AUTHOR

J. Albert Diaz, MD, is a board-certified orthopedic surgeon and sports medicine specialist.
After his orthopedic training at the Hospital for Special Surgery in New York City, he
completed a sports medicine fellowship at the Minneapolis Sports Medicine Center and has
practiced in Connecticut since 1997 specializing in problems of the knee and shoulder. He is
a graduate of Dartmouth College and the Tulane University School of Medicine and is a
member of the American Academy of Orthopaedic Surgeons, the American Orthopaedic
Society for Sports Medicine, and the Arthroscopy Association of North America.
Chapter 1

THE HEALTHY KNEE

Section 1

BASIC ANATOMY

A bony hinge

Three bones fit together like a 3-dimensional puzzle to form the knee: the femur (thigh bone), the
tibia (shin bone), and the patella (kneecap). A fourth bone, the fibula, serves primarily as an anchor
site for muscular attachment and is not important in the context of knee arthritis.
Section 2

ARTICULAR CARTILAGE

Smooth, durable tissue that facilitates low-friction joint motion

The bones that meet to form the knee joint are surfaced with a layer of thin padding called articular
cartilage. Compressible and slippery, cartilage absorbs shock and provides almost frictionless
motion of the joint.
Unlike most body tissue, articular cartilage is avascular (lacking blood vessels) and aneural (lacking
nerves). Without a blood supply, healing and repair cannot occur, so articular cartilage is especially
durable.
Section 3

CHONDROCYTES & THE MATRIX

Articular cartilage under the microscope

Articular cartilage is made up of a dense, well-hydrated proteinaceous “netting” called

the extracellular matrix. The matrix gives cartilage its durable structure, and is produced by a small
number of highly-specialized cells called chondrocytes that are scattered throughout the cartilage.
The primary function of each chondrocyte is to maintain the plot of extracellular matrix which
surrounds it.
Healthy articular cartilage requires healthy chondrocytes to make and maintain the extracellular
matrix.
Section 4

BOUNCE AND FLOW

The shock-absorbing capacity of cartilage

Articular cartilage is like a water-soaked, mousepad-thin sponge. When the knee bears weight during
low-impact activity, the “sponge” flattens as water is squeezed out, distributing the load more broadly
across its surface area. With greater impact, however, articular cartilage reacts differently. It traps
and holds its water, providing a protective “bounce” that shields the matrix from extreme force.
Healthy cartilage can withstand decades of repetitive force by controlling the flow of fluid through its
matrix.
[51,107,176]
Section 5

THE CAPSULE

A watertight sleeve

The knee joint is enclosed in a thin, tough, fibrous tissue called the capsule. Think of the capsule as a
sleeve pulled over the joint and sealed both above and below, creating a watertight space.
Section 6

THE SYNOVIUM & SYNOVIAL FLUID

The joint’s natural lubricant

The capsule has an inner lining of paper-thin and translucent synovium, which makes and secretes
synovial fluid.
Straw-colored and stringy, like egg white, synovial fluid nourishes and lubricates the articular
cartilage. As a result, the knee joint operates with one of the lowest coefficients of friction measured
for any material, organic or not.
The normal amount of synovial fluid in a healthy knee joint is less than a teaspoon.
[19,112]
Section 7

THE MENISCUS

The knee’s shock absorbers

Each knee has two C-shaped shock absorbers positioned between the femur and the tibia: the medial
meniscus (inner side of the knee) and the lateral meniscus (outer side of the knee). The menisci
(plural), composed of rubber-like fibrocartilage, protect the articular cartilage and underlying bone
by shouldering over half the load during weight-bearing activity.
Section 8

“CARTILAGE”

Articular cartilage vs. meniscal fibrocartilage

The distinction between articular cartilage and meniscal cartilage is a common source of confusion.
When a friend tells you, “I tore the cartilage in my knee,” she is referring to her medial or lateral
meniscus, not her articular cartilage. More precisely, she should say, “I tore my meniscus.”
Section 9

LIGAMENTS

The primary stabilizers of the joint

A ligament is a rope-like tissue that anchors one bone to another and stabilizes the joint. The four
major ligaments in the knee are the ACL, PCL, MCL, and LCL. They are not particularly relevant in
the context of knee osteoarthritis and are not included in subsequent illustrations.
Section 10

