Ross Hauser, MD, Caring Medical Florida Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Florida David N. Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, IL
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.
You probably do not need to be told what 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.
Waiting for knee replacement – the burden excessive wait times had on patients
So what happens to your knee while you are waiting for knee replacement?
In one study, doctors from Laval University in Quebec wrote in the medical journal Rheumatology(1) 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 (2) 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.
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 maybe 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.(3) 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).
Patients should be more well educated on the realistic expectation of knee replacement of what they 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,(4) 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 they 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,(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.
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)
Doctors report knee replacement surgery 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.(7) 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, (8) 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, (9) 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.”(10)
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 depressive state as the main predictors (of not meeting the patient’s or spouse’s expectations of a successful knee replacement).(11)
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.”(12) 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 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.(13)
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 use of an effective procedure, while others contend there is over-use of the surgery that relies on subjective criteria.
In other words a medical equation
“knee osteoarthritis = knee replacement”
In 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 wait until they are old enough for knee replacement.
Ethically this should be a problem to many. People forced to live in pain until they are of appropriate age to get a knee replacement.
In October 2015, an editorial appeared in the New England Journal of Medicine. In that editorial Jeffrey N. Katz, M.D., the same mentioned above, cites the arguments that randomized trials (any further research) of total joint replacement are senseless if they all confirm a rationale to use them. After all, joint replacements are among the most significant advances of the 20th century; don’t we already know they are successful? Yes, but maybe not as successful as we think they are.
In this editorial, the readers of one of the most prestigious medical journals in the world learned that total knee replacement poses the following risks:
About 0.5 to 1% of patients die during the 90-day postoperative period.
The procedure is not universally successful; approximately 20% of patients who undergo total knee replacement have residual pain 6 or more months after the procedure.
Third, there are alternatives. Clinical trials have shown that physical therapy (including exercises and manual therapies) can diminish pain and improve functional status in patients with advanced knee osteoarthritis.
Finally, an ideal treatment for one patient may not be right for the next. Patients with knee osteoarthritis differ in the importance they attach to pain relief, functional improvement, and risk of complications. Therefore, treatment decisions should be shared between patients and their clinicians and anchored by the probabilities of pain relief and complications and the importance patients attach to these outcomes.
In a randomized, controlled trial, involving 100 patients with symptomatic knee osteoarthritis, patients were assigned to undergo total knee replacement followed by a rigorous 12-week nonsurgical-treatment regimen (total-knee-replacement group) or to receive only the nonsurgical treatment (nonsurgical-treatment group), which consisted of supervised:
education, patient information
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.(14,15)
Is delaying knee replacement with Hyaluronic Acid Injections worth it in the end?
In our article Are Hyaluronic injections for Knee Osteoarthritis low-value health care? 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:
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.(16)
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 ).”(17)
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.”(18)
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. (19)
You may also be at high risk for post-surgical heart attack. Doctors at Harvard Medical School released their study in October 2015 that showed risk of heart attack was significantly higher during the first postoperative month in those who had knee replacement surgery and that venous thromboembolism was a significant risk during the first month and over time for those having total knee or total hip arthroplasty as well.(20)
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.
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 to 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 explored – 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.(21)
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 to 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 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.
In this video, Ross Hauser, MD explains a Prolotherapy knee treatment as performed at our Caring Medical clinics. This is not typical of the way treatment may be performed in other doctor’s offices.
Video learning and demonstrated points:
Prolotherapy is an injection technique that stimulates growth factor cells that work to repair damaged joints.
Prolotherapy can be very helpful in patients with knee instability or hypermobility caused by damaged knee ligaments and tendons. Knee instability is a cause of knee osteoarthritis and degenerative wear and tear.
In this video, Ross Hauser, MD is seen demonstrating intra-articular (inside the knee) as well as injections surrounding the outside of the knee.
In addition to knee osteoarthritis, Prolotherapy injections can help patients with problems that will eventually lead to degenerative knee disease.
Weakened and damaged ligaments and tendons and their attachments to the bones and muscles that make the knee work.
In the video, you see that Dr. Hauser is injecting into the
The Knee’s medial joint line here where the medial collateral ligament is.
The pes anserine tendon
The medial patellar retinaculum tendon
The distal quadriceps attachments
The lateral joint line where the lateral collateral ligament is located.
The attachment of the iliotibial band
The capsular knee ligament attachments
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.
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(22) 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.(23)
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, (24) 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 (25) continued on their research into Prolotherapy. They found Prolotherapy resulted in 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 which appeared in the Archives of physical medicine and rehabilitation(26) 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.(27)
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.(28)
A study, published in the journal Scientific reports(29) 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 up to 1 year.
