When Is It Time for a Knee Replacement?

When Is It Time for a Knee Replacement?

Knee replacement surgery is one of the most common procedures in the United States, with more than 790,000 performed each year.

Deciding the time for knee replacement needs to be determined by you and your doctor, but certain factors make it more likely, according to experts at Keck Medicine of the University of Southern California.

  • Bad arthritis. “Osteoarthritis, rheumatoid arthritis and post-traumatic arthritis affect the knee through different mechanisms, however, these different conditions are similar in that they all result in loss of cartilage, which causes pain and loss of motion,” Dr. Nathanael Heckmann, orthopedic surgeon at Keck Medicine, said in a Keck news release. “When these symptoms become severe, knee replacement surgery may provide considerable symptom relief by replacing the worn-out surfaces of the knee.”
  • When nonsurgical treatments such as medications, steroid injections and physical therapy are no longer effective. “As time passes, these arthritic conditions tend to progress in severity, rendering these types of treatments less and less effective,” Heckmann said.
  • Your knee pain prevents you from doing normal activities or caring for yourself. “In general, the timing of a total knee replacement is determined by the impact the knee is having on your quality of life,” said Dr. Jay Lieberman, chief of orthopedic surgery at Keck Medicine. “If conservative treatments are not working and you have significant pain while walking, you may be a good candidate for surgery.”
  • Severe knee pain. Especially if it happens even when resting and you can’t sleep.
  • Swollen knees. Particularly if your knee is always swollen.
  • Your knee has become deformed. If you have advanced arthritis, it can affect the way you walk, which can also lead to further problems elsewhere in your body.
  • You’re of a certain age. While knee replacements are done in people of all ages, they’re most common in those older than 60. That’s because younger people’s more active lifestyles may place too much strain on the artificial knee and shorten how long it lasts, and second replacement surgeries may not be as successful.

If you’re thinking about knee replacement surgery, you need to know that you may have to avoid high-impact activities.

“Total knee replacement is quite successful in enabling patients to return to an active lifestyle — patients can perform all types of recreational activities, including hiking, bicycling, skiing, surfing, tennis and golf,” Lieberman said in the release. “In general, we do not limit activities but suggest that patients avoid impact activities on a consistent basis to reduce wear on the prosthesis.”

More information

There’s more on total knee replacement at the American Academy of Orthopaedic Surgeons.

SOURCE: Keck Medicine, University of Southern California, news release, January 2022

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Are Cortisone Injections Good or Bad for Arthritic Knees?

Are Cortisone Injections Good or Bad for Arthritic Knees?

Cortisone injections have gotten a bad rap in recent years as a treatment for arthritis pain, because steroids are known to damage cartilage and could potentially cause the joint to further deteriorate.

But a new study suggests that if used wisely, cortisone shots are as safe as another type of injection used to treat knee arthritis.

Occasional cortisone shots don’t appear to cause knees to deteriorate any faster than injections of hyaluronic acid, a substance injected to lubricate joints stiffened by arthritis, the researchers said.

“Knee replacement rates were, if anything, a little bit less in the group that got the cortisone injections,” said senior researcher Dr. David Felson, a professor of medicine and epidemiology at Boston University School of Medicine.

However, Felson added that the study only looked at people who’d gotten infrequent cortisone shots to their knee, and shouldn’t be interpreted as giving the green light to regular injections for years to come.

“What we know from the study that we can trust is that a few cortisone injections won’t really cause much trouble,” Felson said. “It’s conceivable that repeated injections every three months for years won’t cause any trouble, but you can’t say that.”

Steroids are known to be toxic to cartilage, the connective tissue that keeps your bones from rubbing against each other, explained Dr. Melissa Leber, director of the Emergency Department’s Division of Sports Medicine in the Icahn School of Medicine at Mount Sinai in New York City.

“If you use it enough, it will damage the cartilage,” said Leber, who had no role in the study.

