I recently took a trip to the land of the nearly dead and newly wed – Florida – to help my sister celebrate a landmark birthday. How old is she? I won’t say, but she is content to stay home and read a book (if she can remember where she put her glasses), go to dinner for the early bird specials, cuddle up in bed by 9 PM, and has been getting AARP The Magazine for a few years. All of which is so unlike her. So basically, she is old and a shell of the party animal I grew up with. You may find that cruel, but she will find it funny – I think. While visiting her I found the February/March publication of AARP The Magazine lying around her house and read an article in it, New Hope for Aging Knees, which discussed treatments for arthritic knees including knee replacement surgery. Many of us will get painful knees if we live long enough.
The article reviewed the pros and cons of knee replacement surgery and questioned whether or not the results from knee replacement surgery are as good as they are touted. It also discussed alternative options to lessen knee pain and possibly avoid a knee replacement. Seven hundred thousand knee replacements are done each year throughout the country.
Though current treatments for aging knees are reasonably successful there is certainly room for better outcomes. And, new technology is already being used clinically and offers the chance for better results. We will discuss this new technology at the end of this article. But first, let’s start with the basics.
Symptoms of Aging Knees
Symptoms of arthritic or aging knees are similar to those symptoms for arthritis elsewhere in the body and include:
- knee pain which can vary in severity.
- knee swelling.
- loss of motion of the knee.
- weakness in the thigh or quadricep muscles.
- mechanical symptoms such as locking, catching, or giving way of the knee.
Treatment for Aging Knees
Treatment for arthritic knees run the gamut ranging from therapeutic exercises, anti-inflammatory medications (oral and topical), unloading braces and heel wedges, cortisone and viscosupplementation injections, arthroscopic surgery, and finally knee replacement surgery which can either be a total knee replacement or a partial replacement.
The term “knee replacement” is somewhat misleading, at least in my mind. A knee replacement is more or less a capping of the bone with metal or plastic material – kind of like a crown for the tooth.
Prior to doing what I do now I had an office-based orthopedic practice and treated musculoskeletal problems non-surgically. One of my former partners – a joint replacement surgeon at the Steadman-Hawkins Clinic of the Carolinas – was slow in recommending knee replacement surgery to his patients, which is very unusual for a surgeon.
He went through the entire treatment continuum or gamut I mentioned above on nearly every patient before he would perform a knee replacement, and virtually all patients were required to do aquatic therapy before he would consider performing a knee replacement. He was able to avoid or at least delay knee replacement surgery on a fair number of his patients.
One intervention that worked reasonably well for those arthritic knees he was seeing, happened to be the least costly. And, that was a heel wedge for the shoe that costs a few bucks. It is amazing how much pain relief a piece of felt or silicon in a shoe can do to relieve knee pain.
Most patients with aging knees wear out the inner half of the knee or medial compartment to a greater degree than the outer half. A heel wedge is put in the shoe with the thickest portion of the wedge being on the outside of the heel and thinner side on the inside. When a patient steps in the shoe the wedge turns or pronates the foot, which has the effect of opening the inside of the knee providing some pain relief.
Now, such a wedge doesn’t work all the time, but is a simple thing to try especially in patients who are not ideal surgical risks. It is almost too simple to even think it would work, and outside this particular surgeon, I have not seen another joint replacement surgeon regularly recommend a trial of a heel wedge.
Pros and Cons of Knee Replacement Surgery
By and large knee replacement surgery is effective in eliminating pain and improving function and quality of life. Anywhere from 82% to 89% percent of patients are satisfied with their result, yet many of them were expecting more. And, 20% will still suffer chronic pain – the main reason joint replacement surgery is performed. So we could say the results from knee replacement surgery are good with room for improvement.
The main complications from knee replacement surgery include:
- failed implants. These are implants that have loosened triggering pain and inflammation. Ten percent of knee implants eventually fail.
- infections. Infections are potentially limb-threatening and even life-threatening. While care is taken to avoid joint infections they still happen 1 to 2.5% of the time and even happen in the hands of the very best surgeons.
- blood clots. Blood thinners are routinely given to patients undergoing joint replacements but blood clots can still occur in the legs and are life-threatening if they travel to the lungs known as a pulmonary embolism.
- nerve injury. This happens less than 1% of the time but can be a source of ongoing pain and numbness when they occur. Some improvement in nerve function is typically seen, but not always and not alway completely.
A word about complications in general.
Some complications are minor, but some are major. All the complications listed above for knee replacements are major. What you need to know about complications is this. In any given patient the complication rate is either 0% or 100%. There is no such thing as a 1% complication rate when talking about a single individual. A joint infection may only occur 2.5% of the time but if it happens in you it is 100%. And, here’s the other thing. You get the whole complication. You don’t get 2.5% of an infection. You get 100% of an infection. So keep all of that in mind when assessing the risk of a procedure or even a medication.
If you do undergo a joint replacement we do recommend you see surgeon who does at least a couple hundred of them a year (knees and hips) as they generally have better outcomes and lower complication rates.
Options to Avoid Knee Replacement Surgery
The AARP article discussed eight ways to minimize knee pain and avoid knee replacement surgery. But, it only mentioned briefly what I think will become the best option in avoiding any type of joint replacement. I will get to that option towards the end.
Here are the eight strategies to avoid knee replacements discussed in AARP The Magazine.
