Alternatives to Knee Replacement Surgery

Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C.

Many people are faced with a decision when they go to to their orthopedist surgeon with the knowledge that all conservative care treatments have now failed and they will be told that they should strongly consider knee replacement surgery. 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 topical 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. When you meet with your orthopedist surgeon, he or she will walk in with your latest MRI and tell you that you are still “bone on bone.” You should get a knee replacement. You may have asked, “is there any other way?” The answer may have been, 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 and you started doing your research online.

In this article we will:

Article Summary:

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:

But if you can still work, your knee still bends, and 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.

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

But the question many people ask is “Did I try everything”

Study: What is the best knee osteoarthritis treatment to help avoid knee replacement? Researchers can’t tell based on the studies.

Let’s start with a February 2022 paper from doctors in Norway who published their review of knee osteoarthritis treatments in the journal Osteoarthritis and Cartilage Open (1). The researchers of this paper sought to provide evidence for comparing one set of treatments against another in the treatment of knee osteoarthritis. Let’s see what they found by comparison.

First, the researchers “constructed 17 broad categories, comprising drug treatments, exercise, surgery, herbs, orthotics, passive treatments (for example acupuncture, TENS units, magnets, etc), regenerative medicine (Platelet-rich Plasma), diet/weight loss, combined treatments, and controls (placebos).” Then they reviewed previously published reviews encompassing 445 research papers.

Here are some of the comparisons of the results

The researchers concluded with these statements:

“Direct comparison of different available treatment options for osteoarthritis is desirable, however not currently feasible in practice, due to heterogeneous (non-consistent) study populations and lack of clear descriptions of control interventions. We found that many treatments were effective, but since the network as a whole was not coherent and lacked high confidence in the treatment comparisons, we could not produce a ranking of effects.” Then the answer to the question “What is the best knee osteoarthritis treatment?” Cannot be given.

What are we to make of this? Many of these above treatments do help you and can help many avoid knee replacement. Are any of these treatments better than others? Probably but research does not allow to make the one superlative recommendation that this is the “best treatment for knee osteoarthritis pain.”

Patients are seeking their own information on an alternative to knee replacements because they are not getting all the information they could from their doctors.

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. (2) 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).

Doctor providing information on knee replacement to patient

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,(3) 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.

Study: when given more information, a group of 65 year-olds, with many health problems, were less likely to have surgery

Continuing their line of research, the above study authors updated their findings in a September 2022 paper in the journal Osteoarthritis and Cartilage Open (4):

The average patient in this study was about 65 years old, was more likely to be a female than a male, and had a Body Mass Index classified as obese. According to the researchers the average patient was experiencing mild/moderate symptoms of depression, moderate to severe osteoarthritis symptoms, and moderate to severe pain or discomfort.

The group was divided into two. One group of patients would receive a one-page summary of the surgeon’s report/recommendation along with possible outcomes and issues following the knee replacement surgery as a decision-making help tool. One group would not get the decision-making help tool and be given “routine” information on their recommendation for knee replacement.

Again, when given more information, the group of 65-year-olds, with their health problems, were less likely to have surgery, than their counterparts who received no such information. This confirms research like that above and other studies that suggest “trends in a reduction in surgery have been seen in previous studies of decision aids in total knee replacement) in similar contexts to this. Importantly, studies of decision aids in underserved (people who did not get the decision aids) populations have shown an increase in surgery.”

What made these people change their minds and not have the surgery?

Patients with knee pain and osteoarthritis management are often confined mainly to the use of painkillers and waiting for eventual total joint replacement

In a 2015 study in the Journal of Medical Internet Research, (5) 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.

Sometimes doctors will expand their knowledge of conservative management beyond painkillers to
1. nonsteroidal anti-inflammatory drugs (NSAIDs)
2. corticosteroid injections
3. Hyaluronic Acid Injections

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. (6) This theme will be expanded throughout this article.

The benefits of being able to delay knee replacement – avoiding a “double risk of failure.”

An April 2023 paper in the journal Cartilage (7) documented the knee replacement survival rate in middle-aged patients up to 65 years old and to compare it with other age groups of patients undergoing total knee replacement for knee osteoarthritis. Over 45,000 patients were in this study.

