Do alternatives to knee surgery make sense?
Studies show that physical therapy may help, but injections probably do not
Like many people, I have relatives and friends who have gone through a knee replacement surgery and are happy with the results of having better function and less pain. I also know others who have put off the inevitable surgery for years, relying on temporary fixes. In the end, though, pretty much everyone who ends up with extremely painful bone-on-bone arthritis decides to go forward with replacement surgery.
What about options to delay knee surgery? A lot of them do not work.
Researchers from The University of Texas participated in a study that was recently published in The Journal of Arthroplasty.
They looked at non-surgical options for management of knee osteoarthritis, including hyaluronic acid (HA) and corticosteroid injections, physical therapy, braces, wedge insoles, opioids, non-steroidal anti-inflammatories (like ibuprofen), and tramadol.
In particular, they looked at cases patients had one or more of these treatments in the year prior to a knee replacement surgery.
The researchers concluded that the non-surgical treatment costs could be decreased by 45% if orthopedic surgeons only used the treatment options recommended by the American Academy of Orthopaedic Surgeons.
The Academy has published clinical practice guidelines on the surgical management of osteoarthritis, compiling a list of treatment options for surgeons that are supported by research and evidence. Treatments that are not supported by evidence have fallen out of favor and are not found on the Academy’s clinical guidelines list.
What grabbed my attention is what the Academy does not recommend, including corticosteroid and hyaluronic acid injections. That has not stopped many orthopedic surgeons from still recommending these injections to patients.
Corticosteroids injections help to fight inflammation. At best, this is a Band-Aid-type remedy that may reduce pain. Experts say it does nothing to help the underlying problem of physical damage to the knee.
Hyaluronic acid is already found in your knee, and helps to lubricate and cushion the knee joint. It follows that hyaluronic acid injections just supplement the naturally-occurring substance that is already there.
What does it do? Researchers have extensively reviewed the evidence and have concluded that hyaluronic acid injections either have no effect or a clinically irrelevant effect that would make no difference to patients. Even worse, some experts have concluded that these injections could actually cause harm, in the form of an increase in the risk for adverse effects.
Are there any pre-surgical treatments that might work?
The rate of knee replacement surgeries has almost doubled from 2000 to 2010, according to data from the U.S. Department of Health and Human Services.
That makes one wonder if there are any non-surgical options that could be considered before going under the knife for a knee replacement.
The American Academy of Orthopaedic Surgeons clinical guidelines to surgeons concluded that there is moderate evidence supporting that an eight month delay to total knee arthroplasty (replacement) does not worsen outcomes.
So, if you want to try a non-surgical route first, what are the potential options?
According to the Academy’s clinical guidelines to surgeons, there is only strong evidence to support three pre-surgical treatment options: physical therapy, non-steroidal anti-inflammatories (like ibuprofen), and tramadol.
Some research shows that physical therapy can have good results.
A study published in The New England Journal of Medicine investigated 50 adults with moderate to severe osteoarthritis who had nonsurgical treatment, including physical therapy, exercise, and weight loss, and compared them to a similar group who had total knee replacement surgery.
After one year, 85% of the surgical patients reported pain relief and an improvement in mobility and function. For the non-surgical group, 68% reported the same positive results.
The conclusion of the research is that physical therapy and certain medications for pain and inflammation may work as a surgical alternative. On the other hand, other pre-surgical treatments will likely on bring you a large cost and little to no promise of any help with your underlying problem of bad knee pain.
In addition, there is also a potential increased risk of an adverse outcome. Some people have delayed knee surgery—either by their own decision or by following a doctors’ recommendation—and end up damaging their hip or other knee by over-compensating while walking.
Talk to your surgeon before making any decisions
Always remember that medical care is a two-way street. Listen to and carefully consider your surgeon's recommendations. Ask questions to make sure you are fully informed before making a decision on whether to go to surgery immediately or whether to give non-surgical alternatives.
Knee surgery complications
As an experienced Texas medical malpractice lawyer, I have represented clients who have had bad results from orthopedic surgeries, including knee and hip replacements. Sometimes, an orthopedic surgeon’s delay in taking a patient to surgery can lead to permanent complications that could have been avoided. In other situations, poor care after the surgery can lead to lost-lasting infections, sepsis, and even the need for additional surgeries.
If you or someone you care for has been seriously injured as a result of a botched orthopedic, hip, or knee surgery, call 281-580-8800 for a free consultation with one of our Houston-based medical negligence attorneys at Painter Law Firm.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
A physician has to supervise the care and prescriptions of nurse practitioners and physician assistants under written, signed agreements [...]read more
On 4/1/2018, the new law will end the current practice where doctors can secretly enter a DNR order against patient and family wishes [...]read more
A physician has to supervise the care and prescriptions of nurse practitioners and physician assistants under written, signed agreements
On 4/1/2018, the new law will end the current practice where doctors can secretly enter a DNR order against patient and family wishes
This article was originally published in the September/October 2017 edition of "The Houston Lawyer" magazine
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