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You may not need a total knee replacement after a serious injury

If you have an arthritic knee or if you have suffered a serious knee injury in the past, you may have been told that sooner or later you will need to have a total knee replacement. While knee replacements are the best option for some people, others may benefit from an alternative approach.

A total knee replacement means removing the worn-out, arthritic and painful knee joint surfaces and replacing them with metal and plastic components. It involves placing a metal end on the thighbone, (femur) and a metal and plastic tray on the shinbone, (tibia.) For many people, after years of agony, this operation is a godsend. The procedure relieves pain and greatly enhances their quality of life, allowing them to return to work and resume some of the activities that they have not been able to enjoy in years.

Unfortunately, most people are told they need to wait until they are 60 for a knee replacement. Surgeons are reluctant to perform knee replacements on younger people because the parts don’t last. A second replacement is often more complicated and costly. Since the average age for people to start to develop osteoarthritis is 40 years old, patients may be condemned to suffer chronic arthritis for 20 or more years.

On top of this, a total knee replacement is not the perfect solution. 50% of patients say they still have some level of pain, even after the procedure and patients are advised not to run on an artificial knee. Not surprisingly, people are reluctant to get knee replacements because of activity constraints and stories of failed replacements.

So, what can you do if you’ve been told to wait? And is it possible to avoid a knee replacement altogether? The answer is: you can do plenty. Advancements in modern medicine mean that it is possible to rebuild a knee joint with biologic tissues rather than artificial materials to help relieve pain immediately and delay or even avoid the time in which an artificial joint replacement is necessary.


Do

Do learn to recognize the symptoms of osteoarthritis

The reason that most people need knee replacements is because their osteoarthritis has gotten so bad. If you can recognize the symptoms of arthritis early on, you may be able to do something to halt the disease in its tracks and avoid a knee replacement. Osteoarthritis is characterized by damage to the articular cartilage, which protects the end of the bones. The damage exposes the underlying bone, and any rubbing against this exposed bone produces the symptomatic pain at the joint: inflammation, stiffness, loss of flexibility and range of motion.

Do find out what has caused your arthritis

A thorough surgical evaluation is the best way to discover what has caused your arthritis. It could be that you damaged your articular cartilage in an injury. In some cases, osteoarthritis may be the result of a missing or damaged meniscus cartilage. The meniscus is the natural shock absorber in the knee. Without it, the unprotected femur and tibia bones grind together. It could be that your bones are misaligned, or that a ligament is malfunctioning or you may be carrying too much weight. An MRI and an X-Ray, as well your medical history and a physical assessment by a both a surgeon and a physical therapist, can help identify the cause.

Do get your cartilage damage repaired as soon as possible

There are now a number of ways to regenerate damaged cartilage to fill the hole that is causing the arthritis. Think of it like having a dentist fill a hole in your tooth. Just as it’s better to have a filling to catch tooth decay early on rather than get a set of dentures, it’s the same with cartilage damage. You fill the hole to stop it getting bigger and causing further damage that will ultimately result in the need for a knee replacement.

One of the best ways to regenerate cartilage is an advanced procedure called the Articular Cartilage Stem Cell Paste Graft. With a stem cell paste graft, a small amount of the patient’s own bone, adult stem cells (from the patient’s bone marrow) and cartilage are taken out of the knee, crushed into a paste, and impacted back into the arthritic defect in the joint. From there, the knee grows its own replacement tissue, right inside the joint, taking full advantage of the healing ability of the patient’s own stem cells. It’s an arthroscopic, outpatient surgery.

Do address the causes of your arthritis

At the same time as fixing the articular cartilage, you should you should take steps to fix the problems that may have contributed to your arthritis in the first place. If you have a missing or damaged meniscus, you should get this repaired or replaced. It is sometimes possible to save the meniscus cartilage by bringing new blood supply into damaged tissue, often adding growth factors, stem cells, and clot materials to help the healing process. It is also possible to replace all or a portion of the meniscus with donor cartilage. A meniscus transplant can reduce pain and improve function even in people with severe arthritis. Over the past 20 years, the technique of replacing the meniscus while minimally disrupting other joint tissues has developed into an outpatient arthroscopic procedure. A meniscus allograft, a donor meniscus cartilage matched to a patient’s height and weight is used. The allograft meniscus is accurately placed into the knee and carefully secured with sutures. The patients then follow a specific rehabilitation protocol to get them back to full fitness.

Do see a physical therapist

A smart physical therapist can look at a patient with an injury and figure out why they got injured or developed arthritis; help the patient learn exercises and techniques to recover from the injury and guide and motivate them to work to improve (without fear of pushing too hard.)