A 2019 study reported a threefold increased risk of knee arthritis progression in people who’d received repeated cortisone injections, compared with people who’d never gotten the shot, Felson and his colleagues said in background notes.

Comparing two types of shots

However, no clinical trials had ever compared the two most common types of knee arthritis injections, cortisone jabs and hyaluronic acid shots, Felson said.

The two types of shots do different things in the joint, and are sometimes used in combination, Leber said.

Cortisone shots are anti-inflammatory and help reduce pain, while hyaluronic acid injections are like a gel that provides lubrication in the ailing joint.

“You’re injecting WD40 almost into the knee. That acts to allow smoother gliding in the joint,” Leber explained.

Unlike cortisone, hyaluronic acid gel isn’t harmful to cartilage.

The latest study looked at nearly 800 people with knee arthritis, of whom 4 out of 5 reported getting cortisone shots for their knee pain. The rest had reported receiving hyaluronic acid injections.

After seven years of follow-up, researchers found that those who got steroid injections had no greater cartilage loss than those treated with hyaluronic acid.

In fact, people who got cortisone shots were about 25% less likely to need a total knee replacement than those who got hyaluronic acid.

The message to knee arthritis patients regarding cortisone shots is simple, Felson said: “Don’t be scared.”

“There’s nothing bad that’s going to happen with one shot or even a few shots,” Felson said. “People should be reassured. They shouldn’t avoid getting an effective treatment.”

Wise use is crucial

The findings bolster the approach orthopedic specialists already take in handing out cortisone shots to treat knee arthritis, Leber said.

“If someone already has a ton of damage to the cartilage in their knee, a lot of arthritis, then we don’t worry as much about using a steroid to help with pain control because they already have a lot of arthritis in the knee,” Leber said. “Damaging it a touch more just to give them good pain control is a very minor thing. It’s not as risky.

“In someone who’s young, in their 20s to 40s, who has very little cartilage damage but has pain, we try to use it sparingly,” she continued. “Would you use them on occasion in a young person? Yes. That’s only as a one-time thing. You don’t want to use it repetitively.

“Steroid is bad for cartilage, but that doesn’t mean it’s bad for every patient,” Leber concluded. “It’s a case-by-case situation.”

Regardless, you wouldn’t expect any patient to receive frequent cortisone injections, whatever their condition, added Dr. Jeffrey Schildhorn, an orthopedic surgeon with Lenox Hill Hospital in New York City.

“If you give someone a shot in January and they come back in April saying they want another one, and they come back in August and want another one, how well are they working?” said Schildhorn, who was not part of the study. “They’re not working, if you’re only getting two or three months of relief.”

The new study was published recently in the journal Arthritis and Rheumatology.

More information

The Cleveland Clinic has more about knee arthritis.

SOURCES: David Felson, MD, professor, medicine and epidemiology, Boston University; Melissa Leber, MD, director, Emergency Department’s Division of Sports Medicine, Icahn School of Medicine at Mount Sinai, New York City; Jeffrey Schildhorn, MD, orthopedic surgeon, Lenox Hill Hospital, New York City; Arthritis and Rheumatology, Dec. 1, 2021

Copyright ©2022 HealthDay. All rights reserved.
Jog on: Exercise Won’t Raise Your Odds for Arthritic Knees

Jog on: Exercise Won’t Raise Your Odds for Arthritic Knees

Dr. Kim Huffman, an avid runner, gets a fair amount of guff from friends about the impact that her favorite exercise has on her body.

“People all the time tell me, ‘Oh, you wait until you’re 60. Your knees are going to hate you for it’,” Huffman said. “And I’m like, ‘That’s ridiculous’.”

Next time the topic comes up, Huffman is well-armed: An extensive British analysis of prior study data has found no link between a person’s amount of exercise and their risk for knee arthritis.

The research team combined the results of six clinical trials conducted at different places around the globe, creating a pool of more than 5,000 people who were followed for 5 to 12 years for signs of knee arthritis.

