Which Knee Injection is “Better” for Knee Arthritis?

May 11, 2017 By Stefan D. Tarlow MD Leave a Comment

Have you tried taking oral medications for your knee arthritis but to no avail? Are you not getting the relief that you need from these meds? A knee injection can be a great option. Injection is beneficial to patients who had no relief from taking medications but are not quite ready to undergo surgery. Since there are various kinds of injection for knee arthritis, the question really is: which is better?

Hyaluronic Acid Vs. Corticosteroid

Patients with mild to moderate knee arthritis commonly receive injections for relief of knee pain and knee stiffness associated with arthritis. Patients with severe or “bone on bone’ knee arthritis were excluded from this study since these patients do not respond as well to these two treatments. The two common options for injection treatment of knee arthritis are hyaluronic acid (HA, visco supplementation) and corticosteroid (steroid). Patients often ask which option “is better.” A comparison study of these two treatments was published recently.

According to studies, there are no significant differences noted between patients who were injected with hyaluronic acid and those injected with corticosteroid. Both knee injection treatments provide improvements in patients with knee arthritis, relieving their pain and improving their function. However, of the two, hyaluronic acid is more expensive.

Hyaluronic Acid/Viscosupplementation

Hyaluronic acid injection is also known as viscosupplementation. This is a medical procedure which involves injecting lubricating fluid into the joint of the affected knee. This is used to treat the pain and other symptoms of knee osteoarthritis. The hyaluronic acid is naturally found in healthy joints. However, there’s a significant reduction in this joint fluid when the knees are affected by arthritis. Hence, there is a need to inject the joint with such acid.

This knee injection helps in facilitating better knee movement and function, reducing pain and other symptoms, and slows the progression of the knee arthritis. However, in order for the hyaluronic acid injection to work better, it must be coupled with a strong rehabilitation program.

Corticosteriod

Corticosteroids are similar to the hormone substances that our body naturally produces to reduce inflammation. The primary function of corticosteroid is to reduce the inflammation by decreasing our body’s immune response. Because of this, this medication is now used as a knee injection for arthritis. Low doses of corticosteroids are injected into the affected joint. The shots can increase the function, reduce the inflammation and relieve the pain of the patients. These effects may last from weeks to months.

The Results

Both Triamcinolone (corticosteroid) and SynviscOne (hyaluronic acid) provided successful and similar improvement in pain relief, function and range of motion at the 6 month interval. There are no significant differences when it comes to the pain relief and improvement of function in patients. So which knee injection is better? That depends on your preference and that of your health provider. Both treatments, as proven by studies, are equally effective and safe.

If you need help your arthritis or knee problem, make an appointment. Contact Tarlow Knee today and we will help you regain your normal function and relieve your pain.

Total Knee Replacement After ACL Reconstruction

May 5, 2017 By Stefan D. Tarlow MD 12 Comments

Suffering from a knee injury or advanced arthritis in the knee makes it hard for one to perform even simple activities like walking. Some still feel pain and discomfort even when lying down or sitting. In some cases, using walking supports and taking medications may be helpful. However, some consider total knee replacement as a viable option to correct the deformity and relieve the pain, among others.

Impact of Arthritis After ACL Reconstruction

According to a new study, people who have undergone reconstructive surgery such as total knee replacement have high chance of developing wear-and-tear arthritis, three times more in the injured knee than in the injured one (as published in the American Journal of Sports Medicine, 57 percent of patients who had ACL-reconstructed knees).

The risk of advanced arthritis in knee following successful ACL knee ligament reconstruction is greatly increased (50 percent greater) over the uninjured population. When a patient undergoes Total Knee Replacement (TKR) surgery in this setting it is not just a routine surgery.

TKR operative time is significantly longer and the risk of reoperation due to various causes (infection, stiffness, instability) is 5 times higher than the control group.

Total Knee Replacement Precautions

There are several precautions that the patient must undertake in order to achieve a safer and more successful total knee replacement. This includes several evaluations, tests and planning.

Medical Evaluation

Physical examination for medical evaluation may be necessary weeks prior the scheduled operation. This is a precaution to make sure that you are in good health and shape to undergo the surgery successfully. The safety of the patient is of paramount importance.

Tests

There are several tests that you may need to take as part of the plan of your surgery. Usually, the tests include electrocardiogram and taking urine and blood samples. In line with this, people with a history of urinary infections need to undergo urological evaluations before the surgery. The required treatments must be completed first before undertaking total knee replacement surgery.

Medications

The surgeon needs to know what medications you are taking for your advanced arthritis in knee or any condition for that matter. This is important as there are certain medications that you need to refrain from taking before the surgery.

Social Planning

You need to plan ahead, especially for period immediately after the surgery. You need someone to assist in you in things during the recovery period. Aside from the fact that you will need crutches or walker after the surgery, you also need to have a company to help you with your daily activities. If you live alone, you can plan that ahead so you can arrange with someone or a professional to be with you until you have fully recovered.

Assessing the Appropriateness of Total Knee Replacement Surgery

You must remember that having a total knee replacement surgery for advanced arthritis in knee or injury takes more than just yourself. You must also cooperate with your surgeon, your physician and your family. You need to be fully assessed to determine if you really need to undergo surgery and what will you benefit from it.

The following are the most common instances when patients are recommended to undergo knee replacement surgery:

Knee deformity.
Moderate and severe knee pain.
Chronic knee inflammation and/or swelling which do not improve even when you have been taking medications.
Severe knee pain or stiffness that makes it hard for you to walk and do everyday activities.
Common treatments like injections, therapies and medications have not proved to be beneficial to your condition.