OVERVIEW

As you walk, your knee straightens and bends. The articular cartilage surfaces glide over one another.
The menisci, with the articular cartilage, absorb the impact, protecting the underlying bone from high
contact stress. The synovium produces synovial fluid which provides the lubrication necessary to
keep the joint moving smoothly. The muscles provide the power, the capsule and ligaments the
stability.
In a healthy knee, this all goes unnoticed. But a failure in any part of the structure can set in motion a
domino effect of damage which compromises its painless efficiency.
Chapter 2

OSTEOARTHRITIS
Section 1

DEFINING ARTHRITIS

The two categories of arthritis

Arthritis is the general term for joint disease or degeneration, and is classified broadly into two
categories: inflammatory and non-inflammatory.
Over 100 different conditions can lead to inflammatory arthritis –– principal among them is
autoimmune disease, a group of disorders in which the normal function of white blood cells is
corrupted, causing them to target and destroy joint tissue. Other disorders that can cause inflammatory
arthritis include gout, pseudogout, and infection. The common variable in this category of arthritis
is the mobilization of white blood cells to the joint resulting in an intense inflammatory response.
The vast majority of arthritis, however, is non-inflammatory. The lone condition in this category is
osteoarthritis, also known as wear-and-tear arthritis. Osteoarthritis can be accompanied by
inflammation, but not at the levels seen in the inflammatory group.
[15]
Section 2

UNDERSTANDING KNEE OSTEOARTHRITIS

Organ failure

The joint is viewed conceptually as an organ comprised of articular cartilage, synovium, bone,
muscle, nerve and even fat. The loss of cartilage remains the hallmark of osteoarthritis, but the
disease is increasingly regarded as an “organ failure.”
The earliest changes to articular cartilage include softening, peeling, and cracking. In time, the
cartilage may wear away entirely, leaving the bony surfaces fully exposed – a condition referred to
as bone-on-bone osteoarthritis.
[215]
Section 3

WHAT CAUSES CARTILAGE LOSS?

Damage at the cellular level

Many factors, operating alone or together, can contribute to the onset of knee osteoarthritis. Obesity,
trauma, and a number of other factors, including the natural aging process, can damage chondrocytes
(the cells that make and maintain articular cartilage) and trigger cartilage loss.
[131]
Section 4

FOCAL VS DIFFUSE

Damage report

Osteoarthritis, by definition, is a diffuse loss of articular cartilage. Most middle-aged and older
patients with joint damage have diffuse changes to the joint surface rather than smaller, focal injury.
Focal damage can occur, usually in younger patients as a result of injury, and is analogous to a divot
in an otherwise healthy bed of tissue. Treatment options exist for these lesions that are not
appropriate for diffuse osteoarthritis.
Section 5

SYNOVITIS

Inflammation and painful osteoarthritis

Damaged articular cartilage cannot directly cause pain since it lacks a nerve supply. It does, however,
shed particles that trigger an inflammatory reaction in the synovium called synovitis.
Synovitis can result in swelling and stiffness. Synovial tissue has a rich nerve supply and is a potent
pain generator when inflamed.
Section 6

EFFUSION

The swollen knee

The synovium normally produces a small amount of synovial fluid — all that is needed to lubricate
the joint. However, an inflamed synovium produces an excess of fluid, known as an effusion. Like
squeezing a water balloon, bending a swollen knee results in increased pressure and a painful
stretching of the knee capsule.
An effusion is a sign of an inflamed knee, and can be caused by a number of conditions other than
osteoarthritis, such as a meniscal tear or Lyme disease.
Section 7

BAKER’S CYST

A fluid collection behind the knee

When the knee swells, the capsule stretches to accommodate the excess synovial fluid. In some cases,
fluid will leak out through a weak spot in the back of the capsule, forming a distinct collection
referred to as a Baker’s cyst or popliteal cyst.
A Baker’s cyst does not typically require treatment and will often resorb, provided it is not
replenished by a persistent knee effusion.
Section 8

BONY CHANGES

Stressed out bone

The bones in the knee joint often have a physical reaction to the stress of osteoarthritis.
Directly beneath the articular cartilage is a dense layer of supportive subchondral bone. When
articular cartilage breaks down, subchondral bone is exposed to increased pressure. Some patients
develop painful bone marrow lesions, which are similar to bone bruises. Others develop
subchondral sclerosis, a hardening of the bone.
In other cases, an arthritic joint responds to stress by producing new bone around its edges. The
abnormal growth is referred to as an osteophyte, or more commonly, a bone spur. The excess bone
serves no purpose and does not typically cause pain. Removing the spur does not lessen osteoarthritis
symptoms.
Bone marrow lesions are only visible on MRI, while subchondral sclerosis and bone spurs can be
seen on X-ray.
Section 9