In each clinical trial, researchers tracked participants’ daily activities and estimated the amount of energy they expended in physical exertion.

Neither the amount of energy burned during exercise nor the amount of time spent in physical activity had anything to do with knee pain or arthritis symptoms, the researchers concluded.

“This helps dispel a myth that I’ve been trying to dispel for quite a while,” said Huffman, an associate professor at the Duke University Medical Center’s division of rheumatology.

“If you add up the amounts of activity that people do and also the duration of activity, neither of those is associated with knee arthritis,” added Huffman, who wasn’t involved in the analysis.

Dr. Bert Mandelbaum is chief medical officer of the Los Angeles Galaxy soccer club and team physician for the U.S. Soccer Men’s National Team.

He agreed the study “further corroborates the fact that levels of exercise in one’s personal life do not increase the risk, the onset or progression of osteoarthritis.”

So where did this misconception come from?

Huffman thinks it’s because people mistake exercise-related injuries for the effect that exercise itself has on your joints.

“Right now, the clear risks for knee arthritis are genetics, injuries and female sex,” Huffman said. “People who exercise more may be more likely to injure their knee. That’s where I think the myth comes from.”

In fact, exercise can help ward off knee arthritis in several ways, Huffman said:

Flexing and extending the knee during exercise promotes the diffusion of fluid into the joint, promoting better nutrition.

An elevated metabolism created by exercise helps control inflammation in the knee joint.

Weight loss reduces the amount of load placed on the knee.

Exercise strengthens the muscles surrounding the knee, stabilizing it and reducing the risk of injury.

“I don’t think we’re finding that simple overuse or using your joint is a problem. It’s more an association with injuries and perhaps in the setting of obesity or high genetic risk,” Huffman said.

Your best bet is to choose an exercise that poses the least risk of a knee injury, Huffman said.

“If you want to go snow skiing, I don’t think that’s a huge problem but you’re probably going to be more likely to injure yourself downhill skiing than, say, walking in your neighborhood or training for a marathon,” Huffman said. “It’s not soccer or football or skiing itself. It’s just the risk for injury during those activities.”

On the other hand, exercise provides benefits that go far beyond healthy joints, said Mandelbaum, co-chair of medical affairs at Cedars-Sinai Kerlan-Jobe Institute at Santa Monica, Calif. He played no role in the research review.

“Physical activity is essential to optimize both physical and mental health and plays a central role in facilitating life’s quality and quantity,” Mandelbaum said. “The list of benefits includes decreased anxiety, better mood, decreased levels of coronary disease, hypertension, diabetes and obesity, and therefore a longer life.”

The analysis was published recently in the journal Arthritis and Rheumatology.

More information

The Arthritis Foundation has more about knee osteoarthritis.

 

SOURCES: Kim Huffman, MD, PhD, associate professor, Duke University Medical Center, division of rheumatology; Bert Mandelbaum, MD, co-chair, medical affairs, Cedars-Sinai Kerlan-Jobe Institute, Santa Monica, Calif.; Arthritis and Rheumatology, Nov. 3, 2021

4 COMMON ACL TEAR SYMPTOMS & WHEN TO SEEK TREATMENT

4 COMMON ACL TEAR SYMPTOMS & WHEN TO SEEK TREATMENT

ACL tears are common in physical activities that involve quick stops, changes in direction, or direct contact with the knee. Knowing the symptoms of ACL tears can help you recognize an injury and prevent it from getting worse. Explore our guide to learn how to tell if an ACL is torn and the procedures a knee specialist can perform to help you get back on your feet faster.