The recommendations for the surgery are based on the patient’s disability and pain. Age is not a factor, as there are no age or even weight restrictions before the surgery can be performed. However, most patients that undergo such procedure age from 50 to 80. This is because these are the ages when arthritis is common. Overall, with proper precaution and evaluation, total knee surgery may prove to be successful, regardless of the patient’s age.

If you have advanced arthritis in knee or injury and if you are looking for effective treatments with high chance of success, checkout Tarlow Knee today. We have extensive experience treating knee conditions and can help you find the right solution for you.

Stem Cell Therapy for Knee Osteoarthritis and Focal Cartilage Defects

May 2, 2017 By Stefan D. Tarlow MD 1 Comment

Stem cell therapy is a modern and novel procedure which is used to treat certain orthopedic knee )conditions and diseases. It makes use of stem cells, most commonly those derived from the patient’s bone marrow. This therapy works by adding new cells to the defected, diseased or damaged knee. Stem cells are helpful because they actively signal, recruit and produce healing cells and proteins from your body in just two to six weeks’ time. This helps in the regeneration of the cells and the healing of the affected area.

Stem Cell Treatment for Arthritis

Stem cell therapy is a treatment with potential promise and high public interest. However, there is little basic science to support its use as an injection to the knee in 2017.

Because of the potential of stem cell treatment, some doctors now use it to treat arthritis. Researchers think that applying stem cells to the arthritic joint can help in the development of the cartilage cells, release proteins which are helpful for the pain and the cartilage degeneration and suppress inflammation.

However, many still do not consider this as standard practice. The effectiveness of stem cell therapy remains controversial and undecided among medical professionals. Critics say that this treatment only works like a placebo, and that there is no concrete proof yet as to its effectiveness. Nevertheless, stem cells for arthritis are considered safe. That is why, many adults, despite the absence of standard procedure and studies, still use stem cell treatment for their arthritis.

Stem Cell Therapy for Knees

Adult stem cells have the ability to renew themselves, reproduce and differentiate (turn into other cells). They are found in the body, particularly in various tissues and in the bone marrow. Normally, their function is to repair damage in the body. This is why they are now extracted and injected into a damaged or defected area. This procedure is known as stem cell therapy.

Stem cell populations can be derived from the patient (autologous) or a donor human (allogenic). Sources include bone marrow aspirate, adipose tissue, blood progenitor cells and even amniotic tissue. These cells can then be manipulated or concentrated and injected into the knee.

Stem cell therapy is now used to treat knee injuries, focal cartilage defects, knee osteoarthritis and other knee pain and problem. Some researchers and practitioners attest to the effectiveness of stem cell therapy for pain, despite the fact that there are also other professionals who oppose such claims.

Believers of stem cell treatment say people with knee injuries are good candidates for such treatment. Stem cells are now used as an alternative to traditional options like total knee joint replacement and arthroscopic knee surgery. With stem cells, the recovery period is said to be faster and better compared to surgery.

My Final Word on Stem Cell Therapy

A review of the English scientific literature was published recently. The efficacy of these treatments has not been established. In theory, stem cells are beneficial to knee injuries and arthritis. However, as already mentioned, this is not widely accepted yet as standard practice and there are still debates as regards its effectiveness. Nevertheless and fortunately, this treatment is safe and there are no associated risks for the patients. Still, it is important for prospective patients to become familiar with the science behind this treatment before seeking cellular-based therapies.

Aside from stem cell therapy, there are other surgical treatments using autologous stem cells and a biologic scaffold (hylofast) that is implanted directly into focal chondral lesions of the knee. This is a different treatment altogether and may hold promise in the near future. Meanwhile, we will just wait for further developments regarding stem cell therapy in general.

If you’re interested in seeking treatment for your knee arthritis, please make an appointment with my office so we can talk about the best scientifically validated treatments out there.

Unicompartmental Knee Replacement

April 24, 2017 By Stefan D. Tarlow MD 2 Comments

Partial knee replacement – Medial Uni

This is an xray of a partial knee replacement. Specifically, this is a medial unicompartmental knee replacement. This fifty something year old man had pain localized to the medial aspect of his right and left knees. Carefully look at this xray and note that the lateral compartments (outside of each knee) has a well maintained joint space while the medial compartment of the untreated knee has bone on bone. The treated knee has a femoral component cemented into the femur(thigh bone), a tibial component cemented to the tibia (shin bone), and a ultra high molecular weight polyethylene component (xray invisible space) which is locked into the tibial tray. This procedure has provided the patient complete relief of his symptoms of knee arthritis. He went on to have his left knee partially replaced in the exact same manner and now functions normally without knee pain. He has returned to work and feels good. He was hospitalized only overnight in the hospital and was riding an exercycle within 10 days after surgery.

Unicompartmental Knee Replacement Has Advantages Over Total Knee Replacement

Unicompartmental knee replacement (e.g. Makoplasty partial knee replacement) offers a number of advantages over TKR including reduced risk of complications, bone and ligament preservation, and a more naturally feeling knee. One study looking at 14,000 knee joint replacement patients found the partial knee patients (compared to TKR patients) were more likely to achieve an excellent result and more likley to be highly satisfied and were less likely to have had a complication or hospital readmission.

Unicompartmental Knee Replacement : A Twenty Year Outcome Study

A study from France published by Jean-Noel Argenson, MD demonstrated impressive implant survival with good function for unicompartmental knees years after the initial surgery. Implant “survival” rate was calculated to be 83 % at 15 years after surgery and 74 % at 20 years after surgery. Age of the surviving patients was 52 – 90 years (some patients had received the partial knee replacements while in their 30’s).

Medial Makoplasty – Unicompartmental knee

Unicompartmental knee replacement is a less invasive alternative resulting in a more natural feeling knee compared to Total knee replacement in properly selected patients. This studies supports the belief that long term knee function and long term pain relief is predictably attainable with unicompartmental (partial) knee replacement. Improved precision in surgical technique available today using robotic surgical technique (Makoplasty) will likely lead to even better long term outcomes for today’s patients.

