinely collecting patient-reported outcome measures (PROMs) pre and post total knee replacement. Further, “While these data have been collected to support decision-making at a health systems level, we believe there is a role for these data to inform setting realistic expectations for patients, and promoting shared decision-making with their care provider.”
In other words, the suggestion is that patients should be more well educated on the realistic expectation of knee replacement of what the surgery can actually do for them. It is thought that the more information the patient gets, the less likely that the patient will have a knee replacement.
Patients with knee pain and osteoarthritis management are often confined mainly to the use of painkillers and waiting for eventual total joint replacement
In the Journal of Medical Internet Research,(8) doctors suggest that despite the availability of this educational material and the evidence-based guidelines for conservative treatment of osteoarthritis. Patients with knee pain and osteoarthritis management are often confined mainly to the use of painkillers and waiting for eventual total joint replacement.
Unfortunately these “alternatives,” have also been found lacking. Research published in The Journal of the American Osteopathic Association has shown: These “conservative” treatments while serving as the standard of care, do not really help a patient avoid knee replacement surgery. (9)
Doctors report knee replacement surgery as a success. Their patients say not so fast. What is a successful knee replacement surgery? To a patient that would be long-term relief from pain and increased function and mobility. This is NOT a realistic expectation for patients to have according to researchers
Doctors in Spain examined what factors influenced a patient having a successful knee replacement surgery, and what influences prevent patients from having successful knee replacement surgery. (10) In their study appearing in the Journal of Evaluation in Clinical Practice, they write:
There is conflicting evidence about what factors influence outcomes after total knee replacement. The objective of this study is to identify baseline factors that differentiate patients who achieve both, minimal clinically important difference and a patient acceptable symptom state in pain and function, measured by WOMAC (Pain scoring system), after total knee replacement from those who do not attain scores above the cutoff for improvement.
What were the two most important factors the Spanish team looked at one year after surgery?
Expectations -patients did not have a realistic expectation of what they could and could not do after the knee replacement.
The mental anguish and health of the patient while they were waiting for the knee replacement.
The recommendation from this research?
While they wait for surgery, doctors and caregivers should manage the patient’s expectations so they have a realistic opinion of what happens after the surgery. Manage their mental health before the surgery to help with a more positive outlook afterward.
Patient expectations of greater independence immediately following the surgery not met. Patients upset that they cannot walk as well as they thought they could.
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.
For many patients, simple expectations turned out 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.
Doctors say we are rushing too many patients to knee surgery, this can be why expectations are not met.
The rising number of unmet patient expectations is why some doctors believe we are rushing too many people to surgery.
In a 2012 study appearing in the Clinical Journal of Sports Medicine, (11) 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 a 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.”
Before you say, that was 2012, what about now? In December 2019, (12) a study published in the journal Health and Quality of Life Outcomes noted that patients who valued quality-of-life improvements before knee replacement surgery and expected such after the surgery were among the highest unsatisfied with their knee replacement groups. One reason? Inappropriateness and over expectation of how the knee replacement would change their quality of life.
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.
From research from the University of Bristol in the United Kingdom: “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.”(13)
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 in the International Journal of Orthopaedic and Trauma Nursing:
“(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 the depressive state as the main predictors (of not meeting the patient’s or spouse’s expectations of a successful knee replacement). (14)
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 published in the Australian and New Zealand Journal of Surgery.
“Walking ability and speed are important to the total knee replacement patient and are representative of their pain and function.”(15) 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.
If you have joint pain in joints OTHER than the knee being replaced, you are at risk for less successful knee replacement
In their research study researchers were looking to determine whether symptomatic (painful/problematic) joints pre-total knee replacement surgery influenced the outcomes of knee replacements, and they did
Pre- and post-surgery, worse outcome scores were observed with an increasing joint count. (The more joints that hurt, the less successful the knee replacement). Why?
Patients had worse pre-surgery fatigue and anxiety.