SIGNS AND SYMPTOMS

Section 10

PAINLESS ARTHRITIS

Osteoarthritis without symptoms

It is an underappreciated fact that many patients with osteoarthritis are pain-free. The absence of
synovitis or bone marrow lesions in these individuals may explain the lack of symptoms.
Chapter 3

THE OFFICE VISIT

Section 1

TERMINOLOGY

Speak the language

Flexion Bending the knee.

Extension Straightening the knee.
Range of Motion (ROM) The total motion of the knee, from full extension to full flexion. In a healthy
knee, ROM is from 0 to approximately 135 degrees.
Crepitus The palpable, sometimes audible, grinding sensation in an arthritic knee, usually under the
patella, which is the result of damaged opposing surfaces grating rather than gliding.
Section 2

OSTEOARTHRITIS ZONES

Medial, lateral, and patellofemoral compartments

The three weight-bearing areas in the knee are referred to as compartments. Think of these
compartments as zones. They are: medial (inner side of the knee), lateral (outer side of the knee), and
patello-femoral (under the kneecap).
Patients with arthritis in only one zone (uni-compartmental arthritis) are in the minority. In most
cases, two or three compartments are involved. Tri-compartmental arthritis refers to involvement of
all three zones.
A diagnosis of knee osteoarthritis should specify the compartments involved.
Section 3

X-RAYS

PA View of both knees, taken standing

 Lateral View and Sunrise View

Take a hard look

An X-ray allows assessment of bony anatomy. Soft tissues, like muscles, ligaments, tendons, and
cartilage, are not visualized. Conventional knee X-rays include three views: a standing view from
back to front (PA), a standing view from the side (lateral), and a tangential view of the patella
(sunrise or Merchant). This series allows visualization of all three compartments.
X-rays are an essential component of the orthopedist’s examination. They reveal certain signs, like
narrowing of the joint space and bone spurs, that confirm the diagnosis of osteoarthritis.
Section 4

THE JOINT SPACE

Mind the gap

The joint space refers to the gap seen between bones on X-ray. A wide space implies healthy, full-
thickness articular cartilage. When the cartilage wears away in an arthritic knee, however, the joint
space narrows. Bone-on-bone arthritis is the end result, with complete loss of articular cartilage and
obliteration of the joint space.
Patients with mild osteoarthritis may have normal X-rays since early changes to the articular
cartilage, like softening or cracking, do not result in joint space narrowing. Consequently, a normal
X-ray does not preclude the possibility of early osteoarthritis.
Section 5

BONE SPURS

An indirect sign of osteoarthritis

The presence of bone spurs on X-ray confirms a diagnosis of osteoarthritis, even in the absence of
joint space narrowing.
Section 6

A CASE FOR MRI

High power magnetic imaging

Magnetic resonance imaging (MRI) provides detailed imaging of bones and all soft tissues,
including articular cartilage.
If severe arthritis has been confirmed by X-ray, MRI is not necessary. On the other hand, if the X-ray
shows mild osteoarthritis, MRI may reveal the presence of an unrelated pain generator, such as a torn
meniscus. Ultimately, the orthopedist’s decision to order an MRI is based on the history of the
patient’s symptoms, the physical examination, and the X-ray findings.
Unlike X-rays or CT scans, MRI does not utilize ionizing radiation, and presents no currently known
risk.
[65]
Chapter 4

TREATMENT
Section 1

A TREATMENT PHILOSOPHY

Risk and benefit

Before consenting to a treatment, it is important to be aware of the associated risks and have a
realistic expectation of the benefits. Risk-benefit analysis should underpin decision-making.
Section 2

PLACEBO EFFECT

Real biology

The placebo effect has been shown to exert distinct biologic effects on the brain, activating the
reward system through the release of endocannabinoids, dopamine, and endorphins, and up-regulating
the immune system. The result can be real pain mitigation. Several studies have shown that about one-
third of patients are likely to respond favorably to a placebo treatment for osteoarthritis.
The placebo effect confounds the determination of efficacy for any treatment. It is important to keep
this in mind as you consider options.
[143]
Section 3

WEIGHT LOSS: POUNDS AND PRESSURE

Wait!