Partial Knee Replacement for Unicompartmental Knee Arthritis on the Rise

Doctors and Patients continue to seek treatment options that spare normal knee tissue and is less invasive to their body. Partial Knee Replacement (unicompartmental knee replacement) is an example of this principle.

In one select data base, from 1998 to 2005 the number of Partial Knee Replacements increased from 6570 to 44,990 procedures – a 32 % increase. In the same time period Total Knee Replacement increased by 9 %.

At this same time studies have shown Unicompartmental Knee Replacement surgery is > 90 % successful at five years and another study shows 85 % implant survival at ten years.

Partial knee replacement of any one of the three knee compartments preserves all the knee ligaments, can be done with minimally invasive techniques, feels more transparent, is less painful and results in a faster recovery compared to Total Knee Replacement. The age range for unicompartmental surgery is typically between 40-70 years of age.

New techniques for partial knee replacement are evolving and one would expect that in the future more patients will opt to have a partial rather than a total knee replacement.

Arthrosurface Wave for Knee Joint Surface Defects in Knee Cap

April 17, 2017 By Stefan D. Tarlow MD Leave a Comment

Patello-Femoral

The Arthrosurface HemiCAP® Wave system is a surgical method for the treatment of localized cartilage lesions in the patellofemoral joint (knee cap). This product is similar to the UniCAP in theory but has a different shape to match the femoral groove in which the knee cap tracks. The Wave can be used with or without a patellar (knee cap) resurfacing product. The HemiCAP® system is intended to provide an effective interim means for managing pain and disability in the middle-aged patient until a total joint replacement treatment option becomes more necessary, and is part of a clinical treatment strategy to help avoid early-age-revision scenarios.

The HemiCAP® implants and instruments are designed to remove a minimal amount of bone stock, preserve functional structures and tissues, and allow for an uncomplicated removal in the event of revision. This system is comprised of three elements; a three-dimensional mapping technology, a set of instruments to map and prepare the damaged area and a cobalt-chrome and titanium implant.

There are 2 systems that comprise the Patello-Femoral Line. The first is the Classic Focal HemiCAP which is used for smaller, isolated and well contained lesions of the trochlea groove. This is not combined with a patellar resurfacing. The second system is called the WAVE and is used for those patients that have more diffuse or extensive damage to their PF joint. This may or may not be combined with patellar resurfacing using a UHMPE patellar implant, depending on whether the patellar joint surface is healthy or damaged. Both systems use the same proven intra operative mapping technology of all Arthrosurface systems.

Arthrosurface UniCAP for Knee Joint Surface Defects

Femoral Condyle Inlay Resurfacing

The UniCAP knee system is the first meniscus sparing implant designed specifically for the Sports Medicine surgeon. Articular cartilage is a thin, whitish, glistening layer of protective tissue that covers the joint surfaces of bones. Articular cartilage is composed of hyaline cartilage cells, which have many unique properties that allow it to function effectively as a smooth and lubricious load-bearing surface. Small defects in the articular surface can cause pain and restrict range of motion. Arthrosurface UniCAP is indicated for use for partial replacement of the articulating surfaces (femoral condyle) of the knee when only one side of the joint is affected due to the compartmental primary degenerative or post-traumatic degenerative disease.

The system is comprised of the following elements: a 3-D mapping technology, a set of instruments to map and prepare the damaged area and a cobalt-chrome CAP mated to a Titanium post to fully cover the defect. The system precisely aligns the surface of the implant to the contours of the patient’s articular cartilage surface, thus filling the defect and restoring a smooth and continuous articular surface. The best use is in the Millennium Patient with an intact meniscus and intact tibial articular surface that is “in between” options.

These patients are too old or have exhausted the conservative and biologic treatments yet are considered too young for a total knee replacement. Ironically, this is one of the most effective uses of this product but is considered off label use by the US FDA.

Acupuncture Effect on Knee Arthritis Pain

April 11, 2017 By Stefan D. Tarlow MD Leave a Comment

Acupuncture is a popular alternative medicine. A key component of traditional Chinese medicine, acupuncture involves inserting thin needles into the body. This technique is believed to promote the balance of the flow of energy and the chi. It is commonly used to treat different kinds of pain.

Acupuncture for Arthritis

Acupuncture has traditionally been used to treat various conditions, including arthritis. People suffering from arthritis may consider acupuncture as an option to manage and relieve the pain. It may not cure the condition, but can naturally relieve the arthritic symptoms, particularly the inflammation in the joints and the pain.

This technique dates back more than 2,000 years ago. The Chinese have continually used this for various conditions since then. As such, it is considered to be one of the oldest traditional medical procedures. As already mentioned earlier, the main goal of acupuncture, aside from alleviating certain symptoms, is to resolve energy imbalances and promote a well-balanced chi.

But how can acupuncture help arthritis? Acupuncture involves the insertion of fine needles into the skin. These needles are not just inserted anywhere, but at specific locations called “acupoints.” When these “acupoints” are inserted with needles, our body releases endorphins, which are natural pain-killing chemicals; thus, the pain is relieved. It also helps alleviate discomfort and other symptoms because acupuncture is said to affect the body’s serotonin, which is a brain chemical responsible for promoting good mood. This way, the technique helps alleviate the pain and other symptoms associated with arthritis.

Acupuncture Treatment for Knee Arthritis

Knee pain is now being treated using acupuncture. This is because this traditional Chinese medicine is known for its ability to promote comfort and relieve pain. But how effective is it and how long does the relief last?

There have been studies that confirm the benefits of acupuncture in reducing knee pain, inflammation, immobility and stiffness. Patients with knee problems experienced comfort and relief after trying out acupuncture.