Patients had worse fatigue, depression, pain, and function in non-operated joints post-surgery
Conclusion? Findings suggest that a comprehensive approach to osteoarthritis management/care is warranted, and identify important associations between painful joints and mood that negatively impact post-total knee replacement pain and physical function. (16)
So 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 if these treatments failed to improve your condition:
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 the use of an effective procedure, while others contend there is an over-use of the surgery that relies on subjective criteria.
In other words a medical equation
“knee osteoarthritis = knee replacement”
In the 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.”
Further as discussed below, patients are being made to wait until they are old enough for knee replacement.
Ethically, this should be a problem for many. People forced to live in pain until they are of the 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
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.(17,18)
Is delaying knee replacement with Hyaluronic Acid Injections worth it in the end?
In our article Research on Hyaluronic injections for Knee Osteoarthritis, We write: It should be noted that we see many patients who have tried hyaluronic acid injections. These injections have worked for these people in the short term. These patients are now in our office because the short-term has not transpired to the long-term and now a different treatment approach needs to be undertaken.
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:
For 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. (19)
HOWEVER, the second in the journal American Health and Drug Benefitssuggest 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 ).”(20)
We talk more about these injections below when we compare Hyaluronic Acid Injections with other knee injections.
Knee Replacement – How old is too young? Is it 55?
Knee Replacement – How old is too young? Is it 55?
Here is research from researchers at the University of Tampere, Finland 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.”(21)
22 different risks associated with total knee replacement
Researchers writing in the journal Clinical Orthopaedics and Related Research say 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. (22)
You may also be at high risk for a post-surgical heart attack. Doctors at Harvard Medical School released their study in October 2015 that showed the 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 overtime for those having total knee or total hip arthroplasty as well. (23)
Maybe everyone is NOT a candidate for knee replacement
The debate over whether or not to have a knee replacement is not a new one. Back in 2006, the rate of knee replacement failures caused some concern that maybe everyone is NOT a candidate for knee replacement.
Findings at that time published in the medical journal Clinical Orthopedics and Clinical Research suggested 37% of operations supported by a significant disorder on magnetic resonance imaging were unjustified. (24)
Unjustified: Surgeons were sending patients to knee replacement with slight to moderate osteoarthritis
That was 2006, certainly, things have changed. Eight years later, on June 30, 2014, research in the medical journal Arthritis & Rheumatology, suggested more than one-third of total knee replacements in the United States were the “inappropriate” treatment. Researchers in this study, lead by Daniel Riddle, PT, Ph.D. of the Department of Physical Therapy, Virginia Commonwealth University, found that surgeons were sending patients to knee replacement with slight to moderate osteoarthritis. (25)
In December 2017, Dr. Riddle assessed The American Academy of Orthopaedic Surgeons (AAOS) recently published appropriateness criteria for patients with knee osteoarthritis who are being considered for total knee arthroplasty in the medical journal Osteoarthritis Cartilage. Here are the highlights:
The number one reason for patients seeking a knee replacement is function limiting pain
Functioning limiting pain is not part of the new AAOS criteria for appropriate patient selection. Rather surgeons are now looking at:
Structural damage to the knee causing reduced or severely impeded knee range of motion
This new classification tree had an accuracy of 86.7% A significant improvement from the 74.3% in Dr. Riddle’s 2014 study. (26)
Exploring the options for Knee Replacement Surgery
Doctors from Australia published these observations about their patients suffering from knee osteoarthritis in the medical journal BioMed Central Musculoskeletal Disorders. (27)
They had concerns about knee replacement being the right choice for every patient.
The Australian team noted that current accepted medical treatment strategies for osteoarthritis are aimed at symptom control rather than curing or reversing the disease. Once symptom control can no longer control pain in knee osteoarthritis patients, surgical options including knee replacement are given.
However, the recommendation for knee replacement is sometimes not carefully examined as the best option. Before knee replacement is agreed to the possibility of significant complications after knee replacement should be discussed with patients.
The answer patients want to explore – non-surgical stem cell treatments:
Encouragingly, results of pre-clinical and clinical trials have provided initial evidence of efficacy and indicated safety in the therapeutic use of mesenchymal stem cell therapies for the treatment of knee osteoarthritis.
