How to Avoid a Total Knee Replacement

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First of all: Don’t get hurt. Once you injure your knee—if the meniscus cartilage, articular cartilage or ligaments do not heal normally, or are not repaired, reconstructed or replaced quickly—the knee may develop arthritis. That’s because loss of function of any of these key tissues means an increase in concentrated force on the joint surface, and early wear. An analogy to a car tire comes pretty close. If your car is out of alignment, the tires wear very rapidly. So does your knee.

If you do get hurt, insist on accurate diagnosis and, if necessary, surgical reconstruction to restore full function. Don’t accept less. The following cases will illustrate some of your potential hurdles, and solutions:

The most common patient story we hear is: “I injured my meniscus cartilage and they took out part of it. Now I have arthritis. Isn’t there just a shock absorber you can put in my knee?” 

The answer is yes. It is called the meniscus. It is available as a collagen scaffold (to regrow part of the meniscus) or as a full allograft (human tissue) to actually replace the meniscus.

The second most common story is, “I tore my ACL and it was reconstructed. Now I have arthritis.”

 The data show that 50% of people with an ACL injury will get arthritis. This is partly due to the force of the original injury, but also due to the inaccuracies of ACL reconstruction techniques. The surgery either fails to restore normal biomechanics, or the harvesting of the patient ‘sham strings or patella tendon (to rebuild the ACL) weakens the knee—leading to abnormal motion and early wear. 

The answer here is anatomic ACL reconstruction, which restores the original knee anatomy as closely as possible. This includes the use of off-the-shelf ACL replacement devices. In the U.S., this will be an allograft; in Europe, either an allograft or the newly available Z-Lig animal-derived tissue.  Long term data will be needed to determine if these alternatives diminish the arthritis. In any case, by using an off the shelf device, you are not injuring one part of the knee to restore another part.

 

The third most common story is: “I damaged my articular cartilage, and the doctor shaved it away.”

Cartilage restoration procedures have advanced to the point where damaged cartilage can now often be repaired rather than removed. At Stone Clinic, we often use a paste graft technique. We have more than 20 years of data demonstrating that paste grafting the lesion leads to effective cartilage repair. Other orthopedic centers have other techniques which also have promising long term data. 

The days of hearing “remove the meniscus”, “cartilage cannot be repaired”, “live with your arthritic knee until you have a knee replacement”, are in the past.

The fourth most-heard story is: “I have arthritis, and have been told I need a total knee replacement.”

This scenario has four possible outcomes. One is that the joint spaces are still open. In this case the patient can be treated with lubrication, growth factors and physical therapy, diminishing many of the symptoms but not curing the problem. Two is that the joint spaces are open and the cartilage can be restored with a biologic knee replacement. Three, the X-ray shows only one part of the knee is bone-on-bone. Here, a partial knee replacement using a MAKO robot can be performed, saving the rest of the knee. Four is that the arthritis has progressed to severe deformity in multiple parts of the knee, in which case a total knee replacement really is the best option.

The reason this is last option is that 50% of people with a total knee replacement have pain at ten years, and there is a high revision rate in the first two years. The replacement knees are not normal, and there is no going back to a biologic solution once the knee is completely replaced. 

So while a total knee replacement is a great solution when and if the knee is completely worn out, we advocate exhausting the other options first. The best advice is if you get hurt, fix the damage immediately....and avoid arthritis.

Posted by Kevin R. Stone, M.D on July 12th, 2016
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Stone, K.R., A. Freyer, T. Turek, A.W. Walgenbach, S. Wadhwa, and J. Crues. 2007.