Moreover, a study in the September 2016 JBJS looked at how acupuncture lowered pain and improved function in patients with osteoarthritis of the knee. The acupuncture group had better knee function at both 13 and 26 weeks compared to controls. The acupuncture group had superior pain improvement after 13 weeks but not after 26 weeks.

So what does this imply? There is no question that acupuncture can help bring pain relief and comfort to the patient. However, it does not really cure the condition and the effect is only temporary.

The Bottom Line

My take on acupuncture is that it is beneficial as temporary treatment. Patients that need short term pain relief should consider acupuncture as a viable treatment option. There’s no harm in trying, especially if all you really want is to be relieved from the pain even just for a while. However, if you want long-lasting relief, there are other options you can try to treat your knee pain and other arthritis symptoms.

If you have arthritis and are looking for other treatment options, contact a professional. Make an appointment with me to discuss your arthritis and what treatment is right for you.

Total Knee Replacements: An Overview

April 10, 2017 By Stefan D. Tarlow MD Leave a Comment

Younger Patients Driving Increase in Total Knee Replacement Surgery

From 1997 to 2007, the number of total knee arthroplasty (TKA) procedures performed annually in the United States doubled, with much of the increase taking place in younger patients, according to a study presented at the 2011 AAOS Annual Meeting. Data has shown that younger and healthier patients have better post-TKA outcomes, the indications for performing surgery have been expanded to include these patients. Keep in mind that more surgery in younger patients drives up the cost of US Healthcare, but better outcomes in young people justify the increase in costs. Treating severe knee disability increases the productivity of these working aged people and improves quality of life for 20-30 years.

During the study period, the overall U.S. adult population grew slightly (1.13-fold and the prevalence of obesity grew 1.12-fold). But the number of TKAs performed more than doubled—from 264,311 in 1997 to 549,707 in 2007. When researchers examined population growth, obesity rates, and number of TKAs performed by age group, they found the greatest growth in TKAs among those younger than age 65.

What is driving the increase?

Obesity and population size accounted for 22.6 percent of the approximately 100 percent increase in the number of TKAs performed,” said author Elena Losina, PhD, director of the Orthopaedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital in Boston.

The rapid expansion of TKA utilization can not be fully explained by increases in population and obesity prevalence.

Other factors that may be driving the increase in TKA include an increasingly active population and expanded indications for surgery among a younger patient population.

Previous studies have linked sport-related knee injuries and increased physical activity in younger people to an increase in early-onset osteoarthritis. Therefore, active lifestyle increases may help explain why rising numbers of younger patients are receiving TKAs.

4 Million Total Knees Walking Around the U.S.

From March, 2013 Journal of Bone and Joint Surgery

In the last decade, the number of total knee replacements performed by Knee Surgeons annually in the United States has doubled, with disproportionate increases among younger adults. While total knee replacement is a highly effective treatment for end-stage knee osteoarthritis, total knee replacement recipients can experience persistent pain and severe complications. We are aware of no current estimates of the prevalence of total knee replacement among adults in the U.S.

We estimated that 4.0 million adults in the U.S. currently live with a total knee replacement, representing 4.2% of the population fifty years of age or older. The prevalence was higher among females (4.8%) than among males (3.4%) and increased with age.

Among older adults in the U.S., total knee replacement is nearly as prevalent as congestive heart failure. Nearly 1.5 million of those with a primary total knee replacement are fifty to sixty-nine years old, indicating that a large population is at risk for costly revision surgery as well as possible long-term complications of total knee replacement.

These prevalence estimates will be useful in planning health services specific to the population living with total knee replacement.

No Benefit Found For Continuous Passive Motion (CPM) After Total Knee Replacement

Advanced Knee Care, experts in knee replacement surgery, is not able to recommend for the use of CPM after Total or Partial Knee Replacement surgery. Unfortunately, some things that we do in medicine, we do because we’ve always done it, not because there are good data to support that practice. Patients have come to expect the CPM — they hear previous patients talking about how it helped them recover, and they think they need it. Here’s the thing — current data does not support it. Over the past 10 years, hospitals that specialize in total joint replacement have studied the use of CPM versus moving a patient rapidly into active therapy, and found that CPM is no better for a patient than introducing physical therapy shortly after the surgery. Evidence based treatment decisions show that CPM had no significant advantage in terms of improving function or range of movement, and that its use increased blood loss and pain medication requirements. Another study concluded Continuous passive motion (CPM) gives no benefit in immediate functional recovery post-total knee arthroplasty (TKA), and the postoperative knee swelling persisted longer. A third study concluded CPM did not lead to improved knee range of motion after Knee Replacement Surgery.

Dr.Tarlow says: “It is time that we as surgeons only prescribe treatments in which costs are justified because of improved patient outcomes after knee surgery. CPM machines do not satisfy this criteria. It’s time to break the bad habit of prescribing things that do not aid in patient recovery”.

High-Impact Sports After Total Knee Arthroplasty

Patient reported activities often reveal non compliant behaviors after total knee
replacement (TKR). Although surgeons generally recommend avoiding heavy manual labor and high impact sports, there has been few medical studies to guide these traditional recommendations.

Mont et. al.reported on thirty one patients with knee replacements that participated in high impact sports including jogging, singles tennis, racquetball, squash and basketball on average 4 times per week. After an average four year followup, thirty two of the thirty three knees had successful clinical and x-ray outcomes. These results indicate that some patients will participate in high-impact sports and enjoy excellent clinical outcomes at a minimum 4 years after surgery. Clearly, patients with TKR participate in activities considered risky by surgeons.

At least in the short term, doing so does not appear to detract from the success of the procedure.

Total Knee Patient Experience Survey for Dr. Tarlow

The quality department at an inpatient surgical facility has provided the following survey summary.