Our goal of treatment is to help the person with knee pain and osteoarthritis who has been told that knee replacement is their only option to avoid that surgery.
While covering studies above in this article which clearly shows the detrimental effects of some “conservative care,” treatments on a knee, deep in degenerative disease, it can not be emphasized enough how damaging nonsteroidal anti-inflammatory medications and corticosteroid injections are to the joint, especially the articular cartilage.
These treatments make it more difficult in the long run for the patient to walk. Besides independence and mobility, your knee needs to walk because that is how nutrients reach the articular cartilage to help it heal.
Our goal of treatment is to help the person with knee pain and osteoarthritis who has been told that knee replacement is their only option, stop destructive treatments, and stabilize their knee to prevent the destructive stress forces from further damaging their knee.
Your knee cannot repair itself because the destruction is greater than your knee’s ability to repair itself. Let’s get to work then on fixing this.
The knee works in concert as a whole. Your knee ligaments keep the impact of weight-bearing centered on the cartilage padding of the knee, the meniscus, and articular cartilage. The cartilage and meniscus cushions the force of walking and running and jumping from damaging your bone.
When the knee ligaments are weakened and damaged, the knee has hypermobility. It is moving around off of its center. This means the stress and impact of force are no longer centered on the protective cushions. Areas of the knee not designed to take impact, are now taking impact they were not designed to take. The knee begins to crumble under your weight.
So we are dealing with more than bone on bone, we are dealing with total knee failure.
The different types of knee injections as an alternative to knee replacement surgery
We have given a lot of research and tried to present information on the good and bad of knee replacement. Again we want to stress that many people do very well with knee replacement surgery. These are people that we do not see at our center. We see the people for whom knee replacement is not an option because the person is not a good surgical candidate, the person who cannot “wait” any longer for knee replacement and needs to do something now. We also see the person who is working and cannot take the time off from work or the person who is a caregiver to a partner or spouse and they themselves cannot be “laid up,” for months.
Here we are briefly going to present the various knee injection options that may help you avoid knee surgery. We have a much more comprehensive article with expanded research here: The different types of knee injections.
In the past, your doctor may have recommended against the use of cortisone because it was clear to him or her that there was a knee surgery in your future. The concern is if you get cortisone injections into your knee prior to surgery, you will have a greater risk of complications after the surgery. There is a lot of debate around this subject. Some doctors say avoid the cortisone, other doctors are saying it is okay to get one shot to hold you over until you can get surgery or maybe the cortisone will reduce your inflammation enough after the first shot that you will have some degree of pain relief and comfort for a few months, a year, maybe longer.
Corticosteroid knee injections provided no significant pain relief after two years. Researchers say: Do not give cortisone for knee osteoarthritis.
In 2017, doctors from Tufts Medical Center in Boston asked, “What are the effects of intra-articular injection of 40 mg of triamcinolone acetonide (a synthetic corticosteroid medication) every 3 months on the progression of cartilage loss and knee pain in patients with osteoarthritis?” Writing in the Journal of the American Medical Association, (JAMA) (28) they published their answer:
“Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.“
We do not offer cortisone injections at our center. In approaching three decades of helping people with knee pain this is a treatment that we did not find beneficial. In 2009, our research team wrote in the Journal of Prolotherapy: “It is (our) opinion that there is no doubt that the rise of osteoarthritis, as well as the number of hip and knee replacements, is a direct result of the injection of corticosteroids into these joints.”(29)
The evidence then was a summary of the effects of cortisone on articular cartilage which included:
a decrease of protein and matrix synthesis (the nutrient and healing bed that cells grow in),
mutation of (cartilage) cell shape
growth of new cartilage inhibited,
cartilage destruction risk and enhancement
cartilage surface deterioration including edema, pitting, shredding, ulceration and erosions, etc, etc.
Hyaluronic acid injections or Viscosupplementation for Knee Osteoarthritis
Much like cortisone, it is very likely that this knee injection treatment has been explained to you already by your orthopedist. It is a conservative care plan to help you try to manage along until you can get a knee surgery scheduled or you are trying to do everything you can to avoid the knee surgery.