Learning points:

  • A total of 45,488 total knee replacement patients for primary knee osteoarthritis were included in the analysis. Of this there were 11,388 men and over twice as many women: The number of women was 27,846).
  • The percentage of knee replacement patients less than 65 years old increased from 13.5% to 24.8% between 2000 and 2019. (Many more knee replacements (increases) in this group.)
  • The survival analysis showed an overall influence of age on the implant revision rate.
    • Patients under 50 years old estimated survival rate of 78.7% at 15 years (revision knee surgery or other procedure will need to be done at age 65 for over 20% of patients)
    • Patients 50-65 years estimated survival rate of 89.4% at 15 years (revision knee surgery or other procedure will need to be done at age 65 to age 80 for over 10% of patients)
    • Patients 66-79 years estimated survival rate of 94.8% at 15 years.

Conclusions: “Total knee replacement in the middle-aged patient population up to 65 years old increased significantly over time. These patients present a double risk of failure with respect to older patients. This is particularly important considering the increasing life expectancy and the emergence of new joint preserving strategies (including knee injections), which could postpone the need for total knee replacement to an older age.

When is waiting for knee replacement a good thing and when is it a bad thing to do?

Another subject that lead patients to seek alternatives to knee replacement, was the inability of the patient to get a knee replacement during the recent pandemic and subsequent medical staff shortages.

What happens when you are waiting for a knee replacement?

What happens when you are waiting for a knee replacement?

Many people have already made up their minds that they will eventually get a knee replacement. For many people, their decision was delayed by the Covid-19 pandemic and the freeze on elective knee surgeries. Knee replacement is elective knee surgery. That means that you chose to have it and it is generally not a surgery that would be considered life-saving in medical terms although we know some will argue that the surgery was very necessary to their quality of life. We would agree.

So what happens to your knee while you are waiting for a knee replacement? Is it all misery? Yes, it can be.

Let’s go back to a 2010 paper from doctors from Laval University in Quebec. We will bring this research forward into 2023. These doctors wrote in the medical journal, Rheumatology (8) 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 are the observations that they published in patients having to wait for 6 to 9 months for knee replacement and those who had to wait 9 to 12 months.

“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 magnitude of deterioration seen in this study may be clinically important.”

What the doctors saw was a clinically important decline in some patients waiting up to a year for knee replacement.

The reason we are using this 2010 study is that many papers over the last decade have referred to it in their own research. So let’s being this 2010 research current into 2023. Let’s focus on the compounded problem that one of the factors that will give a patient pain after knee replacement, is the poor management of their pain before the surgery.

In a September 2022 paper (9) citing the 2010 study led by researchers at the  University of Leeds in the United Kingdom, the authors write: “Patients awaiting total knee replacement often have poor health-related quality of life. Approximately 20% of patients experience persistent pain post-total knee replacement. Pre-operative total knee replacement interventions could improve pre- and postoperative outcomes.”

The researchers explored these pre-surgery suggestions for treatment:

What they found was there was no evidence that anyone had put together a pre-operative program incorporating all these aspects into something that worked for the patient. In other words, these interventions can work, but they are not offered in a coherent way to patients.

An August 2021 paper in the journal Bone & joint open (10) explored the association between long preoperative wait times and acute hospital length of stay for primary knee and hip replacement. This study included data on 11,833 total knee replacements performed in Canada. Let’s point out that according to the researchers 180 days of the wait time is the Canadian national recommended standard. What the researchers found was that patients were waiting almost a year, on average, for knee replacement. This extended wait caused a significant increase in the average hospital length of stay after surgery.

It gets worse for obese and depressed patients.

Researchers at the University of Kentucky and Harvard Medical School (11) 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.

Let’s again return to the theme of patient information. Here is an example of someone who contacted us and their reasoning for not going forward with a knee replacement.

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.