1. 88 % of patients found the preop phone call from the hospital nurse helpful, and none of the patients would have preferred to come to the facility for an in person information session. In 2016 the need for face to face communication for certain tasks is not desirable.

2. 3 months after Total Knee Replacement 37 % of patients rated their pain as worse than expected. The average Total Knee patient needs 9-12 months of healing time so this survey result is expected.

3. One year after Total Knee Replacement 90 % of people believe the surgery met their expectation and 10 % have not had their expectations met. This is better than most scientific studies that report 80 % of patients had expectations met.

What is New in Total Knee Replacement

A summary appeared in the January, 2016 JBJS and here are the highlights.

Risk stratification is predictable and accurate for Knee Replacement patients. Patients at higher risk for complications should postpone (if risk factors are modified) or avoid knee replacement surgery. These risks are uncontrolled diabetes (higher risk of deep infection, blood clot, periprosthetic fracture, aseptic loosening, and poorer Knee Society function score. Morbid obesity (BMI > 40) is a patient factor associated with increased medical costs and complications including medical complication (heart attack, pneumonia, etc), postop knee infection, return to the operating room for a second procedure and longer hospitalization. Morbidly obese patients have a higher risk of in hospital death after knee replacement surgery.

There is no evidence to support a particular design, brand, or material impact range of motion, clinical scores or quality of life.

The value of computer assisted TKR surgery remains undefined. One study showed an insignificant improvement of leg alignment but no better rotation of tibial or femoral components compared to standard non navigated surgery.

Patient specific custom cutting blocks showed no improved clinical, operative or radiographic results.

Knee Arthritis: A Primer

March 21, 2017 By Stefan D. Tarlow MD Leave a Comment

Facts About Arthritis of the Knee

A 15 year study of middled aged (avg 53 years) of normal body weight (BMI avg 25) from the United Kingdom provides insight on the incidence and severity of symptomatic Knee OsteoArthritis.

These data are gender specific and since this is a normal weight population can not be extrapolated to the obese population. The annual rate at which middle-age women develop knee osteoarthritis (OA) is fairly low, but progression is common when x-ray changes in the joint are already present, a community-based cohort study found.
During 15 years of follow-up there is a 49% lifetime risk of developing symptomatic (not necessarily severe OA of the knee). 51% of normal weight women never develop knee arthritis.

Among the entire cohort, 561 had undergone knee radiography at baseline and then at years 5, 10, and 15.
High body mass index also was associated with an increased incidence, with a nearly 20% greater incidence by year 10 among obese women.

At 15 year followup nearly 30 % of those women with knee arthritis had the disease in both knees. 70 % had symptomatic arthritis in only one knee.
The rate of total knee replacement by year 15 was about 10 %.
The also know risk factors in order of significance are genetics, obesity, female gender, serious knee injury (bone or ligament or meniscus).

Knee Osteoarthritis Treatment Options – AUC from AAOS A Guide

AUC (appropriate use criteria) are meant to augment—not supersede—clinician expertise and experience or patient preference. The scope of this AUC includes nonpharmacologic and pharmacologic interventions for symptomatic OA of the knee as well as surgical procedures less invasive than total or partial knee replacement.

The new appropriate use criteria (AUC) on nonarthroplasty treatment of patients with OA of the knee covers 10 different treatment options and more than 500 patient scenarios.
A web-based application (www.aaos.org/aucapp) enables clinicians to submit a patient profile based on specific clinical findings and receive feedback on the appropriateness of various treatment options.
Although the AUC addresses the most common clinical scenarios, it does not include all of the possible indications, and is not meant to supersede clinician expertise and experience or patient preference.

The full AUC can be found on the website of the American Academy of Orthopedic Surgeons. Try it yourself.

Open the AUC. Enter the patient specific information detailing knee pain, knee range of motion, knee stability, knee xray findings, knee aligment (bow legged or knock kneed), meniscal symptoms and patient age. Enter submit and treatment options categorized as appropriate, may be appropriate and rarely appropriate will be shown. These options now provide a basis for an intelligent conversation between the patient and the orthopedic surgeon with respect to non surgical and surgical treatment options.

Viscosupplementation for Knee Arthritis

Dr. Tarlow’s opinion – About half of my patients with mild to moderate osteoarthritis of the knee Visco injections report less pain and better function for 6-12 months following a series 3 weekly injections – brand of Visco does not matter in outcome. Patients with severe OA rarely benefit from type of injection.

OA is the death of the articular cartilage cells that cover the bone.

Here is a summary of the recent literature review:

Hyaluronic acid has little effect on pain, none on function, new review states

Tuesday, June 12, 2012

If the first series of injections help then it is likely a repeat series will be successful. Not all insurers reimburse for this medication – so many patients pay out of pocket for the drug and come to the office for the doctor to inject the drug into their knee.

Another unknown is how and why this medication decreases pain – the mechanism is not clear at this time.

escribe injections of hyaluronic acid, also called viscosupplementation.

There is no evidence to suggest that viscosupplementation results in any relevant reduction in symptoms in patients with knee osteoarthritis, said study co-author Dr. Peter Juni, professor of clinical epidemiology at the University of Bern in Switzerland.

The U.S. Food and Drug Administration in 1997 approved the injections, which are commercially available from several companies and much more costly than pain relievers.

For the study, Juni’s team reviewed 89 studies that compared injections with either a placebo treatment or no treatment. In all, the studies involved more than 12,000 adults aged 50 to 72.

The effect on pain was minimal, and the injections had no effect on functioning, the researchers found.

In some of the studies, the injections reached peak effectiveness at eight weeks, then declined.

“Viscosupplementation therapy for the knee appears to have some transient improvement in a relatively small number of patients for variable periods of time — most often six to 12 months,”

Look at the pros and cons from a patient’s perspective. Many turn to the injections to avoid surgery or medications, which can have their own harmful side effects, he said.

