In our office, we do sometimes see women who had a knee replacement and continued to have pain and complication afterwards. To see if we can help these women with their pain we do a detailed assessment to determine the cause of their knee pain. We rule out hardware failure and other surgery related challenges that we may not be able to help with. For some, knee instability and damage to the remaining natural structures of the knee may be something we can help with. The best way to determine if and how much we can help you, is for you to reach out and contact us.
“Women’s Experiences of Undergoing Total Knee Joint Replacement Surgery.”
This is the title of a recent study (1) that helped nurses identify the path to knee replacement some women take and what happens after the knee replacement. The study sought to help guide medical professionals in understanding what makes a women decide to have a knee replacement and what happens when the knee replacement rehabilitation issues new challenges to the patient. Here is what the study suggested:
“The time before surgery was marked by the experience of constant pain, which affected the women negatively in their everyday lives. During surgery, the information provided by the staff gave each woman a sense of security; the women handed over responsibility to the staff and experienced a sensation of relief. The postoperative period was characterized by a feeling of joy when the surgery was over, although a rough and tedious rehabilitation phase then began. Challenges in everyday life were a factor for motivation and confidence, although postoperative pain was experienced as discouraging.”
The discouraged patient is the one we often see. Realistically, we would like to see this woman before the knee replacement to see if we can help her avoid the knee replacement. One thing we may check for, among many factors, is her bone strength.
In a recent study (2) doctors investigated whether women have poorer pain and functional outcomes following total knee replacement and to investigate factors that may contribute to this poorer outcome. In a group of 494 people, outcomes were the Pain and Function/Daily Activity subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 6 and 12 months post-surgery. Then these scores were divided by the (1) sex of the patient; (2) sex and age of the patient; (3) sex, age and pre-surgery score for respective outcome measures of the patient; and, (4) model 3 and body mass index (BMI), education, low back pain (LBP), depression, comorbidities, and symptomatic joint count of the patient.
Women were significantly worse on several factors pre-surgery: pain, function, depression, obesity, symptomatic joint count (more than 4 joint pain problems)
Women had worse outcomes for pain and function at 6 months.
This effect was attenuated by adding pre-surgery pain/function. However, the magnitude of the association of pre-surgery pain/function was reduced when LBP, depression, BMI, education level, joint count and comorbidity count were added suggesting association with pre-surgery pain and function. Twelve month results were similar.
Conclusion: Women appear to have worse outcomes than men possibly due to a putative pre-operative profile across many factors. Consideration of total knee replacement when impairments in pain and function are less severe along with interventions that address mood and comorbidity may improve outcomes for women having total knee replacement.
For post menopausal women to have a successful knee replacement they most have strong bones also
Doctors have published research in the prestigious Journal of orthopaedic research (3) suggesting something of the obvious. For post menopausal women to have a successful knee replacement they most have strong bones. The problem is many pre-surgical treatments to help women strengthen their bone and alleviate their knee pain cause weakened bones.
In a summary of this research, the investigative team wrote: “Osteoporosis and osteoarthritis commonly coexist in the elderly. In patients undergoing prosthetic total knee arthroplasty (total knee replacement), the bone quality around the knee joint may affect the safety of prosthetic implantation and consequently satisfaction with the surgical outcome.”
What was the conclusion of this study?
Bone volume and bone strength were significantly associated with postoperative pain and the local bone quality, including mineral content and microarchitecture, affects the surgical outcome of the knee replacement.
A problem in identifying women who have strong enough bones for surgery or treatments
This is discussed in troubling research from NYU Langone Medical Center, Hospital for Joint Diseases. They looked at patients suffering from post-traumatic osteoarthritis and suggested that this is a special group of patients who require a different set of pre-surgical rules because of high revision surgical rates and surgery failures.
Post-traumatic osteoarthritis is caused by injury or trauma. For an older woman athlete for instance, this injury could be an ACL tear, meniscal tear, or any injury treated or untreated. Having a previous knee arthroscopic surgery would certainly qualify for as post-traumatic injury. For non-athletes, a broken bone sustained in a fall or car accident could cause post-traumatic osteoarthritis.
What these injuries and treatments have in common is progression to osteoarthritis and microfractures of the bone.
Here is the what the NYU researchers published:(4)
Total knee arthroplasty (replacement) is often the best answer for late or end-stage, posttraumatic osteoarthritis. However Total knee arthroplasty in this setting is often considered more technically demanding, outcomes are typically worse for patients.
Post-traumatic knee replacement patients were on average younger and healthier than the primary knee replacement population yet they had higher rates of superficial surgical site infections and bleeding requiring transfusion.