Also like cortisone, you may have already had viscosupplementation and the effects and benefits have now worn off and you need to treat your knee differently. For some people, they may not even be reading this sentence because they have moved down the article to other treatments because this one is no longer an option for them.
Over the years we have seen many patients who have been on the “gel shots.” These shots are more known by their brand names: Euflexxa ®, Supartz ® Supartz FX ®, Synvisc-One ®, Synvisc ®, Hyalgan ®, Orthovisc ®, et al. All these products offer subtle differences in their treatment goals including the number of injections – however, none of them offer a permanent solution. This is what the American Academy of Orthopaedic Surgeonsposted on their website:
“The theory is that adding hyaluronic acid to the arthritic joint will facilitate movement and reduce pain. The most recent research, however, has not found viscosupplementation to be effective at significantly reducing pain or improving function. Although some patients report pain relief with the procedure, some people are not helped by the injections.”
Are Hyaluronic injections low-value health care? Using Medicare Data to Understand Low-Value Health Care: The Case of Intra-articular Hyaluronic Acid Injections.
A research letter in the Journal of the American Medical Association Internal Medicine, (30) with the title: Are Hyaluronic injections low-value health care? Using Medicare Data to Understand Low-Value Health Care: The Case of Intra-articular Hyaluronic Acid Injections, backed that up with “based on high-quality evidence that hyaluronic acid injections were not associated with clinically meaningful improvement in symptoms compared with placebo injections.”
This statement paper is from 2014, let’s see if we can advance the research forward towards 2021.
The first stop is February 2016 and the journal Clinical Orthopaedics and Related Research. (31) It is an editorial from Seth S. Leopold, MD. Here are the quoted learning points:
“Surgeons who follow the evidence should relegate injectable viscosupplements (hyaluronic acid products) to the list of abandoned treatments. Several comprehensive analyses agree that they either are minimally effective or ineffective. They probably are safe, though their use carries some risk. To the degree that they are not effective, it is hard to make a case for (viscosupplements) value.”
“I (Dr. Leopold) know there are many proponents of these treatments in the orthopaedic community; however, the observations about viscosupplementation’s inefficacy are not mine alone. Well-done reviews and meta-analyses recommending against the use of this treatment have appeared in The New England Journal of Medicine and the Annals of Internal Medicine; The Osteoarthritis Research Society International’s (OARSI) guidelines for the non-surgical management of knee osteoarthritis listed viscosupplementation among the treatments of “uncertain appropriateness. . . “
Then why is your doctor still recommending this treatment?
Let’s let Dr. Leopold continue:
“One reason might be that surgeons have relatively few effective nonsurgical alternatives that help patients with their joint pain, and—being members of a helping profession—we find this frustrating. However, our lack of effective nonsurgical treatments cannot justify the use of an ineffective one, and it must not be used to justify surgery unless surgery is indicated. Some patients will have pain that persists despite well-tested nonsurgical treatments, but not enough to warrant major joint surgery; others may not fit the biopsychosocial profile that supports a decision to perform elective arthroplasty. The answer to this is not to use a treatment like viscosupplementation that studies suggest is ineffective, nor to take a chance on surgery when it seems ill-considered to do so, but rather to explain to patients that there are some problems for which we have no effective treatments, and to help those patients adjust and adapt.”
You can delay knee replacement realistically for about 11 months with hyaluronic acid injections
In September 2020, a study in the journal American Health and Drug Benefits,(32) assessed the value of intra-articular hyaluronic acid injections monetarily. This is a study to determine the treatment’s effectiveness. This is what the study said:
Although limiting hyaluronic acid use may reduce knee osteoarthritis-related costs, in this study hyaluronic acid injection only comprised a small fraction of the overall costs related to knee osteoarthritis. Among patients who had a knee replacement, those who received treatment with hyaluronic acid had surgery delayed by an average of 10.7 months.