Alternative to knee replacement: Weight loss

We have three articles on this website covering this subject

We will summarize the information of these articles here:

Weight loss is not easy, we understand that. But it does help knee pain

Losing weight is difficult, especially for someone with chronic pain. Over the years we have found that when someone achieves their weight loss goals, it is usually not a diet plan that made the difference for them, it is usually some type of motivation or inspiration that helped these people achieve their weight goals. Perhaps it is a desire to reduce the burden of medicines they are taking every day. Many patients we see have pills for many different disorders. For most people, the desire and motivation to lose weight were because of a health scare.

Food can generally be described as “pro-inflammatory” or “anti-inflammatory.” Food that is pro-inflammatory would obviously be considered foods that would cause swelling, bloating in the stomach and joints, and an unhealthy person. The internet is filled with articles about salmon or fish oils, fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), onions, garlic, and even strawberries and grape seed extract which contain resveratrol.

Sugar is one of the top inflammatory foods to eliminate much as possible. Others include trans and saturated fats, fried foods, processed meat, refined carbohydrates, and artificial sweeteners/additives. Choosing fresh, whole foods instead of pro-inflammatory foods as often as possible has far-reaching effects on our health, including our joints.

Degenerative knee pain and metabolic syndrome

Obesity is more than stress from weight load – it creates inflammation without wear and tear and inflammation in the knee

Research has shown that not only does obesity cause osteoarthritis because of weight load, but it also causes osteoarthritis in a “non-mechanical” way – in other words by inflammation without wear and tear. This type of research is helping doctors get away from the excessive weight load model of thinking, although weight load does cause obvious problems, and helps them look at the inflammation problems. Research has also shown that obese people have an increased risk to develop not only knee but also hand osteoarthritis, the concept that adipose (fat) tissue might be related to osteoarthritis not only through overloading suggests that obesity induces a low-grade systemic inflammatory state characterized by the production and secretion of several adipocytokines (inflammatory mediators) that may have a role in osteoarthritis development. (12)

Degenerative knee pain and metabolic syndrome

One of the most obvious ways to help a patient with degenerative knee pain and metabolic syndrome (abdominal obesity, hypertension, and diabetes) is to help them understand that a healthy lifestyle can be extraordinarily beneficial to their joint pain, especially knees and spines.

One of the hardest things to convince a patient of is that they need to examine their food choices and lifestyle choices and make immediate and meaningful changes to help try to save their knee or help with their back pain.

It is very likely that if you are reading this article, you have:

  • high blood pressure that is being controlled by medication,
  • you are constantly challenging yourself to get rid of your “gut,”
  • and you have type-2 diabetes.

Every 1% weight loss was associated with a 2% reduced risk of knee replacement

In a paper from medical university researchers in Australia, (13) doctors described the impact of weight loss on helping people avoid knee and hip replacement. What the researchers found was: “In people with or at risk of clinically significant knee osteoarthritis, every 1% weight loss was associated with a 2% reduced risk of knee replacement and – in those people who also had one or more persistently painful hips – a 3% reduced risk of hip replacement, regardless of (how overweight they were). In other words, if you are a 180-pound person and are 36 pounds overweight and you lost that 36 pounds – you would reduce your chances of needing a knee replacement by 72%.

In our article Research: Knee replacement does not help many people lose weight, a misconception is revealed by numerous papers carried out by researchers across the world. Knee replacement is not an easy way to weight loss. Research: Knee replacement does not help many people lose weight

Many patients are under the assumption that the quickest way to attack their obesity problem is to get a knee replacement. The thinking is that if they eliminate their knee pain they will be able to exercise and lose weight. Surgeons are being told to tell patients that is not true for many obese patients.

In some research, the suggestion is given to patients to lose weight before the knee replacement. And, as written above, that may cancel out the need for knee replacement. Doctors at Oxford University (14) found that overweight patients are at more than 40% greater risk and obese patients are at more than a  100% increased risk of knee replacement surgery compared to patients with normal weight. Weight reduction strategies could potentially reduce the need for knee replacement surgery by 31% among patients with knee osteoarthritis.