“Some patients, however — particularly patients with earlier stage arthritis — benefitted from viscosupplementation for periods of time sufficient to continue the use of this therapy,” he said.

Diet + Exercise Effective

Report in JAMA September 25, 2013 (Journal of the American Medical Association) concludes Diet and Exercise is Effective in Improving quality of life (diminishing symptoms of pain, improving function/mobility) compared to exercise alone in overweight and obese patients with Osteoarthritis of the knee. Weight loss was greater in the Diet/Exercise group (11 %) compared to Exercise group (2%).

Details: According to a study published in the Sept. 25 issue of JAMA, diet and exercise may improve quality of life more than exercise alone for overweight and obese adults with knee osteoarthritis (OA). The authors conducted a randomized, single-blind trial of 399 patients who were allocated to one of three groups: diet, exercise, and diet plus exercise. At 18-month follow-up, the authors found that mean weight loss was 11.4 percent for participants in the diet plus exercise cohort, 9.5 percent in the diet group, and 2.0 percent in the exercise group. In addition, knee compressive forces were lower in diet participants compared with exercise participants, and concentrations of IL-6 were lower in diet plus exercise and diet participants compared against exercise participants. Finally, patients in the diet plus exercise group had less pain and better function than those in the diet group or the exercise group, and the diet plus exercise group had better physical health-related quality of life scores than those in the exercise group.

Link to Abstract – https://jama.jamanetwork.com/article.aspx?articleid=1741824.

Dr. T Speaks —– Hello People. There are simple measure that are dramatically effective in helping you treat yourself with medications, injections, or surgery. Make the effort to convert America into a healthier place. This is an easy way to treat a common problem that is effective and will lower health care costs. Take ownership of your own well being.

Physical Activity

Research suggesting that physical activity could help prevent Knee Osteoarthritis has been presented this week at the AVS 62nd International Symposium and Exhibition, in San Jose, CA.

Researchers including Dr. Burris at the University of Delaware found that as the sliding speed increased toward typical walking speeds cartilage thinning was reversed. At slow sliding speeds (less than would occur in a joint at typical walking speeds) cartilage thinning and an increase in friction occurred over time. This may explain why walking or cycling can mitigate knee pain in patients with osteoarthritis of the knee.
A healthy joint surface is composed of 80 % synovial fluid (water and proteins). To investigate whether hydrodynamic pressurization could refill deflated cartilage, the researchers placed larger-than-average cartilage samples against a glass flat to ensure that there would be a wedge. Pressure forced fluid back into the articular cartilage stopping the joint surface from deflating. If movement occurs faster than the fluid can diffuse then continuous knee movement could prevent deflation.
Articular Cartilage is a firm, porous, rubbery material covering the ends of the bones in the knee joint. It reduces friction in the joint and acts as a “shock absorber.” Loss of synovial fluid occurs when articular cartilage is damaged or diseased. Osteoarthritis is a degenerative disease resulting from a reduction in the articular cartilage thickness, leading to an increase in friction, inflammation, pain and deformity of legs.

When cartilage becomes damaged or deteriorates, it limits the knee’s normal movement and can cause significant pain, and eventually the need for knee replacement surgery.

Surface damage to articular cartilage in a knee

Knee Braces

Non Operative Treatment of Knee Pain/Arthritis with BracingAdvanced Knee Care offers a custom bracing service to patients. This service includes a brief physician visit to confirm the diagnosis and need for the brace, a confirmatory x-ray of the knee and a detailed visit with our bracing specialist, Megan. The charge for this screening visit is $50 (insurance will be billed, if applicable).

The concept for this service is that there are many people that can be treated without surgery. A knee brace may be just what is needed to keep one active for years—no surgery required. This treatment is for people with Knee Pain and Knee Arthritis (either in the main joint or in the patellofemoral joint) that do not want a complex or expensive work up by the doctor, have already tried the myriad of other options for knee arthritis (pills, injections, Physical Therapy, Arthroscopic Surgery) and want a streamlined way to purchase a knee brace to help improve their knee function, help them be more active, and help them exercise to stay fit. There are also good bracing applications for runners with knee pain.

Treat Depression

A Korean study published in March, 2011 concludes that depression is linked to knee arthritis symptoms. The authors evaluated 660 patients aged 65 years or older; severity of knee OA was assessed based on radiographs and symptoms and depression was assessed based on interviews and patient questionnaires. The presence of a depressive disorder was associated with increased risk of symptomatic knee OA among patients with a radiographic severity of minimal to moderate OA.

Mental well being and a positive outlook help people cope with and tolerate symptoms of disease. In this study, a person with minimal to moderate Knee Osteoarthritis was more likely to have moderate to severe symptoms, and the reason for the increased dysfunction was thought to be due to poor mental health, not poor physical health.

This is a good lesson for both patients and doctors. Always consider a person’s overall health when formulating treatment plans. In some cases treatment should be directed at the cause of symptoms (treat depression, not knee arthritis) for the best outcome.

The Obesity Epidemic: A Doctor’s Perspective

March 20, 2017 By Stefan D. Tarlow MD Leave a Comment

Personal Health Risks Obesity Linked to Cancer/Death

The identification of new obesity-related cancer sites will add to the number of deaths worldwide attributable to obesity.

In 2013, there were an estimated 4.5 million deaths worldwide attributable to overweight and obesity. Longevity and wellness is linked to body weight. The absence of excess body fatness reduces the risk of cancers.