Patients often do not realize the extent to which excess weight contributes to knee osteoarthritis.
Orthopedists assume the connection is obvious and, for that reason among others, don’t always
initiate a weight loss discussion.
The more you weigh, the greater the pressure on you knees. For example, if you weigh 150 pounds,
descending stairs can put over 500 pounds of pressure on your knees — or 3.5x your body weight. A
relatively small weight gain of 10 pounds, therefore, has a disproportionate effect; it adds about 35
pounds of pressure to your knees. The good news? For every single pound you lose, you take
several pounds of pressure off your knee.
A recent study found a significant decrease in knee cartilage degeneration in patients who dropped at
least 10% of their body weight. Those who lost less than 10% experienced no benefit.
Excess weight is the risk factor over which you have the greatest control. Lose weight before it’s too
late — aim for 10%.
[47,60,165,170]
Section 4

WEIGHT LOSS: REDUCING INFLAMMATION

Adipose and the effects of inflammation

The biomechanical wear-and-tear effect of excess weight may not fully account for the link between
obesity and knee osteoarthritis.
Chronic low-grade systemic inflammation often exists in overweight patients, the result of pro-
inflammatory proteins secreted by adipose tissue (fat). The quantity released is proportional to the
mass of adipose. The more fat, the more inflammation.
Weight loss decreases these pro-inflammatory proteins, which may contribute to a decrease in
symptoms.
[13,87,93,167,189]
Section 5

MEASURING FAT: BMI

Are you overweight?

Body mass index (BMI), a measure of body fat based on height and weight, provides a useful,
although imperfect, assessment. In the U.S., roughly two-thirds of adults are overweight (BMI 25-30)
and more than one-third are obese (BMI >30). Google “BMI calculator” to compute your index.
A BMI > 30 nearly triples your lifetime risk of knee osteoarthritis.
[87]
Section 6

MEASURING FAT: BY PERCENT

Percent body fat = total fat mass ÷ total body mass

While BMI remains the standard measure for obesity, it cannot distinguish fat mass from lean body
mass. As a result, muscular individuals may have a falsely elevated index. A more accurate
assessment of body composition is percent body fat.
There are a number of ways to measure fat percentage, from the relatively inexpensive skin caliper
method, to bioelectric impedance, hydrostatic weighing, and dual X-ray absorptiometry (DXA).
[4]
Section 7

DIET AND NUTRITION

Eat like a Greek

There is no scientific evidence that specific foods will alleviate arthritis symptoms, decrease
associated knee inflammation, or slow the progression of the disease. Studies have shown, however,
that certain foods can reduce inflammatory proteins in the blood. In addition, a recent study suggests
that a high-cholesterol diet can hasten cartilage damage and worsen osteoarthritis symptoms in
predisposed knees.
The Arthritis Foundation recommends a Mediterranean diet for patients with arthritis –– a diet full of
colorful fruits and vegetables, whole grains, lean proteins like poultry and fish, legumes, and
unsaturated fats like olive oil and nuts. It also includes red meat, dark chocolate, and red wine in
moderation.
[151,200]
Section 8

EXERCISE: BENEFITS

The benefits of routine exercise

Section 9

EXERCISE: JOINT-FRIENDLY ACTIVITY

Low impact activity is better tolerated

Section 10

EXERCISE: A WALKING PROGRAM

Take a walk

A regular walking program, preferably on flat terrain, should be a primary component of a joint-
friendly exercise regimen. Walking strengthens and conditions multiple muscle groups and helps to
improve balance, cardiovascular endurance, and core strength. Cross-training with other low-impact
activities adds variety.
A recent study found that patients with knee osteoarthritis who walked more over the course of the
day, whether as part of an exercise program or as unstructured, normal physical activity, were less
likely to develop functional limitations over the ensuing two years. The effect was dose-dependent ––
the more they walked, the better they did. Approximately one hour of walking (6000 steps/day)
seemed to be the ideal threshold to protect against functional decline.
[145,180,184]
Section 11

EXERCISE: THE PERSONAL TRAINER

Pain, no gain

“No pain, no gain” is a dangerous motivational catchphrase for patients with osteoarthritis. While
well-intentioned, personal trainers sometimes put you through workouts that overload your joints.
Make sure your trainer, or class instructor, understands your limitations. A good trainer will have
specific programs, or will suggest modifications, for clients with shoulder, hip, or knee problems.
Regimens that include hip and core strengthening exercises are effective, as strong hips help to
protect fragile knee joints.
If your knee hurts during or after a particular form of exercise, try something else. Since every case is
different, there is no “one-size-fits-all” approach to exercise. Let trial and error shape your regimen.
Section 12