 

Signs & Symptoms of ACL Injuries
Individuals who suffer an ACL tear often note an audible “pop” or snapping sound as the injury happens. The onset of symptoms is immediate and usually accompanied by:

  • Decreased range of motion in the knee
  • Rapid swelling
  • Severe pain, soreness, and tenderness along the joint
  • Instability and discomfort while walking

ACL injuries usually occur during sports and fitness activities that can put stress on the knee. This includes movements like:

  • Pivoting with your foot firmly planted
  • Suddenly slowing down and changing direction
  • Stopping suddenly
  • Landing awkwardly from a jump
  • Receiving a direct blow to the knee

There are three levels of ACL injuries, which are classified by the amount of damage to the ligament (partial or complete tear). A grade 1 sprain, for example, is when the ACL is stretched but not ruptured. While a grade 3 sprain means the ACL is torn into two pieces, rendering the joint completely unstable.

 

When To Seek Treatment
If you are experiencing symptoms of an ACL tear, you should schedule an appointment with a knee specialist. They will conduct a physical exam in order to determine the extent of the injury. An X-ray may also be performed to assess if there is damage to the surrounding bone, but MRI will ultimately be the deciding factor in treatment.

Rehabilitation can be the first step in the recovery process with the goal of regaining full range of motion. You may spend several weeks working with a physical therapist who will develop a custom exercise program centered around your unique needs and symptoms.

However, ACL reconstruction surgery is often recommended if the ligament is injured or the injury is causing your knee to buckle during everyday activities. During the procedure, a surgeon will remove the damaged ligament and replace it with a new segment of tendon which recreates the ACL. This replacement tissue — called a graft — can be taken from your own patellar, hamstring, quadricep, or cadaver tendons.

The surgery is typically done using a minimally invasive, arthroscopic approach. Special surgical tools and a video camera are inserted through small incisions in the knee joint. The graft is then secured to the tibia (shin bone) and femur (thighbone) using sutures (special surgical thread) or screws depending on the type of graft. This acts as a bridge for the new ligament to grow on and reconnect the bones.

Recovery time varies based on the severity of the injury. Your doctor will recommend physical therapy in order to regain full range of motion, strength, and stability in the affected knee in the weeks and months that follow. Regular follow-up visits with your knee specialist and physical therapists are necessary to assess progress and readiness to return to your favorite activities.

Understanding the common symptoms of ACL tears can help reduce the risk of injury while playing your favorite sports. If you find yourself with pain or injury, CompOrtho offers top-level care to help you get on the road to recovery quicker. To learn more about injury prevention or make an appointment, contact us today!

What Shoes Work Best With Arthritic Knees?

What Shoes Work Best With Arthritic Knees?

WEDNESDAY, Jan. 13, 2021 (HealthDay News) — Lots of Americans suffer from painful arthritic knees, but a new study finds that wearing the right type of shoe may help ease discomfort.

Patients with knee arthritis will achieve greater pain relief by opting for sturdy and supportive shoes rather than flat flexible footwear, researchers in Australia found.

“A ‘sturdy supportive shoe’ is a shoe that gives stability to the foot, via motion control features such as arch support,” explained study author Rana Hinman, a professor of physiotherapy at the University of Melbourne. “It also has a thick, cushioned heel and a rigid sole that does not bend easily.”

In contrast, Hinman noted, “a ‘flat flexible shoe’ is more lightweight, contains no arch support or motion control features, has a low heel (i.e., flat) with minimal/no cushioning and has a flexible sole that bends easily.”

Roughly 1 in 4 adults over the age of 45 has arthritic knees, Hinman noted.

One U.S. expert unconnected to the study agreed that “bum knees” will probably feel better with special footwear.

“I think it’s pretty intuitive that a structured shoe will be more stable and better for arthritis patients,” said Dr. Jeffrey Schildhorn, an orthopedic surgeon at Lenox Hill Hospital in New York City. “I’ve found that to be true in my practice and in my life. But this study is the first to really look at this in a rigorous way, and to show with good science that this isn’t just anecdotal.”

Foot support matters

As the Australian team noted, people with creaky, painful knees are often advised to wear shoes with support. But there’s also a school of thought that flat flexible shoes may deliver greater benefit because they provide more of a “barefoot” experience.