A summary was published online August 25 in the New England Journal of Medicine.
These 13 cancers are linked to obesity ― colorectal, esophageal (adenocarcinoma), renal cell carcinoma, breast cancer in postmenopausal women, uterine endometrial cancer, stomach (gastric cardia), liver, gall bladder, pancreas, ovarian, thyroid, meningioma, and multiple myeloma.
Several mechanisms linking excess body fat with carcinogenesis were identified, including chronic inflammation and dysregulation of the metabolism of sex hormones, the IARC notes.

Worldwide Obesity Epidemic

Worldwide, an estimated 640 million adults were obese in 2014, which is a sixfold increase since 1975. There were 110 million obese children and adolescents in 2013 (a twofold increase since 1975).

What to Do? Prevention is the Answer:

Obviously, the best way forward would be to prevent people from becoming overweight (defined as having a body mass index [BMI] ≥ 25 kg/m²) and obese (BMI ≥ 30 kg/m²) in the first place. There was an increased rate of repeat knee surgery (including revision total knee replacement surgery) as well a striking increase of knee joint infection, a serious complications in the morbidly obese group (BMI 35-40).

But once people have excess body fat, does reducing it also reduce the increased risk for cancer? Here, there is evidence from animal studies, but not yet from studies in humans.

From Medscape August 2016

Extra Weight Piles on Knee Arthritis Risk

Doctors have few weapons to treat obesity. There are detrimental physical and mental consequences of obesity. Medications and surgery infrequently help. Self prevention of obesity is very important for improving the health of our country AND decreasing expenditures for health care. It is time people take ownership of their well being. Eliminating obesity is a mission of top priority.

Reuters Health summarized the findings.

Researchers calculate that as many as half of all cases of knee osteoarthritis could be prevented if obesity was eliminated. Being overweight (BMI 26-30) doubles a person’s risk for osteoarthritis of the knees and being obese (BMI > 30) quadruples it, according to a new review of past studies that was designed to calculate how many knee arthritis cases would be avoided in a normal-weight world.

The researchers calculated that as many as half of all cases of knee osteoarthritis could be prevented if obesity was eliminated.

One in ten people over age 55 have severe knee arthritis, and many more suffer from chronic knee pain, researchers report.

Zhang and his colleagues reviewed 47 studies that compared the chance of developing knee osteoarthritis in normal weight, overweight, and obese people, including a total of almost 450,000 participants.

What is clear is that extra weight and arthritis are closely linked.

Extra weight can also increase a person’s chance of getting arthritis in the hip, but the knee “is the joint where osteoarthritis causes the most trouble, (and) it’s the one where obesity has its strongest effects.”

Lots to Lose: How America’s Health and Obesity Crisis Threatens our Economic Future

A report released by the nonprofit Bipartisan Policy Center offers recommendations for public and private sector promotion of healthy nutrition and exercise to reduce obesity. “Lots to Lose: How America’s Health and Obesity Crisis Threatens our Economic Future” states that escalating healthcare costs are the primary driver of an increasing national debt, and obesity-related illness is an increasing portion of healthcare costs. Among other things, the report argues that nutrition and physical activity training should be incorporated in all phases of medical education, and that large, private-sector institutions should procure and serve healthier foods, using their significant market power to shift food supply chains and make healthier options more available and cost-competitive.

We Can Do Better – Americans Not Much Healthier Now Compared to 15 Years Ago

From nbcnews.com : Maggie Fox, Senior WriterNBC News

Our biggest enemies are our own bad habits – poor diet, smoking and obesity. They’re far more dangerous to our health than pollution or risks from radiation. And although women used to be far healthier than men, men are closing the gap fast, the survey by Dr. Christopher Murray of the University of Washington and colleagues finds.

“We need to really try to get at the social and environmental causes of these issues and really focus on true prevention, which is not managing in a clinical setting but creating the conditions where this doesn’t happen in the first place.”

Americans may be living longer and even exercising a little more, but we really are not much healthier than we were 10 years ago and we are still far behind other rich countries when it comes to our health, researchers said Wednesday.

Americans lost ground compared to people living in other countries in the Organization for Economic Cooperation and Development.

“There are places with the best life expectancy in the world in the U..S., and there are places in Mississippi, for example, or West Virginia where life expectancies are in the mid-60s for men and low 70s for women. That’s about the same as a number of poor developing countries,” Murray says.

The biggest killers: clogged arteries (known medically as ischemic heart disease), lung cancer, stroke, chronic obstructive pulmonary disease and road accidents.

But the diseases that caused the most misery, known in the lingo as disability-adjusted life years, are low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders.

In other words, individuals in the US are living longer, but not necessarily in good health,” they concluded.

“For the first time we’re saying that the composition of diet, which is made up 14 different components, things like fruits, grains, nuts, seeds (and) other aspects of diet being analyzed is the biggest determinant of health in the US, followed by smoking, followed by obesity, and then followed by high blood sugar and physical inactivity,” Murray told NBC news.

“So if you put all of those together there’s huge potential to improve health in the U.S. and in fact get ahead of other high income countries if we were to address these modifiable risks.”

“It’s unsophisticated to say it’s because we are not eating right,” Woolf said in a telephone interview.

“There is a large contingent of Americans who react by saying this is a matter of personal responsibility. To some extent that’s true but there is much more about the way our lives are structured in the U.S.”.

“Those distinctions are really about income and education level,” Levi told NBC News.
“OECD countries are spending more on education and income support than we do and that is what is helping to create this healthier environment.”

Physician’s Weight May Influence Obesity Diagnosis and Care

Released: 1/26/2012 10:10 AM EST
Source: Johns Hopkins Bloomberg School of Public Health

Newswise — A patient’s body mass index (BMI) may not be the only factor at play when a physician diagnoses a patient as obese. According to researchers at the Johns Hopkins Bloomberg School of Public Health, the diagnosis could also depend on the weight of your physician. Researchers examined the impact of physician BMI on obesity care and found that physicians with a normal BMI, as compared to overweight and obese physicians, were more likely to diagnose a patient as obese if they perceived the patient’s BMI met or exceed their own (93 percent vs. 7 percent). The results are featured in the January issue of Obesity.