A March 2023 Korean study published in the Scientific reports (15) assessed the charts of 1,139,463 people, 50 and over looking for an association between general and/or central (belly) obesity and knee osteoarthritis risk. In a review of the medical histories, the researchers noted that general obesity without central obesity and central obesity without general obesity were associated with increased knee osteoarthritis risk than a control comparison group. “Individuals with both general with central obesity had the highest risk of developing worsening knee osteoarthritis.  This association was more pronounced in women and younger age group (early 50s). Remarkably, the remission (weight loss) of general or central obesity over two years was associated with decreased knee osteoarthritis risk.”

Exercise may alleviate knee osteoarthritis pain

Elliptical training knee replacement

Elliptical training

Another challenge is helping the patient who wants to exercise be able to exercise. For many patients, the sedentary lifestyle cycle of “knee pain preventing me from exercising” and “I can’t exercise because of knee pain has made me heavier has occurred.” Many doctors suggest that the best way to help these patients may simply be with the motivation that exercise may eliminate their need for knee replacement.

Providing research studies like the ones below show that patients may achieve better balance, less pain, and the ability to bend their knees again in certain cases.

A January 2023 study in the journal Clinical rehabilitation (16) A study of women between the ages of 40 – 70 years old revealed that balance and proprioception exercises (exercises that during their actions make the person stand or balance on one leg) may have positive effects on dynamic balance and pain.

A July 2022 study (17) suggested that in knee osteoarthritis, evidence suggests that the benefits of diet and exercise in addition to reducing body weight and strengthening muscles could reduce systemic inflammation. One of the benefits patients found in weight loss and exercise was their ability to bend their knees better.

The concept behind exercising, beyond the general health benefits, is that if you build up the muscles around the knee, the muscles can help provide stability and lessen the wear and tear effect of degenerative knee disease. Therapists and researchers have recommended non-weight-bearing exercises such as Elliptical training, Recumbent cycling, and water or pool-based exercises.

Walking may not help

There have been numerous studies to suggest the benefits of walking in knee pain patients. Walking of course is a great exercise if your knee can hold up to it. In a July 2022 paper (18) researchers found walking did not eventually reduce pain for all adults with knee osteoarthritis pain and in some, may induce new or different pain – particularly when starting a walking routine. What the researchers discovered was a single 30-minute walk moderately increased pain in the affected knee among persons with knee osteoarthritis. Healthy adults showed no difference in pain sensitivity.

Maybe everyone is NOT a candidate for knee replacement and alternatives need to be sought

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. (19)

Unjustified: Surgeons were sending patients to knee replacement with slight to moderate osteoarthritis

That was 2006, certainly, things have changed. Let’s follow the research path. 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, led 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. (20)

In December 2017, Dr. Riddle assessed The American Academy of Orthopaedic Surgeons (AAOS) and 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:
  • This new classification tree had an accuracy of 86.7% A significant improvement from the 74.3% in Dr. Riddle’s 2014 study. (21)

What is inappropriate treatment? Is it limited to knee replacement only? No

In March 2019, doctors treating veterans wrote in the journal Federal practitioner (22) wrote: “While patients without knee instability use more non-(knee replacement) treatments over a longer period prior to total knee replacement, patients with less severe knee osteoarthritis are at risk of receiving interventions judged to be rarely appropriate.” In other words, alternatives to knee replacement may not be the right alternatives for some and are deemed an “inappropriate treatment.” Here is what they wrote:

  • “Hinged or unloader knee braces were utilized in about half the study patients; this intervention was classified as rarely appropriate in 4.4% of these patients.”
  • “Medical therapy was also widely used, with all use of NSAIDs, acetaminophen, and tramadol classified as appropriate or may be appropriate.”
  • “Oral or transcutaneous opioid medications were prescribed in 14.3% of patients, with 92.3% of this use classified as rarely appropriate.”
  • The use of arthroscopy knee surgery was deemed rarely appropriate in 72.7% of these cases.

Is knee replacement inappropriate for patients under 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.”(23)

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 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. You have to fix the whole knee. Let’s get to work then on fixing this.

