Do you really need a knee replacement?

Joint replacement surgery is a booming industry as our ageing population faces the degenerative processes that come with getting older.  Surgical techniques and hardware continue to improve, but wait times continue to worsen.  In the Calgary Health Region alone there are thousands of patients on the waiting list for hip or knee replacement, with wait times for a mere consult often over one year.  The reality is that only a small proportion of these people actually NEED a joint replacement.

Medicine is not immune to the powers of marketing, and joint replacement surgery is no exception.  Knee and hip replacements are BIG business in the developed world, and family doctors are indoctrinated early on to refer directly to a surgeon whenever a patient presents with some knee or hip osteoarthritis.  The reality is that only some joints require replacement; the rest can be managed very well with conservative measures.  Reason would suggest that a patient with an osteoarthritic joint should start with the most conservative treatment options first, progressing on to more and more invasive options as needed, with total joint replacement as the final intervention once all others have failed.  Outlined below is a sample continuum that a patient can take on their journey through hip or knee osteoarthritis.

Get a weight bearing X-ray.

Proper positioning and select views in a weight bearing position can help to clarify exactly how much degenerative change has occurred to the joint in question.  Ask your doctor for weight bearing (standing) views to best ascertain the extent of wear.

Get a diagnostic ultrasound or and MRI.

An MRI is not always required, but it behooves the doctor and patient to get a clear picture not only of the boney deterioration of the joint but also the soft tissue and cartilage damage.  Remember that osteoarthritis (OA) is a degenerative joint process involving the soft tissues of the joint as well as the bone.  One does not exist in isolation from the other.

Correlate imaging findings with a thorough, hands-on clinical exam.

Too often I hear stories of doctors conducting a physical examination of a patient without ever putting their hands on the patient.  There is often a poor correlation between imaging findings and clinical symptoms, so it is vitally important to have a thorough, hands on examination of the joint in question to help complete the clinical picture.

Follow the clinical triad:

  1. Treat the actual problem
  2. Strengthen the area
  3. Avoid making it worse

Get stronger.

With increased strength comes increased stability, and instability within an arthritic joint is very often a considerable pain generator.  Beginning a strength program in an already painful joint can be agonizing, but there really is no alternative. Pushing through the first month of exercise-exacerbated pain will be worth it, and study after study suggest that resistance training and loading of an arthritic joint does not cause the joint to wear down faster, but rather helps to prolong the viability of that joint.

Get a custom unloader knee brace

One of the most effective, least invasive interventions that can be done is the use of a truly custom, unloading brace.  Made for both knee and hip osteoarthritis, a custom brace is often the single most effective intervention, and represents ‘the most bang for your buck’.  Custom knee braces in particular can offload the exact region of the knee that is most painful, allowing you to carry on with the activities that you are passionate about with considerably less discomfort.  By reducing the magnitude of impact on the arthritic joint with each step these braces also help to slow the rate of further progression.  They are lightweight, slim and can be worn under ‘most’ day to day clothing.  Custom unloader braces are often covered 100% by your private health insurance with a doctor’s prescription.

Consider a guided lubricant injection.

Viscosupplementation is the name for a type of hyaluronic acid injection that can serve to lubricate the internals of an osteoarthritic joint.  Brand names include Synvisc, Monovisc, Durolane, Cingal, Neovisc, Orthovisc, Synolis and others. Any of them can be beneficial in creating some hydraulic cushioning with the joint and defraying mechanical compressive load on to worn down cartilage.  These injections typically take about one month to begin working and can last for 10 – 12 months.  Some research suggests that repeating these injections once per year for three years (think of it as an annual oil change) can further slow the rate of wear of the joint.  These injections should be done under image guidance (ultrasound or fluoroscopy) to improve the accuracy of the injecting doctor.  Contraindications for viscosupplementation include very severe arthritis (it works best in mild to moderate OA), significant leg deformity (bow legged or knock kneed) and morbid obesity.

Consider Platelet Rich Plasma (PRP) injections

Platelet Rich Plasma is derived from a small fraction of your blood.  Drawn from your arm in the same fashion as having regular blood work done, the blood is spun in a special centrifuge to separate out the growth factors of your blood.  Reinjected into an arthritic joint twice over a six-week span, PRP can help to stimulate the development of new blood vessels and consequently allow for some new tissue regeneration.  With the exclusion of stem cell injections, PRP is the primary regenerative medicine that we have available to us in the management of joint osteoarthritis.  The benefits of PRP can often be felt after about six weeks, and can continue to have a positive effect on joint health for several years thereafter.  The injected joint is often sore for two to three days post injection, and it is important to know that you are not allowed to take anti-inflammatory medication for one week leading up to the procedure

Stay away from repeated cortisone injections

Cortisone (corticosteroid) injections are a very effective way to diminish inflammation within a joint.  The problem is that osteoarthritis, despite its name, is not truly an inflammatory process.  Rather, osteoarthritis is degenerative joint disease, and while you may get some symptom relief from a single cortisone injection as it wipes out any residual inflammation that is present in the joint, it is not a clinically appropriate intervention to repeat.  Why put an anti-inflammatory into something that isn’t truly inflamed?

With any combination of the measures outlined above, patients can expect to have at least some improvement in their symptoms.  Sticking to the clinical triad (treat it, strengthen it, don’t make it worse) helps to keep patients focused on what’s important in the management of an arthritic joint, and will reduce the likelihood of truly needing a knee replacement.  In our clinic we hedge our bets by making the surgical referral on the assumption that it will take about one year to get to the surgeon.  During that year we work diligently with the patient using the interventions listed above.  Most of the time we are able to improve the patient’s symptoms and quality of life so much that they take themselves off the surgical list.  Check out our testimonials page to read some of the success stories.