The latter theory didn’t win out in the new study. After working with 164 knee arthritis patients in the Melbourne area, Hinman’s team found that “58% of people who wore sturdy supportive shoes experienced a meaningful reduction in knee pain on walking, compared to only 40% of the people who wore flat flexible shoes.”

Study participants were 50 years old and older. Prior to the study’s launch, all had experienced near constant knee pain in the prior month (rated at a 4 or greater on a pain scale of 11), and most had worn shoes that featured a mix of sturdy and flat characteristics.

Between 2017 and 2019, half were randomly assigned to wear a flat flexible shoe for at least six hours a day over six months, while the other half was assigned stable supportive footwear. (The team did not compare shoes distributed in the study with the ones patients regularly wore.)

All footwear was commercially available. For the flat variety, the brands included: Merrell Bare Access (for men and women); Vivobarefoot Primus Lite (men and women); Vivobarefoot Mata Canvas (men); Converse Dainty Low (women); and Lacoste Marice.

Stable variety brands included ASICS Kayano (for men and women); Merrell Jungle Moc (men); Nike Air Max 90 Ultra (women); Rockport Edge Hill (men); and New Balance 624 (women).

Each patient was able to switch between two brands throughout the trial. Investigators kept track of reported knee pain levels while walking, functional ability, overall quality of life indicators and overall physical activity levels.

In the end, the team determined that while stable supportive shoes did not restore greater mobility to patients than flat flexible shoes, they did offer a leg up on knee and hip pain reduction and improved quality of life.

‘A Rolls-Royce over potholes’

As well, Hinman noted that “sturdy supportive shoes were much less likely to cause adverse effects at the knee and other joints, such as ankle/foot pain [or] knee swelling.” Moreover, people who wore flat flexible shoes reported twice as many adverse effects as people who wore sturdy supportive shoes, she said.

The upshot: “Shoes are an easy option that can help people self-manage their knee osteoarthritis pain,” Hinman said. “Patients with knee osteoarthritis should think carefully about their footwear and choose shoes that are most likely to reduce their knee pain.”

Schildhorn agreed.

“For someone with knee arthritis,” he said, “a structured shoe is almost like a Rolls-Royce going over potholes. Because the problem with an arthritic knee is that the joints aren’t aligned correctly, and aren’t nearly as supple anymore. And it has cartilage with gaps, like cobblestones, which wear away.”

A structured shoe can absorb those issues, said Schildhorn. But an unstructured shoe or a bare foot “relies on all of the joints of the body to work just as they were designed. They all have to be aligned correctly, the ligaments have to be functional, and the joints have to be supple in order to absorb loads when walking in uneven areas. Because you need your body to be able to adjust to variances.”

The U.S.-based Arthritis Foundation agrees that patients should pay attention to the style and fit of the shoes they wear. But it cites mixed findings as to best practices.

For example, foundation experts acknowledge that stable shoes and boots (without heels) can indeed be helpful for some.

However, they also highlight prior knee research indicating that some flat shoes — such as flip-flops — may trigger less knee stress than more stable shoes. Others, however, such as loosely strapped sandals and so-called “foot gloves,” may prove problematic.

But the foundation has one piece of overriding advice: Never favor style over function and comfort.

The results were published Jan. 11 in the Annals of Internal Medicine.

More information

There’s more on shoe wear and arthritis at the Arthritis Foundation.

SOURCES: Jeffrey Schildhorn, MD, orthopedic surgeon, Lenox Hill Hospital, Northwell Health, New York City; Rana Hinman, PhD, professor, department of physiotherapy, University of Melbourne, Australia; Annals of Internal Medicine, Jan. 11, 2021

Copyright ©2020 HealthDay. All rights reserved.
Knee Procedure Done Earlier Might Prevent Knee Replacement Later

Knee Procedure Done Earlier Might Prevent Knee Replacement Later

MONDAY, Feb. 1, 2021 (HealthDay News) — For some patients suffering from knee arthritis, a special procedure may reduce the need for a total knee replacement, Canadian researchers say.