EXERCISE: KNEECAP ARTHRITIS

Special forces

Due to their anatomy, women are particularly prone to arthritis of their kneecap. Women have smaller
knees and wider hips, and as a consequence, patellofemoral forces can be 20% higher than in men for
the same activity.
For patients with kneecap arthritis, exercises which overload this compartment should be avoided.
They include seated knee extension exercises against resistance, heavy squats or lunges, running hills,
repetitive jumping, and steps. Stay away from stepmills and stair machines as well.
Section 13

EXERCISE: RUNNING AND OSTEOARTHRITIS

Go ahead, get high

There is no evidence to suggest that running causes knee osteoarthritis in patients with healthy joints.
In fact, multiple studies have found that long distance running, including marathons, does not increase
the risk of osteoarthritis and may in fact have a protective, anti-inflammatory effect. As a bonus,
running helps to maintain bone density.
For runners with established arthritis, however, running is not restorative. Running on a bad knee can
accelerate the progression of osteoarthritis. If you must run, cut your mileage, avoid hills, and cross-
train with low-impact exercise.
[33,120,146,147,181,212, 214]
Section 14

ICE OR HEAT?

Ice

The temperature in an inflamed knee can increase by nearly 10ºF over baseline, and this additional
energy stimulates destructive enzymes within the joint.
The application of ice, or cold water, to a swollen knee can lower the temperature inside the joint and
constrict blood vessels, which helps reduce inflammation. It can also slow nerve conduction,
decreasing pain transmission. The application of heat, on the other hand, causes blood vessels to
dilate, and leads to increased blood flow, greater inflammation, and pain.
How long should you ice a painful osteoarthritic knee? Studies have shown significant decreases in
joint temperatures after sixty minutes of cold application that are maintained for another hour. So, if
you have an inflamed knee:
Ice on for 60 minutes, off for at least 60 minutes, repeat as needed.
Beware of ice burn or frostbite, which is a result of direct application of cold to skin without an
intervening layer of protection.
[37,89,166,177]
Section 15

CLIMATE CHANGE

Pack your bags

Osteoarthritis patients often report worsening symptoms when barometric pressure drops before a
storm. These symptoms may be related to the slight expansion of the joint as the pressure changes.
Warm, dry climates with consistent weather seem to be preferable for many arthritis patients. Hawaii,
Southern California, and Southern Florida have the narrowest range of barometric pressure in the
United States, while Alaska and South Carolina have the greatest.
[9]
Section 16

PHYSICAL THERAPY

Limited benefit

Physical therapy is of limited benefit to patients with osteoarthritis of the knee, unless they have a gait
abnormality which requires correction. In patients with chronic osteoarthritis, a long-term, low-
impact exercise program is a better investment.
For some, especially those who are older or have limited mobility, a physical therapist can help
design and implement an appropriate home exercise routine.
Section 17

ARTHRO THERAPEUTICS

An online management program for osteoarthritis

Arthro Therapeutics is a Swedish start-up whose flagship product Joint Academy is a “6-week
journey to reach healthier joints.” The program consists of eight short educational videos, self-
management techniques, and coping strategies. Patients receive a personalized activity schedule and
direct, one-to-one coaching from a physical therapist. The focus is on behavioral change,
neuromuscular training, and improving biomechanics. The program does not include drugs or surgery.
Results are equivalent to traditional face-to-face treatments.
Arthro Therapeutics launched in mid-2016 and plans to expand into the US in 2017 through partnering
with private and public health organizations and corporations.
[210,211]
Section 18

CHIROPRACTIC TREATMENT

Don’t be manipulated

Chiropractic treatment for knee osteoarthritis is not supported by well-controlled long-term studies,
and forceful manipulation of painful or stiff joints may be harmful.
[173]
Section 19

