Can a knee replacement alternative make you like the Borg from Star Trek? In the “you just can’t make this stuff up” category this morning is a new surgical system that lives in the category of “Knee replacement alternatives”, but frankly…Damnnn…. (see above left). This is a surgically implantable system known as the “KineSpring” that does much of what a simple knee unloader brace does, but instead is an invasive surgically implantable device. This big piece of metal hardware (almost guaranteed like a knee replacement to increase your serum metal ion levels) takes the weight off of the side of the knee that has arthritis. You might be asking yourself, why??? Why take the surgical risk to do what a simple knee brace will do? Why not just get the darn knee replaced if you’re willing to do this? Why not look at cell based alternatives first? Your guess is as good as mine!
You might think we know that the knee replacements that surgeons perform everyday work very well, after all we perform 600,000 of these procedures annually. These are invasive surgeries using FDA approved knee replacement devices that are paid for by every insurance company. While there is some data from various studies, a recent large study that looked at long-term data was very disappointing. In fact, it argues that we should be looking at knee replacement alternatives. A recent Lancet article raised some concerns about the wide range of patients who were receiving total knee replacement surgeries. Their concern was that these were not only patients who were disabled by knee pain, but also a host of patients with only mild symptoms. I‘ve blogged before on this issue of joint replacement device manufacturers aiming their advertisements at a younger and more active population with knee pain. The study author noted that the growing number of younger people undergoing knee replacement surgery is something of a mystery (IMHO called advertising). In fact they noted that an international panel found that surgeons’ recommendations for knee replacement were not correlated with pain, disability, or radiographic severity. The study author commented that only patients with longstanding pain at night or pain with weightbearing (just walking) should undergo the invasive surgery. Finally, the authors noted that knee replacement alternatives that are non-surgical should receive major research attention. Sound familiar?
New research out last week shows that because we’re replacing knees in more middle aged patients, the number of revision surgeries needed in the future will be epic. A staggering 1.5 million US adults are likely to need a revision knee replacement surgery before age 70, which is a dramatic jump in these surgeries. The issue is that while a first knee replacement surgery is a big procedure, they tend to be shorter 60-90 minute procedures with less blood loss, anesthesia time, and risk. A revision surgery on the other hand is a very big surgery, usually lasting 3-4 hours with much more risk to the patient. The revision procedure is just technically more difficult, as the old prosthesis has to be removed and a new one inserted. In addition, since tissues have grown into the old knee replacement prosthesis, extracting it safely from those tissues can be a challenge. So what can you do to avoid being one of those patients who needs a revision surgery? Look for knee replacement alternatives. These include:
-Avoid knee meniscus surgeries that remove meniscus tissue after a tear. These knee surgeries are known to advance the development of knee arthritis as there is less cushioning with less meniscus. If your knee is locking due to a torn meniscus, get a doctor to inject SynVisc (or another brand of hyaluronic acid) to dislodge the piece. If it still locks, consider biologic treatments for the tear like PRP or knee stem cell injections. If you still need surgery, have the surgeon remove the smallest possible amount of meniscus.
-Try SynVisc or another brand of hyaluronic acid injection. Make sure the surgeon or physician does this knee injection under imaging guidance and not blind. This WD-40 lubricant injection may help buy you a few more years, especially if you start early when your arthritis is less severe.
-Avoid steroid shots into the knee. Recent research shows that these shots can kill off large numbers of cartilage cells. You need all the cartilage cells you can get.
-If you have mild arthritis that doesn’t respond to SynVisc or hyaluronic acid injections, consider platelet rich plasma injections, which have been shown to work better.
-If you have more significant knee arthritis, consider stem cell injections.
-Have someone look at why your knee has arthritis, as there are usually biomechanical and or other causes.
The upshot? Think twice about getting a knee replacement if you’re under 65 or you may be in the crowd of 1.5 million patients who will need much a riskier knee revision surgery.
I came across this study today, which looked back (retrospective) at patients who had knee replacement. The first group had no previous surgery and the second group of patients had prior knee arthroscopy. The authors found that having prior knee surgery before your total knee replacement was related to a higher rate of complications from the knee replacement surgery and that these patients were less satisfied with their knee replacement. While the study has some problems, such as the fact that it’s retrospective (looking backward in time), it does raise an interesting point. Why? Is it that patients with prior knee arthroscopy are more likely to have chronic knee problems no matter what the surgeon does? Is it related to something in their genetic make-up? Is there something about a prior arthroscopic knee surgery that makes it more difficult to properly install or fit a new metal knee? What was also interesting was that about 1/3 of the patients in the prior knee arthroscopy group needed a second surgery and about 8% needed a new knee replacement surgery (revision arthroplasty) at a mean of about 4.5 years after their first knee replacement. This is a very short time, as most artificial knee joints would be expected to last 10-20 years. Since most patients in the U.S. follow a predictable pattern of a first knee surgery to trim a torn meniscus in their 30′s or 40′s, a second knee surgery to clean up more meniscus tears and torn or worn cartilage (debridement), and then finally require a knee replacement in their 50′ or 60′s, these results could be concerning if the higher complication rate or need for a second knee replacement surgery is caused by some property of the prior knee surgery. On the other hand, if the higher rate of complications and second knee replacement surgery is instead caused by some property of the patients themselves (like genetics that lead to more knee arthritis), then the higher side effects may just be an unavoidable consequence. It will certainly be fascinating to see if another group of researchers publishes something else on prior arthroscopy to confirm these findings.
Interesting study out this week that tries to tie lack of blood flow in the knee cap to why some patients have chronic knee cap pain after a total knee replacement.The study authors found that in about 1/4 of the knee replacement patients with chronic knee cap pain, blood flow in the knee cap area markedly decreased with flexing the knee. To be honest, I was surprised to learn that knee cap or patellar pain is a common complication of knee replacement. A 1995 study identified that chronic pain in the knee cap after total knee replacement occurred in about 13% of knees. The doctors who first reported the side effect believed that the type of metal or plastic knee used by the surgeon may make a difference. Since then there have been many studies trying to figure out why these patients still hurt when they should all be be pain free after having their knee replaced. So why do some patients develop pain in the patella after knee replacement? One study looked at wear on the patella after knee replacement and found much more strain on the inside of the patella in a total knee replacement knee when compared to a knee without a prothesis. Another study looked at many different causes of this knee replacement side effect including shortening of the patellar tendon and that the knee replacement prosthesis may be misaligned in some patients. One surgeon postulated that knee cap pain after knee replacement may be due to instability in the patella due to the metal prosthesis not being properly installed. Whatever the cause of this knee replacement complication, the fact that more than 1 in 10 knee replacement patients is walking around with chronic knee cap pain is concerning. It’s maybe a little more concerning that there isn’t consensus about what causes the problem.