One Third of Knee Replacements Classified as Inappropriate
Many people write to us regularly asking about their options for knee replacement. We will usually see an email that contains concerns such as “the MRI revealed I had no cartilage left…”; “my doctor says that the bone-on-bone condition warrants a total knee replacement.” Now, if these people had received this advice from their doctors, why are they writing to us? Because they are not convinced that total knee replacement is the correct option for them:
In material from Wiley the publishers of the medical joural Arthritis & Rheumatology: Doctors say that more than one third of total knee replacements in the U.S. are “inappropriate” based on using a patient classification system developed and validated in Spain. The study, published in Arthritis & Rheumatology, a journal of the American College of Rheumatology (ACR), highlights the need for consensus on patient selection criteria among U.S. medical professionals treating those with the potential need of knee replacement surgery.
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, with studies showing an annual volume increase of 162% in Medicare-covered knee replacement surgeries between 1991 and 2010. 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.
The present study led by Dr. Daniel Riddle from the Department of Physical Therapy at Virginia Commonwealth University in Richmond, examined the criteria used to determine the appropriateness of total knee arthroplasties. “To my knowledge, ours is the first U.S. study to compare validated appropriateness criteria with actual cases of knee replacement surgery,” said Dr. Riddle.
A modified version of the appropriateness classification system developed by Escobar et al. along with the Western Ontario and McMaster Universities Arthritis Index (WOMAC) Pain and Physical Function scales were used to assess participants enrolled in the Osteoarthritis Initiative—a prospective 5-year study funded in part by the National Institutes of Health (NIH). There were 175 subjects who underwent total knee replacement surgery, and were classified as appropriate, inconclusive, or inappropriate.
The mean age of knee replacement patients was 67 years and 60% of the group was female. Analyses show that 44% of surgeries were classified as appropriate, 22% as inconclusive, and 34% deemed inappropriate. The characteristics of patients undergoing surgery were varied.
“Our finding that one third of knee replacements were inappropriate was higher than expected and linked to variation in knee pain OA severity and functional loss. These data highlight the need to develop patient selection criteria in the U.S.,” concludes Dr. Riddle.
In a related editorial, Dr. Jeffery Katz from the Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital in Boston, Mass., writes, “I agree with Riddle and colleagues, and with Escobar and colleagues, that we should be concerned about offering total knee replacements to subjects who endorse “none” or “mild” on all items of the WOMAC pain and function scales.” 1
Is Knee Replacement the only answer for Knee Osteoarthritis?
Researchers writing in the medical journal KNEE say that “Patients with medial unicompartmental osteoarthritic disease of the knee requiring arthroplasty can be treated with either Total or Unicompartmental Knee Replacement (TKR or UKR). Currently, the decision to choose one operation over another is not well defined and may depend on the profile of the surgeon consulted.” Further, they found “a variation in decision making of up to 59%.” (2)
This means that there are a lot of variables (59% worth) to consider in making your knee replacement decisions and the first one is are you getting the right procedure for you?
This may explain why knee replacement expectations are not met according to researchers: “Despite high expectations, there were statistically and clinically significant differences between actual and expected activity at 12 months (following knee replacement surgery) suggesting that expectations may not have been fulfilled.” (3)
New research says: Prolotherapy may result in safe, significant, sustained improvement of knee pain in adults with moderate to severe osteoarthritis
Research appearing in the Journal of Alternative and Complementary Medicine says “In adults with moderate to severe knee osteoarthritis, dextrose prolotherapy may result in safe, significant, sustained improvement of knee pain, function, and stiffness scores.”
Looking at outpatients, researchers selected adults with at least 3 months of symptomatic knee osteoarthritis, recruited from clinical and community settings. The patients received extra-articular injections of 15% dextrose and intra-articular prolotherapy injections of 25% dextrose at 1, 5, and 9 weeks, with as-needed treatments at weeks 13 and 17.
Results: Thirty-six (36) participants (average age about 60 with 15 being male, 21 female) with moderate-to-severe KOA received an average of a little more than 4 prolotherapy injection sessions over a 17-week treatment period and reported progressively improved scores during the 52-week study (4)
Osteoarthritis is by far the most common form of knee arthritis and is generally caused by wear and tear. As the cartilage that lines the surfaces of the knee wears away, you are left with rough surfaces. As a result, your knee becomes stiff and painful.
Prolotherapy and PRP for the Knee
Most of the patients we see in our office are patients that have already been to many different doctors with varying degreess of success or failure in their knee pain treatments. While we are in New Jersey, we see patients from all over the worldk looking for the “answer” to their knee osteoarthritis.
In Prolotherapy, we use a dextrose based solution and for many this offers the desired results of ligament, tendon and cartilage rebuild. Sometimes we offer the patient Prolotherapy in the form of Platelet Rich Plasma Therapy for their knee osteoarthritis. Here we draw the patients blood, spin it, until we can harvest the blood platelets, which are rich in healing cells. Sometimes we offer Stem Cell Therapy to the patient, where stem cells from the patient’s body fat are introduced into the knee. Stem cells have the capability to mimic the building blocks of proteins to heal the knees.
1. One Third of Knee Replacements Classified as Inappropriate. Daniel L. Riddle, William A. Jiranek, Curtis W. Hayes. Using a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: A multi-center longitudinal cohort study. Arthritis & Rheumatology, 2014; DOI: 10.1002/art.38685
2. Beard DJ, Holt MD, Mullins MM, Malek S, Massa E, Price AJ. Decision making for knee replacement: Variation in treatment choice for late stage medial compartment osteoarthritis. Knee. 2012 Jun 6. [Epub ahead of print]
3. Jones DL, Bhanegaonkar AJ, Billings AA, et al. Differences Between Actual and Expected Leisure Activities After Total Knee Arthroplasty for Osteoarthritis. Journal of Arthroscopy http://dx.doi.org/10.1016/j.arth.2011.10.030
4. Rabago D, Zgierska A, Fortney L, Hypertonic dextrose injections (prolotherapy) for knee osteoarthritis: results of a single-arm uncontrolled study with 1-year follow-up. J Altern Complement Med. 2012 Apr;18(4):408-14.