In another study led by 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.(30)
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 relative 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 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 the way for them to go, medicine is moving towards providing alternatives to knee replacement. This is a shift away from surgery towards “biomedicine” and the use of patient’s own stem cells and blood platelets as a healing alternative to knee replacement is occurring.
At Caring Medical Regenerative Medicine Clinics, we specialize in pain cures, not pain management. As such we always research, write our own research, and explore new methodologies to curing knee pain.
1 Desmeules F, Dionne CE, Belzile E, Bourbonnais R, Frémont P. The burden of wait for knee replacement surgery: effects on pain, function and health-related quality of life at the time of surgery. Rheumatology (Oxford). 2010;49(5):945-954. doi:10.1093/rheumatology/kep469 [Google Scholar] 2 Jacobs CA, Vranceanu AM, Thompson KL, Lattermann C. Rapid Progression of Knee Pain and Osteoarthritis Biomarkers Greatest for Patients with Combined Obesity and Depression: Data from the Osteoarthritis Initiative. Cartilage. 2020;11(1):38-46. doi:10.1177/1947603518777577 [Google Scholar] 3 Stacey D, Taljaard M, Dervin G, Tugwell P, O’Connor AM, Pomey MP, Boland L, Beach S, Meltzer D, Hawker G. Impact of patient decision aids on appropriate and timely access to hip or knee arthroplasty for osteoarthritis: a randomized controlled trial. Osteoarthritis and Cartilage. 2016 Jan 31;24(1):99-107.[ Google Scholar] 4 Bansback N, Trenaman L, MacDonald KV, Hawker G, Johnson JA, Stacey D, Marshall DA. An individualized patient-reported outcome measure (PROM) based patient decision aid and surgeon report for patients considering total knee arthroplasty: protocol for a pragmatic randomized controlled trial. BMC musculoskeletal disorders. 2019 Dec;20(1):89. [Google Scholar] 5 Umapathy H, Bennell K, Dickson C, Dobson F, Fransen M, Jones G, Hunter DJ. The Web-Based Osteoarthritis Management Resource My Joint Pain Improves Quality of Care: A Quasi-Experimental Study. J Med Internet Res. 2015 Jul 7;17(7):e167. [Google Scholar] 6 Van Manen MD, Nace J, Mont MA. Management of primary knee osteoarthritis and indications for total knee arthroplasty for general practitioners. J Am Osteopath Assoc. 2012 Nov;112(11):709-15.[Google Scholar] 7 Escobar A, García Pérez L, Herrera‐Espiñeira C, Aizpuru F, Sarasqueta C, Gonzalez Sáenz de Tejada M, Quintana JM, Bilbao A. Total knee replacement: Are there any baseline factors that have influence in patient reported outcomes?. Journal of Evaluation in Clinical Practice. 2017 May 26. [Google Scholar] 8 Klett MJ, Frankovich R, Dervin GF, Stacey D. Impact of a surgical screening clinic for patients with knee osteoarthritis: a descriptive study. Clin J Sport Med. 2012 May;22(3):274-7. [Google Scholar] 9 Felix J, Becker C, Vogl M, Buschner P, Plötz W, Leidl R. Patient characteristics and valuation changes impact quality of life and satisfaction in total knee arthroplasty – results from a German prospective cohort study. Health Qual Life Outcomes. 2019 Dec 9;17(1):180. doi: 10.1186/s12955-019-1237-3. PMID: 31815627; PMCID: PMC6902559. [Google Scholar] 10 Johnson EC, Horwood J, Gooberman-Hill R. Trajectories of need: understanding patients’ use of support during the journey through knee replacement. Disabil Rehabil. 2016 Dec;38(26):2550-63. [Google Scholar] 11 Stark ÅJ, Salanterä S, Sigurdardottir AK, Valkeapää K, Bachrach-Lindström M. Spouse-related factors associated with quality of recovery of patients after hip or knee replacement – a Nordic perspective. Int J Orthop Trauma Nurs. 2016 Nov;23:32 [Google Scholar] 12 Graff C, Hohmann E, Bryant AL, Tetsworth K. Subjective and objective outcome measures after total knee replacement: is there a correlation? ANZ J Surg. 2016 Nov;86(11):921-925. [Google Scholar] 13 Perruccio A, Power J, Evans H, Mahomed S, Gandhi R, Mahomed N, Davis A. Multiple joint involvement in total knee replacement for osteoarthritis – effects on patient-reported outcomes.Arthritis Care Res (Hoboken). 