Most people are unaware of their posture, of how they walk or how their feet hit the ground. They don’t realize how loose or stiff their joints are or their back is. If you’re hurt or in pain, a physical therapist can teach you about the mechanics of your gait and the mechanics of your sport, valuable information to help speed your recovery and protect you from further injury. In some cases, physical therapy can help you avoid surgery altogether.

Soft tissue manipulation makes a huge difference in how people heal, in large part by reducing swelling, inflammation and scar tissue. People who follow a great physical therapy program before and after they undergo surgical procedures do a lot better than those who do not.


Don't

Do not assume just because you’re young, you don’t have arthritis

Arthritis is not just an older person’s disease; it can start young. After a joint injury, even in your 20s, your cartilage can begin the process of wearing away. Taking steps to avoid a knee replacement starts young. If you catch arthritis early, you can stop it in its tracks. You won’t have to compromise your activity or suck up the pain until you’re a knee replacement candidate.

Do not forget that carrying extra weight puts pressure on your knees

Consider that when walking, ten pounds of added weight can mean up to fifty pounds of excess force in the joints. If you want to avoid a knee replacement, it’s a good idea to keep the weight off. With so many contradictory dietary recommendations and nutrition trends, many of them based on inaccurate information gained from flawed food diary surveys; it’s difficult to know what to eat. A simple approach is best: focus on lean protein, fruits and vegetables. Cut back on carbohydrates, sharply reduce processed foods and avoid all sugary drinks. Combine this with a tall glass of water each hour and an hour of exercise a day. This will reduce weight, build muscle and improve health.

Do not rely too heavily on ibuprofen and anti inflammatories

While these non-steroidal anti-inflammatory drugs (NSAIDs) ease the pain and take down the swelling, they inhibit bone and collagen formation the very tissues we are trying to heal after injury or an operation. Use ice, soft tissue massage, elevation and repair the problem rather than continuously damage the joint. Injections of hyaluronic acid (HA) and PRP (your own blood platelets) combined may be an effective therapy for some joints and help diminish the use of anti-inflammatory medications.

Do not stop exercising just because you have arthritis

For people with arthritis or recovering from knee surgery, it is possible to custom design a set of exercises to work around the injured joint. So for a severe knee injury, a single leg squat with a partner ball throw is a great example of training almost all the body’s musculature and skills. Combining a round robin of exercises, completed almost non-stop, increases the heart rate, trains the cardiovascular system, and most of all is fun. Elderly people, recovering from a knee or hip replacement, can combine balance skills standing on a pillow, while swinging a very light kettlebell. This rapidly improves their core strength and balance skills. We want our patients to increase not decrease their exercises as fitness reduces pain and improves the quality of life.

Do not think that an artificial knee replacement is your only option

If your arthritis is too severe for you to undergo any of the biologic replacement techniques or treatments that will help you avoid a total knee replacement, there may be another option open to you: A partial knee replacement. Knees do not necessarily wear out evenly, sometimes one part of the knee is perfectly fine while another part is completely destroyed. If only part of the knee joint is worn out, why replace all of it? A partial, (or unicondylar) joint replacement involves resurfacing the worn out portion of the joint, either the inside, outside or kneecap, and leaving the rest of the joint alone. To work properly, the components must be put in extremely accurately. Even a millimeter or two of tilt or rotation dramatically affects the wear patterns and longevity of the components. Think of how a car out of alignment means rapid tire wear. With a robotic assistant, surgeons can plan the surgery on a computer screen with a virtual model of the patient’s own knee (built in 3D from their CT scans.) They can put the components in place virtually and adjust them before making only a small incision. During surgery, the robotic arm and computer navigation provides surgeons with pinpoint precision to enable optimal implant positioning and alignment that results in a more natural knee motion. Afterwards, people say their knees feel normal, which almost never occurs after a full knee replacement. With a partial knee replacement, there is no need for saws, drills or guides. In fact, the procedure is so minimal that you can walk out of the surgery center 1-1/2 hours after surgery and begin physical therapy the next day.


Summary
Jumping cartoon

Osteoarthritis ruins far too many lives. Don’t let it ruin yours. Be proactive in seeking biologic treatment that doesn’t just mask the symptoms but more importantly addresses the cause of the arthritis and fixes the problem. Waiting 20 years for your arthritis to get bad enough for you to be a knee replacement candidate is unacceptable. In our opinion, biologics trumps bionics any day of the week.


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Kevin R. Stone M.D.Orthopedic Surgeon

Kevin R. Stone, MD, is an Orthopedic Surgeon at The Stone Clinic and Chairman of the Stone Research Foundation in San Francisco. He pioneers advanced orthopedic surgical & rehabilitation techniques to repair, regenerate and replace damaged carti...

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