By getting what is known as a ‘high tibial osteotomy,’ younger patients with less severe joint damage who are physically active might be able to delay the need for a knee replacement by 10 years or more, though they may have to search for a doctor who performs the surgery.

“High tibial osteotomy is a knee surgery aimed at treating patients in earlier stages of osteoarthritis by correcting the alignment of bowed legs and shifting load to less diseased parts of the knee,” explained lead researcher Trevor Birmingham, the Canada research chair of musculoskeletal rehabilitation at the University of Western Ontario.

During the procedure, the tibia (shinbone) is cut and then reshaped to relieve pressure on the knee joint.

Beyond improving pain and function, a goal of the procedure is to prevent or delay the need for total knee replacement, Birmingham said.

Although high tibial osteotomy can improve pain and function and is cost-effective, the procedure is underused in North America, Birmingham said. “Rates of high tibial osteotomy continue to decline, while rates of other knee surgeries continue to rise,” he added.

“The low rates of high tibial osteotomy are partially due to the perception that the procedure is only suitable for a very specific subset of patients with knee osteoarthritis, and that the patients will go on to require total joint replacement anyway. So why bother?” Birmingham said.

But the researchers found that among nearly 600 people in the study who had a high tibial osteotomy, 95% did not need a total knee replacement within five years, and 79% did not get a total knee replacement within 10 years.

Even patients not usually considered good candidates for high tibial osteotomy, such as women and those with later-stage disease, 70% did not need a knee replacement within 10 years, the researchers found.

“Knees treated earlier in the disease process had the highest longevity after high tibial osteotomy, with 87% not getting a total knee replacement within 10 years,” Birmingham said.

The findings from this study suggest that high tibial osteotomy has the potential to delay or prevent the need for total knee replacement, bringing the limited use of high tibial osteotomy into question, he said.

Dr. Jeffrey Schildhorn, an orthopedic surgeon at Lenox Hill Hospital in New York City, reviewed the study and said that the goal of this procedure is to realign the knee to help prevent arthritis progression in younger patients.

“The high tibial osteotomy is designed to help patients avoid the knee replacement altogether, or at the very least to get further along in life before it’s necessary,” he said. “The idea behind the operation is solid, and in the right patient, it’s absolutely the right thing to do.”

Schildhorn said the one downside of the procedure is that patients have to keep their weight off the knee for at least a month after a high tibial osteotomy, which is one reason it’s only used for patients strong enough to use crutches.

“When I treat patients, one of the things that limits me in offering certain things is what I think they can tolerate, so if I see someone who I don’t think is going to be able to get through the nuanced rehabilitation that’s going to be required, like not putting weight on it for four to six weeks and the arduous physical therapy that can be involved, I won’t offer them something like this,” Schildhorn said.

He also said that whether a patient is offered a high tibial osteotomy depends on the doctor the patient sees.

“In other words, usually the doctors who do joint replacements don’t do this, and vice versa,” Schildhorn said. “It depends on the philosophy of the surgeon; there are surgeons who are joint replacement surgeons and there are surgeons who are joint-preserving, and some crossover. But for the most part, it depends on your philosophy and how you frame your practice — there’s a lot less doctors who specialize in osteotomy than specialize in joint replacement.”

Patients need to do their homework, he noted.

“Ask your doctor, “Would this be right for me? Would this preserve my knee for longer? And do you think I’m a good candidate?'” Schildhorn said. “You have to arm people with information so they can understand the risks — basically that’s what informed consent really is.”

The report was published Feb. 1 in the Canadian Medical Association Journal.

More information

For more on knee osteoarthritis, see the American Academy of Orthopaedic Surgeons.

SOURCES: Trevor Birmingham, Ph.D., professor and Canada research chair, musculoskeletal rehabilitation, University of Western Ontario, London, Canada; Jeffrey Schildhorn, MD, orthopedic surgeon, Lenox Hill Hospital, New York City; Canadian Medical Association Journal, Feb. 1, 2021

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