LOW-LEVEL LASER THERAPY

Shine the light

Low-level laser therapy or cold laser treatment exposes tissue to focused light from the near-red
and infrared region of the electromagnetic spectrum. Although the precise effect is not fully
understood, cold laser treatment seems to stimulate mitochondria, initiating a chain of events that
leads to a reduction of inflammatory cells in the treated tissue.
Much of the early work in low-level light therapy utilized a helium/neon laser. The recent
development of light-emitting diodes or LEDs has led to a dramatic rise in the popularity of “laser
therapy.” LED light lacks the focus of true laser, and it has not yet been determined if there is a
significant therapeutic difference between the two.
Results in the literature regarding low-level laser therapy for the treatment of osteoarthritis are
mixed. Laser therapy remains controversial because its mode of action at the cellular level has not
been fully elucidated, and the optimal parameters (wavelength, power level, pulsation, duration, etc.)
for treatment of a given condition have not yet been determined. More research is necessary before
laser treatment is regarded as a valid treatment alternative for osteoarthritis of the knee.
[27,62,66,70,71]
Section 20

PROLOTHERAPY

Soft tissue stimulation

Prolotherapy (short for proliferation therapy) is the practice of injecting an irritant solution, usually
dextrose (sugar water), into a target tissue. This triggers an inflammatory response, which, in addition
to its harmful effects, can stimulate a healing response. It has been shown to be effective in the
management of tendon and ligament injuries, but evidence is lacking for efficacy in the treatment of
knee osteoarthritis.
Section 21

MAGNETS & COPPER

Fashion therapy

No scientific evidence suggests that wearable magnets and copper jewelry alleviate
the pain and inflammation of osteoarthritis or have any real benefit over placebo.
Interestingly, copper does have intrinsic antimicrobial properties that kill over 99% of
bacteria on its surface within two hours.
[187]
Section 22

ORTHOTICS

A slight correction

Wedge-shaped orthotics can alter the forces in the knee, particularly in patients who have become
knock-kneed or bow-legged as a result of their osteoarthritis.
A heel wedge may decrease pain by lessening the contact force in the affected compartment. For
patients with arthritis in the medial compartment, a lateral heel wedge is prescribed. For those with
painful lateral compartment osteoarthritis, a medial heel wedge.
It is a simple option worth considering.
Section 23

KNEE BRACES

A slightly greater correction

Unloader braces or OA braces are functional braces designed to unload or offload the arthritic
compartment –– lessening pressure on the painful, damaged part of the knee and shifting it towards the
less affected side. They can be of particular benefit in patients with arthritis predominantly affecting
the medial or lateral compartment. These braces are usually prescribed by physicians based on
clinical and x-ray findings.
Braces are often most helpful in patients whose symptoms are aggravated by sports or exercise, but
are less symptomatic with normal daily activities. Wearing the brace full-time can be inconvenient,
and limited use during exercise is better tolerated.
Section 24

ACUPUNCTURE

Ancient Chinese secret

Originating in China more than 2000 years ago, acupuncture is an ancient form of medicine with
many modern-day adherents. It is based on the theory that energy flow can be rebalanced through the
insertion of fine needles along twelve vital energy pathways in the body called meridians.
Acupuncture may initiate several biological mechanisms to include the release of endorphins,
proteins that inhibit the transmission of pain and induce a feeling of euphoria.
In a 2014 study of patients older than 50 with moderate to severe knee pain, acupuncture failed to
provide meaningful benefits. In contrast, a 2016 review provided evidence of short-term pain relief.
Patient expectations, placebo and self-empowerment effects, as well as the empathetic nature of the
treatment may account for some of the symptomatic relief obtained from acupuncture. In the hands of a
licensed practitioner, the risks are negligible.
(69,123,198]
Section 25

