Alternatives to Total Knee Replacement in Patients with Arthritis of the Knee
By Steve A. Mora, MD
This is a very common question I get asked in my office almost daily: Doc I have bone on bone knee arthritis, other than surgery is there anything else I can do other than knee replacement?
I saw 60 year old gentleman this week who was told he had severe arthritis of the right knee. He was told by another surgeon that there was nothing else that could be done and that he needed a total knee replacement because he had severe arthritis. He came to me for a second opinion, specifically to see if there were options other than a total knee replacement surgery for his knee arthritis.
I see patients like this everyday. People tend to not want surgery. People do want options other than surgery for their arthritis. It is not unreasonable to not want surgery. Although total knee replacements (TKA) have a great track record, the surgery can be difficult to recover from, there are potential serious complications (DVT and Pulmonary Embolism), and the life changes during the recovery are difficult to manage. As a surgeon who has seen hundreds of patients go through the recovery of TKA I can totally sympathize. In addition I suffer from severe knee arthritis so I am also very interested in non operative options for severe knee arthritis.
Patients who have severe arthritis, i.e. “bone on bone” can take certain steps to decrease some of their pain. I tell patients who are seeking non-operative treatment that there is no one easy solution. Going through a non operative program takes time. I tell my patients that it is indeed possible to have a positive effect on their pain and improve their function but a lot depends on their effort.
In most cases the effects of the arthritis has led to joint contracture (loss of motion), tendon/muscle stiffness, inflammation (swelling) and deformity (bowing). These issues have been present and ever so slowly worsening over the years. It is not uncommon for a patient to not have noticed that they cannot fully extend the knee compared to the opposite side or that there is actually a noticeable bowing.
These are my usual recommendations for patients with severe arthritis. I have had the best luck when patients implement all of these measures.
1) Physical Therapy- Improve range of motion, flexibility, patella mobiltity, maximize extension, loosen up the IT Band, stretch hamstrings, and anterior hip flexors. This a a critical component of treatment. For this reason the therapy needs to be done by an experience physical therapist with a keen eye for identifying and correcting this soft tissue mal-adaptions that have occurred over many years. If a patient has a difficult time with prolonged weight bearing I sometimes recommend pool therapy.
2) Steroid Injections and Traumeel- The injection is done to decrease the pathologic inflammation and improve pain. This usually allows the patient to follow through with therapy. Traumeel is a natural occurring anti inflammatory which contain Arnica. I tell patients that I am not planning on injecting forever. I might to 2 or maximum 3 injections
3) Hyaluronic Acid Injection/ Platelet Rich Plasma (PRP)/ Stem Cell Injections- Once the motion and flexibility and inflammation has improved I will do a Synvisc One injection mixed with Platelet Rich Plasma. There is literature which supports the use of both injectables for knee arthritis therefore I inject both. I will repeat the injection in 3 months. There is also new information coming out about Adult mesenchymal stem cell treatment. These cells can be obtained from either adipose tissue or bone marrow. I am very interested in orthobiological options, however only time will tell if stem cell treatment will become standard treatment for arthritis. Although the evidence is not solid, adult stem cell and PRP treatment is an option.
4) Unloading Brace, Hinged knee braces and Hiking poles- I recommend patients use these for their exercise. The Unloading brace has to be obtained from a brace supplier while the hinged brace can be obtained over the counter. The poles can be obtained at a local Big 5. Unloading the knee is critical. The braces help to stabilize the knee and provide support. The hiking pole helps to unload the knee.
5) Weight Loss- As I said above, unloading the knee is critical. Patients should be able to do a stationary bike or pool. Additionally the upper extremity pedaling exercise can help burn calories.
6) Supplements- Glucosamine and chondroitin can be obtained at any CVS, Trader Joes or costco.
7) Other Exercise- Yoga and Pilates are great exercise routines that improve core strength and flexibility. Your core strength is the platform required to generate strength in your arms and legs. Without core strength your arms and legs do not work as effectively.
8) Oral Medication- I limit the amount of anti-inflammatories I prescribe. I worry about side effects such as peptic ulcer disease or kidney problems. If I prescribe a anti-inflammatory it is usually only for a few days. I prefer to use natural occurring anti inflammatories such as cumin. It is inexpensive and can be bought as pills or put into food and shakes.
9) Wedge shoe inserts- These are for patients who have either severe bowing or knock knees. You can get them at http://www.drlannysinsoles.com/AboutUs.aspx
10) Simple Knee Arthroscopy- Its actually not so simple. In some cases I recommend arthroscopic surgery with the goal of removing or shaving loose or rough cartilage. Arthroscopy for arthritis is usually only done when the patient complains of catching or locking. The results of arthroscopy are not always predictable. If I do abrasion chondroplasty I recommend crutch or walker use for 6-8 weeks. In cases where there is sub chondral edema on MRI I will recommend a subchondroplasty procedure. The subchondroplasty procedure is done by injecting a paste like calcium into the weak and stressed bone which is associated with arthritis.
I have seen patients improve significantly with the above regimen. I believe that some patients can avoid joint replacement surgery. As I mentioned above patients have to understand that the benefits of the above program may take 3-4 months before they see improvement. Patients who are going to do well with non operative treatment usually know after the 3-4 months.
I hope you found this information useful.
About Steve A. Mora MD:
Dr. Mora is a native of Orange County. He graduated from Anaheim High School in Orange County CA. He completed his training at the UC Irvine where he finished in the top of his class with AOA Medical Society honors. He completed his Orthopedic Surgery training USC. He completed an extra year of training with a Sports Medicine, Cartilage, Shoulder, and Knee Fellowship at Santa Monica Orthopaedic and Sports Medical Group. He is currently practicing Orthopedic Surgery in Orange County. Dr. Mora’s practice focus on sports related trauma, knee ligament and cartilage repair, shoulder rotator cuff and instability, hip arthroscopy and partial knee replacement. He sees athletes of all levels including professional soccer and UFC/MMA. He is team doctor for the Anaheim Bolts pro indoor soccer team and Foothill High School. Dr. Mora performs Cartilage transplantation (Genzyme), partial custom knee replacement, OATS, tibial osteotomies, meniscus transplant, ACL reconstruction, shoulder reconstruction, elbow arthroscopy, hip arthroscopy, platelet rich plasma and adult stem cell injections. Dr. Mora’s family heritage is Peruvian. He speaks fluent Spanish.
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