A December 2023 paper (24) from doctors at the Department of Orthopedics & Sports Medicine, Houston Methodist Hospital list the three primary: factors involved with preservation of the knee joint (preventing knee replacement) include joint alignment (the knee has to be straight and not bowed in or out, back or front), meniscal status (Meniscus has to be reasonably intact), and ligament stability (in particular that of the anterior cruciate ligament [ACL]). . . When a deficiency exists in one of the factors, it will affect the others.”

Let’s stop here for a brief review. We have maintained in our writings and publications that you cannot fix one part of the knee and not address the other aspects that may cause knee instability. The authors of this study agree. They write: “For example, the ACL and posterior horn of the medial meniscus both act as restraints to anterior tibial translation (the shin bone in motion in relationship to the thigh bone). Thus, medial meniscal deficiency increases the risk for failure of ACL reconstruction, and chronic ACL insufficiency increases the risk for medial meniscus tears. Furthermore, all 3 of the factors of joint preservation have an impact on the articular cartilage status of the knee joint. Studies have shown that cartilage-preservation procedures do not result in optimal outcomes if there is joint malalignment, meniscal deficiency, or ligament deficiency.” So here is the summary. If the medical meniscus is damaged, greater strain and likelihood of ACL tear will occur. Conversely, if the ACL is lax or weakened, that puts the medical meniscus at risk for failure or tear. Further, addressing any aspect in surgery without looking at all the problems of the knee will likely lead to unsatisfactory surgical results.

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 the 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.

Cortisone injections

Alternatives to cortisone shots: Updated reviews of corticosteroid options. Ross Hauser MD

In the past, your doctor may have recommended 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 to avoid 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) (25) 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.”(26)

The evidence then was a summary of the effects of cortisone on articular cartilage which included:

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. Some people, 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 Surgeons posted on its 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.

Is delaying knee replacement with Hyaluronic Acid Injections worth it in the end?

Research and reviews of Hyaluronic injections for Knee Osteoarthritis

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. (27)

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 healthcare 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 ).”(28)

We talk more about these injections below when we compare Hyaluronic Acid Injections with other knee injections.

A research letter in the Journal of the American Medical Association Internal Medicine, (29) 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 toward 2021.

The first stop is February 2016 and the journal Clinical Orthopaedics and Related Research. (30) 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,(31) 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)

Platelet Rich Plasma for Knee Osteoarthritis: When it works, when it does not work

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 (32) 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 (33) 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 (34) 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. (35)

In our article Platelet Rich Plasma for Knee Osteoarthritis: When it works, when it does not, we point to more research on when the treatment can be successful and when the treatment may not help you.

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 (36) 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, (37) 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, (38) 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:(39)

“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.”

In our article Platelet Rich Plasma for Knee Osteoarthritis: When it works, when it does not, we point to more research on when the treatment can be successful and when the treatment may not help you.

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. (40)

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.

Stem Cell Therapy

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, while 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:

At our center, we use stem cell therapy, but not all of these are 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 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)

“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:

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 are) 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.

In the medical journal Clinical Medicine Insights Arthritis and Musculoskeletal Disorders, (44) our Caring Medical research team published our findings on seven patients. You can read all the case histories here: Bone marrow stem cell therapy and Prolotherapy: Published review 7 case histories.

Patient case  – Knee pain: A 69-year-old man

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.

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.

In this video Ross Hauser, MD demonstrates an ultrasound examination of a patient’s knee with COMPLETE LOSS OF ARTICULAR CARTILAGE

The evidence for Prolotherapy Injections for knee osteoarthritis

For extensive research please see our article 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 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.

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! 

Get Help & Information on your knee pain problem

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This article was updated November 25, 2023

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Prolotherapy specialistsWhen should I involve a Prolotherapist in my care?

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Prolotherapy, an alternative to surgery
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Caring Medical Florida
9738 Commerce Center Ct.
Fort Myers, FL 33908
(239) 308-4701 Phone
(855) 779-1950 Fax

Hauser Neck Center
9734 Commerce Center Ct.
Fort Myers, FL 33908
(239) 308-4701 Phone
(855) 779-1950 Fax
We are an out-of-network provider. Treatments discussed on this site may or may not work for your specific condition.
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