ORAL SUPPLEMENTS

Caveat emptor

Billions of dollars are spent annually on supplements that promise to relieve a wide range of
afflictions. None of these supplements has been proven effective for the treatment of osteoarthritis,
and many have side effects, interactions with other medications, and/or unintended consequences.
Worse yet, the industry is not well-regulated and quality concerns, including outright substitution of
active ingredients with fillers, have been reported. In one recent study, the majority of herbal
supplements tested were adulterated; a full one-third had no trace of the plant advertised on the
bottle.* Various studies have revealed dangerous levels of lead, selenium, and anabolic steroids in
dietary supplements. Over 20,000 ER visits a year, tracked over a ten-year period from 2004-2013,
were attributed to the ingestion of supplements.
VITAMIN D Deficiency has been shown to be harmful to articular cartilage in recent animal studies
and should be corrected with supplementation. However, supplementation in healthy individuals
does not appear to prevent or slow the progression of osteoarthritis.
FISH OILS There is currently insufficient evidence to support the use of fish oil (omega 3 fatty
acids EPA and DHA), at low or high doses, for the treatment of osteoarthritis.
GLUCOSAMINE AND CHONDROITIN These supplements have been marketed broadly for the
treatment of osteoarthritis. The National Institutes of Health (NIH) funded a large 2006 study of their
effectiveness when taken alone, or in combination, and found results similar to placebo. An ancillary
study in 2008, and additional data collected in 2010 confirmed those results.
ANTIOXIDANTS These dietary supplement are widely used based on the assumption that they help
the body cleanse itself of oxygen free radicals, which are the byproducts of normal aerobic
respiration. Free radicals play an important role in normal cellular function and help to defend the
body against invading microorganisms. However, they are also responsible for a number of harmful
effects and their accumulation can lead to oxidative stress, which has been implicated in general
age-related cellular deterioration, and specifically in articular cartilage degeneration. In theory,
antioxidants modulate oxidative stress by deactivating free radicals, but there is little scientific
evidence to support the use of antioxidants in the prevention of osteoarthritis or the lessening of
symptoms.**
In fact, taking high doses of antioxidants may have unintended negative consequences. A recent study
of the effects of supplementation (vitamins C, E, and resveratrol) on exercise found it hampered the
beneficial cellular adaptations that typically occur with exercise, such as increased endurance,
decreased blood pressure, improved cholesterol profiles, and healthier arteries. The low doses of
antioxidants found naturally in foods like blueberries, dark chocolate, and red wine are unlikely to
have this blunting effect, and provide a safer method of supplementing antioxidant levels.

* Supplements can be independently tested by U.S. Pharmacopeial Convention (USP),

ConsumerLabs.com (CL), or NSF International (NSF). Look for products supported by these
standards for purity. Labdoor runs detailed chemical analyses on selected supplements and energy
drinks and posts grades and ranks.
** A recent animal study found that antioxidants given together with cholesterol lowering drugs can
dramatically slow the progression of arthritic changes in predisposed knees by suppressing oxidative
damage. This approach may soon form the basis for treatment in early osteoarthritis patients with
certain risk factors.
[14,79,102,109,122,125,126,127,130,134,148,160,186,200]
Section 26

NON-NARCOTIC ORAL PAIN RELIEVERS

NSAIDs and acetaminophen

Non-steroidal anti-inflammatory drugs, referred to as NSAIDs, are a class of compounds that

decrease inflammation, pain, and fever, and are relatively safe when used judiciously. While effective
in treating pain associated with knee arthritis, NSAIDs do have side effects, the most common of
which are gastrointestinal, from mild stomach upset to serious GI bleeding.
COX-2 inhibitors are NSAIDs that are more selective in their action, developed to preserve the anti-
inflammatory action but lessen the GI side effects. Celebrex is the only COX-2 inhibitor currently
available in the United States. It must be prescribed by a physician. At the recommended dose
(200mg daily), Celebrex poses no higher risk to your heart than ibuprofen or naproxen, and is less
likely to cause significant gastrointestinal or kidney problems.
An increased risk of serious adverse cardiovascular events, including heart failure, is a class
effect of all NSAIDS. The risk increases with dose and duration.
General advice for NSAID use:
Take the lowest dose needed to alleviate symptoms, for the shortest duration of
time. Don’t take more than the recommended dose. Avoid taking NSAIDs routinely.
Acetaminophen (Tylenol), known as Paracetamol outside the US, is an analgesic and antipyretic
(fever reducer). It is not an anti-inflammatory. The exact mechanism of action is not known.
Acetaminophen was found to be ineffective for the treatment of osteoarthritis in a 2016 Swiss
analysis that looked at almost 60,000 patients. High doses can cause severe liver damage.
[25,29,192,196,203]
Section 27

TOPICAL NSAIDS

Safe and effective

All topical anti-inflammatories contain diclofenac, a non-steroidal anti-inflammatory.

In the US, three topical anti-inflammatories are approved for use. Pennsaid and Voltaren Gel are
indicated for knee arthritis; Flector Patch is used for the treatment of strains and sprains.
Topical NSAIDs are applied directly to the knee and can be as effective as oral drugs for joint pain.
They are sold over the counter in Europe but require a prescription in the US.
[80]
Section 28

NARCOTIC PAIN RELIEVERS

Not indicated

Narcotic drugs, or opiates, work by interfering with pain signaling to the brain.

