Q&A Topic: Alternatives to Knee Replacement
Howard Luks, MD
Q: What physical conditions might lead someone to consider knee replacement surgery?
A: The primary driver that brings people into the office to consider knee replacement surgery is the development of osteoarthritis, which is the loss of cartilage, the cushioning in the knees. When the cartilage becomes thinner, the bones see more stress and that causes discomfort and eventually severe pain. Osteoarthritis can also be a highly inflammatory condition, which is why some people feel they have fluid in their knee, or as they refer to it, water on the knee. The inflammation in combination with the loss of the cushioning cartilage can cause severe pain.
Q: Do you find a lot of people seeking knee replacement unnecessarily, and why?
A: A significant number of knee replacements are being done far too early. And probably a lot of it has to do with expectations; that cannot be overstressed. If I have a 50-year-old in my office requesting knee replacement, my first question is why? When the answer is, “ I used to play basketball, I used to play football, I used to be very active,”... that's not the reason why we consider doing knee replacements. We're doing knee replacements to restore someone's quality of life and allow him or her to participate in normal activities of daily living without severe pain. Anything else beyond that is a bonus.
Q: So the No. 1 reason to consider knee replacement surgery is not to get back to playing basketball again, but to get out of pain?
A: Absolutely correct. This is a quality-of-life procedure.
Q: How does osteoarthritis affect someone’s quality of life?
A: Osteoarthritis, in its very early stages, affects your knee joint. Your knee hurts and swells. Eventually, as your pain worsens, you don't want to go up and down stairs in your house. You're not going to go out to the supermarket, or out with your friends, or to the city and see a show. So you're walking less. It's affecting your heart; it's affecting your lungs. If the pain is severe, you may start to become very lonely and depressed. So, we want to get these patients into treatment, whether it's a knee replacement or other forms of treatment, before they start this downward spiral.
Q: What are some alternatives for knee replacement for somebody who maybe doesn't quite need it?
A: Osteoarthritis in its earliest forms tends to respond really well to either ice or moist heat; a lot of more recent research says that heat is probably better. Oral anti-inflammatory medicines such as Motrin, Advil, and Aleve, as long as patients are not on blood thinners or have ulcers or other issues that might help prevent them from taking anti-inflammatories. Most important is resistive exercise or physical therapy, [which] help minimize the pain of osteoarthritis. The first two weeks in physical therapy or exercise might actually stir that knee joint up and make it cranky, so the pain might increase in the first two weeks. They have to stay with it in order to see the benefits.
If we have people who do not respond to therapy or medicine, we have injection treatments, such as cortisone and hyaluronic acid, typically administered as a course of three injections over three weeks. Many people will respond to those, some for eight months or more, at which point those injections can be repeated as long as someone doesn't develop an allergic reaction.
If quality of life remains significantly limited despite exercise, weight loss and injections, then a relatively new procedure may present itself as a reasonable alternative to a knee replacement. At Westchester Medical Center, we have been performing a procedure called an embolization. It is a procedure performed through the small arteries around the knee. Researchers found that the inflammation in the knee from the arthritis comes in the form of synovitis, or inflammation of the lining of the knee joint. The researchers found that these tiny little vessels were growing abnormally around the side of the knee where the inflammation was. The researchers found that when they were able to embolize, or stop the blood flow, in these overgrown vessels, their patients have profound pain relief. The pain often went away at that moment of the procedure because they stopped the blood flow to these areas of synovitis. According to the latest publications, about 80 percent of people are responding well, and they're having pain relief for upwards of five years and on. It's been a pretty dramatic development for the treatment of moderately severe osteoarthritis.
Howard Luks, MD
Westchester Medical Center, flagship of the Westchester Medical Center Health Network (WMCHealth)
19 Bradhurst Avenue, Suite 1300N
Hawthorne, NY 10532