Platelet-Rich Plasma (PRP)
This is one of the injections that you may have been researching because it is somewhat off the traditional conservative care options path and you stumbled upon PRP online. You may have even asked your orthopedist about “PRP” injections and you were told: “They do not work, they are not covered by insurance.”
Well, that is probably enough to chase anyone away. Except for one thing. There is a lot of research that when administered correctly by a doctor experienced in the treatment, PRP works pretty well. So just like the debate about cortisone and the debate about Hyaluronic Acid Injections, there is a debate about PRP injections.
Research comparing PRP injections, cortisone injections, and hyaluronic acid injections
Doctors wrote in a January 2019 study (33) that while PRP injections, cortisone injections, and hyaluronic acid injections are considered equally effective at relieving patient symptoms at three months, at 6, 9, and 12 months the PRP injections delivered significantly better results.
A July 2020 study (34) published in the Journal of Pain Research also suggested that PRP injections provided better results for patients than hyaluronic acid injections. The study’s conclusions were: Besides significantly higher satisfaction belonging to the (PRP) group, there was a statistically significant improvement in pain and function scores at 12 months compared to hyaluronic acid injections
In research published in the Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, PRP was shown to provide significant healing of the meniscus (35) as well as out out-perform hyaluronic acid in patients with knee joint cartilage degeneration. Similar results were documented in the journal Archives of physical medicine and rehabilitation. (36)
PRP is not a single shot miracle cure. The effectiveness of PRP is in how many times the treatment is given
PRP is not a single shot miracle cure. While for the rare patient a single shot may work for them, we have seen in our clinical experience, PRP not to be as effective as a stand-alone, single-shot treatment. When someone contacts our center with a question about PRP, they understand the concept and that it should have helped them. But it did not. Why?
PRP does not work for every patient. The two main reasons are that some knees are “too far gone.” What is typically too far gone? A knee that does not bend anymore or there is significant structural changes like bone spurs that have fused the knee.
The second reason is that they did not allow the treatment a chance to work. Many people think they are supposed to get immediate relief. That is not how PRP works.
In this video, Ross Hauser, MD explains how one injection of PRP will likely not work
A transcript summary is below the video
Is PRP controversial? Yes. Is it effective? Also yes.
When it works. Below are many citations and references showing the effectiveness of PRP.
Let’s start with the most recent research on the effectiveness of PRP for knee osteoarthritis.
While an October 2020 study in The Journal of International Medical Research (37) still acknowledges that “the clinical efficacy of platelet-rich plasma (PRP) in the treatment of osteoarthritis remains controversial,” their examination of five clinical trials including 320 patients found: “intra-articular injection of PRP is an effective treatment for osteoarthritis that can reduce post-operative pain, improve locomotor function, and increase patient satisfaction.”
This is a June 2020 study from the journal Clinical Rheumatology, (38) Here researchers suggested that “Intra-articular PRP injection provided better effects than other injections for osteoarthritis patients, especially in knee osteoarthritis patients, in terms of pain reduction and function improvement at short-term follow-up. (At 1, 2, 3, 6, 12 months).
In a study published in the American medical journal Arthroscopy, (39) medical university researchers suggested that PRP injections were more effective in the treatment of knee osteoarthritis, in terms of pain relief and self-reported function improvement at three, six, and twelve months follow-up, compared with other injection treatments. We are going to show the comparative research below.
Simply put, PRP methods vary by practitioner. Research consistently points to PRP ineffectiveness as being caused by the way the treatment is given and poor patient selection.
In a December 2018 paper titled: “Clinical Update: Why PRP Should Be Your First Choice for Injection Therapy in Treating Osteoarthritis of the Knee,” researchers wrote in the journal Current Reviews in Musculoskeletal Medicine:(40)
“Moving forward, it is imperative that future clinical research be conducted in a more standardized manner, ensuring that reproducible methodology is available and minimizing study-to-study variability. This includes PRP preparation methods (centrifugation times and speeds, harvest methodology, systems being used); PRP composition (platelet concentrations, activation agents, white blood cell concentrations, growth factor, and cytokine concentrations); PRP injection protocols (single versus multiple injections); sufficient clinical follow-up (a minimum of 6 months); and strict inclusion/exclusion criteria.”