2012 May 8. doi: 10.1002/acr.21629. [Google Scholar] 14. Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, Rasmussen S. A randomized, controlled trial of total knee replacement. New England Journal of Medicine. 2015 Oct 22;373(17):1597-606. [Google Scholar] 15. Parachutes and Preferences — A Trial of Knee Replacement. Jeffrey N. Katz, M.D. N Engl J Med 2015; 373:1668-1669 October 22, 2015 [Google Scholar] 16. Altman R, Lim S, Steen RG, Dasa V. Hyaluronic Acid Injections Are Associated with Delay of Total Knee Replacement Surgery in Patients with Knee Osteoarthritis: Evidence from a Large U.S. Health Claims Database. PLoS One. 2015 Dec 22;10(12):e0145776. [Google Scholar] 17. Pasquale MK, Louder AM, Cheung RY, Reiners AT, Mardekian J, Sanchez RJ, Goli V. Healthcare Utilization and Costs of Knee or Hip Replacements versus Pain-Relief Injections. Am Health Drug Benefits. 2015 Oct;8(7):384-94. [Google Scholar] 18. Julin J, Jämsen E, Puolakka T, Konttinen YT, Moilanen T. Younger age increases the risk of early prosthesis failure following primary total knee replacement for osteoarthritis. A follow-up study of 32,019 total knee replacements in the Finnish Arthroplasty Register. Acta Orthop. 2010;81(4):413–419. [Google Scholar] 19. Healy WL, Della Valle CJ, Iorio R, et al. Complications of Total Knee Arthroplasty: Standardized List and Definitions of The Knee Society. Clinical Orthopaedics and Related Research. 2013;471(1):215-220. [Google Scholar] 20. Lu N, Misra D, Neogi T, Choi HK, Zhang Y. Total Joint Arthroplasty and the Risk of Myocardial Infarction: A General Population, Propensity Score-Matched Cohort Study. Arthritis Rheumatol. 2015 Oct;67(10):2771-9. doi: 10.1002/art.39246.2. Complications of Total Knee Arthroplasty: Standardized List and Definitions of The Knee Society. [Google Scholar] 21 Freitag J, Bates D, Boyd R, et al. Mesenchymal stem cell therapy in the treatment of osteoarthritis: reparative pathways, safety and efficacy – a review.BMC Musculoskeletal Disorders. 2016;17:230. doi:10.1186/s12891-016-1085-9. [Google Scholar]2 Hassan F, Trebinjac S, Murrell WD, Maffulli N. The effectiveness of prolotherapy in treating knee osteoarthritis in adults: a 22 systematic review. Br Med Bull. 2017 Mar 4:1-18. [Google Scholar] 23 Eslamian F, Amouzandeh B. Therapeutic effects of prolotherapy with intra-articular dextrose injection in patients with moderate knee osteoarthritis: a single-arm study with 6 months follow up. Ther Adv Musculoskelet Dis. 2015 Apr;7(2):35-44. [Google Scholar] 24 Rabago D, Nourani B. Prolotherapy for Osteoarthritis and Tendinopathy: a Descriptive Review. 2017 Jun;19(6):34. doi: 10.1007/s11926-017-0659-3. [Google Scholar] 25 Rabago D, Mundt M, Zgierska A, Grettie J. Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis: Long term outcomes. Complementary therapies in medicine. 2015 Jun 1;23(3):388-95. [Google Scholar] 26 Rabago D, Kijowski R, Woods M, Patterson JJ, Mundt M, Zgierska A, Grettie J, Lyftogt J, Fortney L. Association between disease-specific quality of life and magnetic resonance imaging outcomes in a clinical trial of prolotherapy for knee osteoarthritis. Archives of physical medicine and rehabilitation. 2013 Nov 30;94(11):2075-82. [Google Scholar] 27 Hauser R. The regeneration of articular cartilage with prolotherapy. Journal of Prolotherapy. 2009;1(1):39-44. [Google Scholar] 28 Topol GA, Podesta LA, Reeves KD, Giraldo MM, Johnson LL, Grasso R, Jamín A, Clark T, Rabago D. Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis. PM R. 2016 Apr 4. pii:S1934-1482(16)30054-5. [Google Scholar] 29 Sit RW, Chung VCh, Reeves KD, Rabago D, Chan KK, Chan DC, Wu X, Ho RS, Wong SY. Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis. Sci Rep. 2016 May 5;6:25247 [Google Scholar] 30 Rabago D, van Leuven L, Benes L, Fortney L, Slattengren A, Grettie J, Mundt M. Qualitative Assessment of Patients Receiving Prolotherapy for Knee Osteoarthritis in a Multimethod Study. Journal of alternative and complementary medicine (New York, NY). 2016 Dec;22(12):983. [Google Scholar]