- Lose weight.
- Perform more low impact fluid exercises (biking, walking, swimming, rowing).
- Strengthen and stretching exercises of the muscles above and below the knee joint.
- Using an unloading brace (more directly does what a heel wedge can do, but braces are more expensive and less comfortable than a heel wedge).
- Acetaminophen and non-steroidal anti-inflammatory medications.
- Hyaluronic acid injections into the knee joint (viscosupplementation).
- Glucosamine HCL and chondroitin sulfate nutritional supplements (also fish oil and curcumin are natural anti-inflammatories).
A few comments on the above strategies. Getting your weight down can make a dramatic difference in pain level if you have arthritis of the knee. Forces three times you body weight are placed on the knees when walking and anywhere from five to nine-fold when you run. So if you weigh 250 pounds your knees see 750 pounds of stress when walking. So even losing 25 pounds if you weigh 250 (10% body weight) can reduce the stress on the knees significantly.
The problem for patients with knee arthritis is they have a difficult time burning calories from exercise because of knee pain. What they don’t realize is the biggest bang for the buck when it comes to weight loss is on the nutrition end and not the exercise end. They would be better served meeting with a nutritionist rather than trying to find ways for them to be more active.
Recently, I had a patient who decided to go on a ketogenic diet (very low carb diet) and in two weeks he said all his aches and pains went away including his knee pain. He is in his 40s and has early arthritis. It’s unlikely such a diet will lead to such dramatic results across the board, but such a diet is probably worth trying if you have painful joints as we do know sugar is linked to joint pain and inflammation.
Exercise is important in lessening knee pain. Most people know to focus on low impact rhythmic exercises (cycling and swimming), but do not forget to stretch. Increasing flexibility across a joint enables the joint to function with less stress and more mechanical efficiency.
Studies on nutritional supplements yield mix results, but they are relatively inexpensive and such easy things to try that we recommend taking high quality fish oil, curcumin, and glucosamine/chondroitin supplements. While they may not provide pain relief for everyone, they may still slow the progression of the arthritis.
Time for New Technology
The joint replacement technology started in the 1940s and 50s. Every technology can only deliver so much and we are approaching the point where knee and hip replacements are delivering all they can deliver.
Here’s the unfortunate reality about knee and hip replacement surgery (shoulder replacements are still in their infancy). It is unlikely that the complication rates and the success rates are going to improve much more. Everything that can be done to prevent the above complications is already being done. Such complications much of the time – just happen. And, they happen to the best surgeons, they happen in the best hospitals, and they happen under the best of circumstances.
And, while outcomes from knee replacements are good, they are not great. Success rates hovering around 85% are equivalent to a B average. And, it is unlikely they will ever get into the A range.
A train powered by a steam engine can only go so fast and can only carry so much load no matter how much you tweak the design. And, putting metal and plastic in the body can only yield a certain level of results. Metal and plastic cannot match the natural human design. New joint designs continue to come out and new surgical techniques are developing but they are not likely to change outcomes significantly. And, the physical therapy before and after surgery is about as good as it can be.
In other words, joint replacement surgery, for all intents and purposes is about good as it is going to get. That technology is at its zenith. Joint replacements are not going to go away, but some day they will yield to a new technology. And, what is that new technology?
Hope is on the Way for Aging Knees: Stem Cells
I believe stem cell therapy will be the future treatment of choice for arthritic joints including aging knees, so much so, that I am now enrolled in stem cell fellowship I plan on completing by the end of 2017.
Stem cell therapy will provide a long-term solution to many problems and has the potential to restore arthritic joints to normal or near normal. It is a very practical intervention for musculoskeletal problems. I see a day where between the ages of 40 and 50 you will go to a Regenerative Medical Clinic and receive stem therapy for a host of medical problems – kind of like a 40,000 mile tune-up for your car.
Today – right now – in nearly any large metropolitan area you can find a physician offering stem cell therapy for musculoskeletal problems. But, you will have to pay out of pocket for the procedure as insurance does not yet pay for stem cell therapy, outside stem cell treatment for leukemias.
Stem cell therapy will enable physicians to intervene early in the arthritic process when stem cell therapy is most effective and can potentially reverse arthritic changes. This makes far more sense than waiting for pain and disability to reach a point that a joint replacement is the only alternative. And, all those other options to treat aging knees can lessen pain, but they do not reverse the arthritic changes. Stem cell therapy burns no bridges. It can be done as often as needed and all other treatment options for arthritis remain available if needed.
Some centers performing stem cell therapies for arthritic joints like the Institute of Regenerative Medicine are already reporting success rates of 85% – and the technology and application of stem cells is in its infancy. And, there is far little down time. Many can have the procedure and be back at work the next day. And, you are using your own stem cells. You are using your own body to repair your body. That makes far more sense then using metal and plastic.
You cannot undo a joint replacement and you have burned many bridges once a joint replacement has been performed. Once you have a joint replacement you are are committed to repeat replacements if necessary. And, each subsequent repeat replacement yields less chance of success.
So, if you have aging knees there are plenty of treatment options with stem cell therapy having the potential to restore aging joints to near normal while improving quality of life greatly for a malady that afflicts many. Life isn’t much fun when your knees ache. But….
…hope is on the way for aging knees through stem cell therapy.
As I learn more about stem cell therapy, I will share here providing you with “insider information”.