This is one of the treatments that is considered very promising and equally very controversial. This is also a treatment that may suffer from an over-expectation of what this treatment can do and a misunderstanding of what this treatment cannot do.
If you have a bone on bone knee, stem cell therapy will not grow a new meniscus out of thin air.
As we say to many patients, if you have a bone on bone knee, stem cell therapy will not grow a new meniscus out of thin air. Stem cell therapy can grow new cartilage as a method to patch cartilage and meniscus defects but is not a “miracle” one-shot cure that will rebuild your knee to “good as new.” Some people may get benefit from the one-time shot, others will not. As we will point out in this article and links to our other articles, there is too much being made of young versus old stem cells. We may be getting ahead of ourselves here so let’s start with a basic understanding.
There are different types of stem cell therapy. You have:
Bone Marrow Aspirate Concentrate or bone marrow concentrate type stem cell therapy
Lipoaspiration, Adipose-derived stem cells, Microfragmented Fat, or Lipogems type stem cell therapy
Afterbirth material stem cell therapy which would be umbilical cord blood, amniotic and placenta products, Wharton’s jelly, and Exosomes
At our center, we use stem cell therapy, but not all of these listed above. We also use stem cell therapy on a few patients, not every patient.
One injection stem cell “treatments” are not sustainable pain relief
In the video below, Ross Hauser, MD explains the 5 myths we see concerning Stem Cell Therapy. The biggest one is that people believe that one stem cell injection will make all their pains go away. For most this is not true. It is not true for the same reasons outlined above, a single injection will not be comprehensive enough to reverse years and possibly decades’ worth of damage affecting the entire knee structure. This one-shot thinking leads to an unrealistic expectation of pain relief and joint regeneration.
Bone Marrow Aspirate Concentrate or bone marrow concentrate type stem cell therapy
Using stem cells taken from a patient’s bone marrow is becoming a therapy of interest due to the potential of these mesenchymal stem cells to differentiate into other types of cells such as bone and cartilage. This is not a new revolutionary treatment, this treatment has been studied and applied for many years. It is a difficult treatment for some doctors to give. You do need experience in all aspects of the treatment to give the patient the best chance at achieving their healing goals.
Bone Marrow is the liquid spongy-type tissue found in the hallow (interior) of bones. It is primarily a fatty tissue that houses stem cells that are responsible for the formation of other cells. These mesenchymal stem cells (MSC), also called marrow stromal cells, can differentiate (change) into a variety of cell types including osteoblasts (bone cells), chondrocytes (cartilage cells), myocytes (muscle cells), adipocytes (fat), fibroblasts (ligament and tendon) and others when reintroduced into the body by injection. Bone marrow also contains hematopoietic stem cells that give rise to the white and red blood cells and platelets.
Where do the bone marrow stem cells come from?
The bone marrow aspirate is taken from the iliac crest of the pelvic bone. It is a simple, easily tolerated procedure and is demonstrated in this video below:
In clinical observations at Caring Medical, great benefit is seen in injecting bone marrow directly after extracting it.
The theory is that the number of stem cells is not as important as how long they live in their natural environment. In other words, when the bone marrow is directly injected, the source of stem cells is fresh and has great potential for healing. We also believe that the body knows best – it can use these immature cells to regenerate all injured tissues in the joint.
Mayo Clinic and Yale University studies on your own bone marrow stem cells
Doctors at the Mayo Clinic and Yale University published their research on the benefits of Bone Marrow Aspirate Concentrate for Knee Osteoarthritis in the American Journal of Sports Medicine. Here is the summary of that research:(41)
In their single-blind, placebo-controlled trial, 25 patients with bilateral knee osteoarthritis were randomized to receive Bone marrow aspirate concentrate into one knee and saline placebo into the other. Early results show that Bone marrow aspirate concentrate is safe to use and is a reliable and viable (stem cell) cellular product. Study patients experienced a similar significant relief of pain in both bone marrow aspirate concentrate- and saline-treated arthritic knees.