Osteoporosis drugs to promote implant fixation
A main cause of knee replacement failure is that the implant loosens or slips out of the bone. The bone is too weak to hold it. Doctors have come to an understanding that if you treat the bones with an osteoporosis treatment program, the joint implant may perform better. This was expressed in an October 2020 study (5) which stated:
“Clinical studies have not only demonstrated the growing prevalence of osteoporosis in patients undergoing total joint replacement but may also indicate a significant gap in screening and treatment of this comorbidity. Osteoporosis negatively impacts bone in multiple ways beyond the mere loss of bone mass, including compromising skeletal regenerative capacity, architectural deterioration, and bone matrix quality, all of which could diminish implant fixation. Recent findings both in preclinical animal models and in clinical studies indicate encouraging results for the use of osteoporosis drugs to promote implant fixation. Implant fixation in osteoporotic bone presents an increasing clinical challenge that may be benefitted by increased screening and usage of osteoporosis drugs.”
At the Magaziner Center, we specialize in treating chronic pain
A study from the University of Oxford (6) reported that 63% of women age 50 and older reported persistent, incident, or intermittent knee pain during the 12-year study period this research conducted. Mostly these women suffered from obesity, osteoarthritis, and previous knee injury leading to posttraumatic osteoarthritis.
Most of the patients we see in our office are patients that have already been to many different doctors with varying degrees of success or failure in their knee pain treatments.We see patients who may have been given unrealistic expectations before the surgery as to how long their recovery may be. In a December 2019 study,(7) doctors revealed that “Surgeons often inform patients that the recovery time after a knee replacement is one year, which in light of this study, might be too short.” This is someone we see. Someone who thought their knee “would be fixed by now.”
At the Magaziner Center for Wellness we treat knee pain holistically, taking advantage of treatments that include prolotherapy, platelet-rich plasma and cellular regenerative therapies to stimulate the body’s natural healing process. This allows the body to heal itself naturally, without surgery and without the side effects that come along with taking drugs to temporarily cover up the pain. We may also recommend various nutraceuticals to help stimulate healing, an anti-inflammatory diet and energy medicine modalities to help restore normal function and alleviate pain.
We cover our treatments in these related articles:
Menopause Hormone Therapy May Prevent Bone Loss
Options For Partial Knee Replacement
Stem Cell Therapy for Bone on Bone Knees
Joint Replacement Loosening Problems – Is it a Hormone Problem?
The Importance of Weight Loss in Avoiding Knee Replacement
Why Are Post-Menopausal Women Prone to Falls?
References
1 Engström Å, Boström J, Karlsson AC. Women’s Experiences of Undergoing Total Knee Joint Replacement Surgery. J Perianesth Nurs. 2017 Apr;32(2):86-95. doi:10.1016/j.jopan.2015.11.009. Epub 2016 Jul 27. PubMed PMID: 28343648.
2 Huang CC, Jiang CC, Hsieh CH, Tsai CJ, Chiang H. Local bone quality affects the outcome of prosthetic total knee arthroplasty. J Orthop Res. 2016 Feb;34(2):240-8. doi: 10.1002/jor.23003. Epub 2015 Aug 11.
3 Kester BS, Minhas SV, Vigdorchik JM, Schwarzkopf R. Total Knee Arthroplasty for Posttraumatic Osteoarthritis: Is it Time for a New Classification? J Arthroplasty. 2016 Aug;31(8):1649-1653.e1. doi: 10.1016/j.arth.2016.02.001. Epub 2016 Feb 13.
4 Anderson KD, Ko FC, Virdi AS, Sumner DR, Ross RD. Biomechanics of Implant Fixation in Osteoporotic Bone. Current Osteoporosis Reports. 2020 Jul 30:1-0.
5 A. Soni, A. Kiran, D. Hart, K.M. Leyland, L. Goulston, C. Cooper, M.K. Javaid, T.D. Spector, N.K. Arden. Reported knee pain prevalence in a community-based cohort over 12 years. Arthritis & Rheumatism, 2011; DOI: 10.1002/art.33434
6 Mehta SP, Perruccio AV, Palaganas M, Davis AM. Do women have poorer outcomes following total knee replacement?. Osteoarthritis and cartilage. 2015 Sep 1;23(9):1476-82.
7 Skogö Nyvang J, Hedström M, Iversen MD, Andreassen Gleissman S. Striving for a silent knee: a qualitative study of patients’ experiences with knee replacement surgery and their perceptions of fulfilled expectations. Int J Qual Stud Health Well-being. 2019;14(1):1620551. doi:10.1080/17482631.2019.1620551
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