According to the Centers for Disease Control and Prevention (CDC) obesity affects more than one-third of the U.S. adult population and is estimated to cost $147 billion annually in related health care costs. Obesity increases the risk of many adverse health conditions including osteoarthritis of the knee, type 2 diabetes, coronary heart disease, stroke and high blood pressure. Despite guidelines for physicians to counsel and treat obese patients, previous studies have found only one-third of these patients report receiving an obesity diagnosis or weight-related counseling from their physicians.

Improving Total Knee Replacement Surgery Results: Optimize Risk Factors PreOp

March 20, 2017 By Stefan D. Tarlow MD Leave a Comment

One way of improving the results of Total Knee Replacement Surgery is to optimize the risk factors. The common patient risk factors include the following: uncontrolled diabetes (Blood Sugar >150, HbA1C>8), Smoking, Obesity (BMI > 40), Opioid use, and Kidney disease. All these risk factors should be corrected prior to having the surgery.

There are treatments available to reverse these risk factors. Uncorrected, the above listed factors increase the chance a patient will suffer an prosthetic joint infection, a return to the operating room for another knee procedure, wound healing problems, revision knee surgery or an unsatisfactory surgical result.

Knee Replacement Surgery Risks

Like any other surgery, total knee replacement carries some risks. However, the occurrence of these risks is quite low: infection, nerve damage, stroke or blood clot. The aforementioned risks are those that might occur during or after the surgery. What we are going to focus on are the factors that might affect the outcome of the surgery. Such factors or risks must be corrected before the surgery is conducted. They include the following: uncontrolled diabetes, smoking, obesity, opioid use and kidney disease.

Uncontrolled Diabetes

The Risks

According to a number of studies, people with diabetes face a higher risk of postsurgical complications. The possible complications that a patient may experience if he/she undergoes a surgery such as total knee replacement with uncontrolled diabetes are the following: joint loosening, fracture around the implant, blood clot, stroke and wound infection.

The Treatment

Diabetes is an important consideration before a patient undergoes a surgical procedure. The research suggests that patients need to control their diabetes before undergoing a major surgery such as total knee replacement. While your blood sugar will be tightly monitored right before and after surgery, it’s up to you to make the long-term lifestyle changes necessary to ensure you get the best outcome. This is an important conversation to have with both your surgeon and the physician or provider who helps you manage your diabetes. Eating well and exercising (if appropriate and with approval from your providers) can help you get your body ready for surgery.

Smoking

The Risks

Research shows that there is a correlation between smoking and the success of knee surgery. Some studies put the chance of redoing the surgery at a rate ten times higher in smokers than in non-smokers. Smokers also show higher rate of surgical complications which include blood clots, kidney problems, urinary tract infections, and abnormal or irregular heartbeats. This is because nicotine constricts the blood vessels, which interfere with and affect the healing process.

The Treatment

The best way to get rid of the risks is to quit smoking. You may have tried to do so in the past and not found success, but if you’re going to have total knee replacement surgery, let this be the big push you need to finally quit. In addition to the possibility of increased post-surgical complications, just imagine trying to find a place to smoke while you’re recuperating. Talk with your primary care provider about available techniques and support.

Obesity

The Risks

Obesity is the root of various health conditions and diseases like type 2 diabetes, obstructive sleep apnea, cardiovascular diseases, hypertension and metabolic syndrome. All these conditions increase the risk of knee replacement surgery. Aside from these, patients with obesity are also more at risk to experience the following postsurgical risks: blood clots, difficulty breathing, poor and slow wound healing, infection and pulmonary embolism.

The Treatment

To lower the risks and to promote a better result, patients with obesity are advised to lose some weight. It is important that the patient is in good health and weight prior the surgery. Try hard to lose some weight and eat healthy before the scheduled surgery. Your immediate post-surgical health will improve—and along with your new knee, being in better shape will give you a new lease on life.

Opioid Use

The Risks

One of the total knee replacement precautions a patient must know concerns opioid use. One study showed chronic opioid use before a total knee arthroplasty led to worse outcomes for patients, including “longer hospital stays, more postoperative pain, and higher complication rates… [patients] were also more likely to need additional procedures, require referrals for pain management, suffer from unexplained pain or stiffness, and have lower function and less motion in the replaced knee.”

The Treatment

The FDA suggests that patients undergoing knee replacement surgery should decrease the duration and amount of opioid use. There are many other pain management treatments available besides opioids, and you should explore them with your pain management physician—not just because of your surgery, but because chronic opioid use itself brings a whole host of problems you don’t want.

Kidney Disease

The Risks

Patients with kidney disease, particularly chronic renal disease, have increased risk for readmission after the surgery. The success of knee replacement surgery is also low and the occurrence of common complications is high among patients with kidney problems.

The Treatment

If you have kidney disease and need to have surgery—any kind of surgery—you and the doctor managing your disease, as well as the surgeon, need to work closely together to assess your risk and make sure surgery is the right course for you. If you and your providers move ahead, techniques like post-operative dialysis, substituting or changing the normal dose of medications like antibiotics given before and during surgery and avoiding pain medications that are known to cause problems are all good strategies to keep you healthy.

Reducing Total Knee Replacement Complications

We, the patient and the doctor, both want something in common. That is, the best outcome possible of the surgery. Knowing how to reduce the complications is powerful information. It is very important that you follow the tips mentioned in this article and control the risks mentioned to improve the results of your total knee replacement surgery.

If you’re contemplating knee replacement, schedule an appointment to see me and the rest of the team here at Advanced Knee Care. Assessing your needs and the appropriate treatment for you is our top priority.