“The current literature demonstrates the potential benefits of utilizing concentrated bone marrow aspirate for the repair of cartilaginous lesions, bony defects, and tendon injuries”
Doctors in New Jersey at the Department of Orthopedic Surgery, Jersey City Medical Center published their findings in support of this research, in the World Journal of Orthopedics, here is what the paper said:
“The current literature demonstrates the potential benefits of utilizing concentrated bone marrow aspirate for the repair of cartilaginous lesions, bony defects, and tendon injuries in the clinical setting. The studies have demonstrated using concentrated bone marrow aspirate as an adjunctive procedure can result in cartilage healing similar to that of native hyaline tissue, faster time to bony union, and a lower rate of tendon re-rupture.”(42)
Successful, safe, and encouraging results
A January 2020 (43) study published in the journal Knee Surgery, Sports Traumatology, Arthroscopy found:
“Pre-clinical studies have demonstrated (intra-articular injections of bone marrow-derived mesenchymal stem cells is) successful, safe and (with) encouraging results for articular cartilage repair and regeneration. This is concluded to be due to the multilineage differential potential, immunosuppressive and self-renewal capabilities of bone marrow-derived mesenchymal stem cells, which have shown to augment pain and improve functional outcomes.”
Caring Medical Research – Case studies
Our research team has published research on patient outcomes and case studies using bone marrow aspirate. Here is a sample of those outcomes. Again, we must remind you that this treatment does not work for everyone. Unfortunately, if you are reading this article you are probably very attuned to medical treatments that do not work.
A 69-year-old male came into our office with pain in both knees, with his right knee significantly more painful. Pain resulted in frequent sleep interruption and limitation of exercise.
Two months after the final treatment, the patient reported that he was completely free of pain or stiffness in both knees, had regained full range of motion, no longer suffered sleep interruption, and was no longer limited in exercise or daily life activities.
Patient case – Knee pain – A 56-year-old woman
A 56-year-old female came into our office with pain in both knees and her right hip. The pain was severe in the right knee, with frequent crepitus and instability, and had forced the patient to discontinue running.
The patient received bone marrow/dextrose treatments for six visits with 8–10 week intervals.
The patient reported modest (20%–35%) overall improvement following these treatments. At the final two visits, both knees and right hip were treated with bone marrow prolotherapy injection. During the treatment period, the left hip was also treated for pain resulting from a flexor injury incurred following visit 1.
Two months after visit 6, the patient reported 65%–95% overall improvement for the three joints. She is able to walk for two hours, no longer has disturbed sleep, and has been able to resume bicycle exercise with minimal discomfort.
In this video Ross Hauser, MD demonstrates an ultrasound examination of a patient’s knee with COMPLETE LOSS OF ARTICULAR CARTILAGE
At 1:14 the patient’s knee instability caused COMPLETE LOSS OF ARTICULAR CARTILAGE
In this patient, we would recommend Prolotherapy to the ligaments and stem cell treatment into the joint. Prolotherapy to address the knee instability and stem cell treatments to address the cartilage issue.
We rarely offer stem cell treatments. In this case, the complete loss of cartilage in the knee calls for it.
The evidence for Prolotherapy Injections for knee osteoarthritis
The knee is the most common joint treated with Prolotherapy at Caring Medical. We use a comprehensive Prolotherapy injection approach that stimulates the natural repair of connective tissue. This is a treatment available quickly for knee osteoarthritis and a possible alternative to knee replacement surgery.
Research: Prolotherapy treatments for patients with knee osteoarthritis showed significant improvement in scores for pain, function, and range of motion
Prolotherapy is a remarkable treatment in its simplicity. The treatment can help many patients avoid joint replacement. But it is not a miracle cure. The research and evidence for how Prolotherapy may help you are presented here and intermingled with our own 27+ years of empirical observation of patient benefit.
In research from June 2017, doctors publishing in the British Medical Bulletin(45) reviewed and evaluated Prolotherapy findings and determined Prolotherapy treatments for patients with knee osteoarthritis showed significant improvement in scores for pain, function, and range of motion, both in the short term and long term. Patient satisfaction was also high in these patients (82%).
Researchers found that Prolotherapy treatments in female patients with knee osteoarthritis resulted in significant improvement in pain, function, and range-of-motion scores. (46)
In this study, they took 24 female patients with an average age of 58 (the youngest being 46 the oldest 70) and gave them three monthly Prolotherapy injections.
At the end of week 24 of the study, knee range of motion increased, pain severity in rest and activity decreased. Improvements of all parameters were considerable until week 8 and were maintained throughout the study period.
In June 2017 research, (47) doctors from the University of Wisconsin School of Medicine and Public Health write: Systematic review, including meta-analysis, and randomized controlled trials suggest that Prolotherapy may be associated with symptom improvement in mild to moderate symptomatic knee osteoarthritis and Prolotherapy was effective in overuse tendinopathy.
Doctors from the University of Wisconsin (48) continued their research into Prolotherapy. They found Prolotherapy resulted in the safe, significant, progressive improvement of knee pain, function, and stiffness scores among most participants and continued as such at follow up an average of 2.5 years after initial treatment, this study from 2015.
This followed up on an earlier study that appeared in the Archives of Physical Medicine and Rehabilitation(49) and suggested “Prolotherapy resulted in safe, substantial improvement in knee osteoarthritis-specific Quality of Life compared with control over 52 weeks. Among prolotherapy participants, but not controls, magnetic resonance imaging-assessed intra-articular cartilage volume change (intra-articular cartilage volume stability) predicted pain severity score change, suggesting that prolotherapy may have a pain-specific disease-modifying effect.”
In Caring Medical research appearing in the Journal of Prolotherapy, Dr. Hauser was able to document articular cartilage regeneration. (50)
In April 2016, A multinational team representing university researchers in Argentina and Dr. Dean Reeves from the University of Kansas Medical Center, Dr. J Johnson Michigan State University, and Dr. Rabago from the University of Wisconsin, School of Medicine and Public Health researchers confirmed that Prolotherapy could regrow articular cartilage in the knee in a study of patients with an average age of 71 seventy-one. (51)
A study, published in the journal Scientific Reports(52) found that three to five sessions of Prolotherapy knee injections have a statistically significant and clinically relevant effect in the improvement of WOMAC composite score, (a scoring system of pain, function, and stiffness) at 12 to 16 weeks compared to formal at-home exercise. The benefits of the treatment were sustained for up to 1 year.
In another study led by the University of Wisconsin School of Medicine and Public Health researchers, patients reported substantially improved knee-specific effects, resulting in improved quality of life and activities of daily living. (53)
Can our treatments help you?
Perhaps the most important prognostic indicator that Comprehensive Prolotherapy, PRP Prolotherapy, or Stem Cell Prolotherapy is going to work for your osteoarthritis is knee range of motion. When a person’s range of motion has been relatively maintained, it typically means the architecture of the joint is still relatively intact, meaning the osteoarthritis destruction has not progressed yet to the point of massive osteophytes (bone spurs) for stabilization, osteonecrosis (subchondral bone death) or complete articular cartilage collapse.
In regard to which Prolotherapy solution often depends on several factors including the amount of joint instability, range of motion, suspect pain sources, amount of degeneration, joint configuration, exercise or ambulatory goals, lifestyle considerations, adjacent joints, and others.
As osteoarthritis starts with ligament injury, the most important aspect of Prolotherapy is to stimulate ligament tightening and strengthening, even when the joint has little remaining cartilage.
When joint instability is the primary issue in a person’s joint pain with osteoarthritis and the osteoarthritis is mild to moderate, then Dextrose Prolotherapy to induce the inflammatory and proliferative phases of healing in the degenerated tissues, including the ligaments, as well as inside the joint itself is probably all that will be needed. It is important to induce a healing milieu throughout the whole joint including an inflammatory synovial fluid, which can then attract cells and growth factors that are needed for healing.
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 a 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 a healing alternative to knee replacement is occurring.
At Caring Florida, we specialize in pain resolution, not pain management!
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