Opiates have high potential for abuse and are not appropriate for the treatment of knee
osteoarthritis. In fact, long-term use of narcotics can actually increase sensitivity to pain. The liberal
prescribing of narcotics for the management of musculoskeletal pain and injury has contributed
significantly to the current epidemic of drug abuse and dependency.

Tramadol is an atypical synthetic opioid with a lower risk of dependence. In early studies, tramadol
was not found to be highly addictive when injected, but recent work has surprisingly demonstrated a
much stronger risk of dependency when taken orally. ER visits in the US due to tramadol misuse
tripled between 2005 and 2011.

[194,195]
Section 29

CORTISONE INJECTION

A potent anti-inflammatory

Synovitis, the primary pain generator in an arthritic knee, can often be effectively treated with an
injection of cortisone, a potent anti-inflammatory. Of the injectable corticosteroids, Triamcinolone
(Kenalog) is arguably the most effective for the treatment of knee osteoarthritis. Typically, cortisone
begins working 1-3 days after injection, but it can take a week or more for the full effect.
Cortisone is commonly mixed with a local anesthetic, such as lidocaine, prior to injection. Multiple
studies have demonstrated that local anesthetics, particularly lidocaine, inside the joint may lead to
articular cartilage damage. This effect seem to be dose- and time-dependent. The risks of an
occasional cortisone + anesthetic injection in the knee is probably negligible, but their indiscriminate
use should be avoided and anesthetic volume should be limited.
Cortisone can stimulate the production of glucose in the liver up to one week after the injection, so
diabetics should carefully monitor blood glucose levels. Additional potential adverse effects include
joint infection (<0.01%) and post-injection “flare” (5-10%), a self-limited worsening of symptoms
that lasts 1-2 days after the shot.
By mitigating the damaging effects of inflammation, corticosteroids can have a protective effect on
articular cartilage, if used judiciously. So, how many shots can you get? There is no hard and fast
rule. Your approach should be dictated by your age and the severity of your osteoarthritis. For
example, if you are 45 years old with mild arthritis, you should avoid multiple injections. On the
other hand, if you are 70 years old with bone-on-bone arthritis, there is not a lot of downside to
multiple injections if they are providing lasting pain relief. Repeat cortisone injections given over a
short period of time tend to have diminishing returns so, in general, it’s best to spread them out.
[10,18,36,40,41,68,77,83,138]
Section 30

VISCO-SUPPLEMENTATION

A hyaluronic acid recharge

Hyaluronic acid (HA) is a naturally occurring molecule found throughout the body, and is an
important component of both synovial fluid and articular cartilage. It provides viscosity to synovial
fluid, compressive strength to cartilage, and enhances the function of chondrocytes.
In patients with osteoarthritis, HA breaks down and concentration decreases. HA levels can be
restored by injecting the acid directly into the joint, a common therapy referred to as visco-
supplementation. The HA used in these injections is either extracted from chicken combs or
synthesized through bacterial fermentation. The procedure has not been shown to reverse
osteoarthritis or regrow articular cartilage in humans, and may work by decreasing inflammation and
neutralizing pain-producing proteins in the synovial fluid.
A single shot, or a series of weekly injections, is administered in the doctor’s office and can be
repeated every 6-12 months. Unlike cortisone injections that yield diminishing returns with
subsequent injections, HA shots tend to maintain their efficacy and pose no risk to the well-being of
the joint. Despite conflicting results in clinical trials, most orthopedists anecdotally report that 50-
70% of their patients improve with these injections. Potential side effects are minimal, and visco-
supplementation is a safe option for the treatment of knee osteoarthritis.
A number of HA injections are available. Your insurance company may dictate which brand your
doctor uses.
[28,78,88,105,115,162,169,174]
Section 31

PRP INJECTION

The healing power of blood

Platelet-rich plasma, known as PRP, is being used increasingly for the treatment of a wide range of
orthopedic injuries, including osteoarthritis.
Blood is mostly liquid, or plasma, which carries solid elements — red cells, white cells, and
platelets. Platelets are best known for their role in blood clotting, but they also contain over 300
bioactive proteins and growth factors that stimulate tissue growth, repair damaged tissue, decrease
inflammation, and trigger the secretion of a lubricant protein.
Blood is drawn in the doctor’s office and spun down in a centrifuge, separating most of the heavier
solid components (red and white cells) from the lighter platelets and plasma. The platelet-rich plasma
layer is siphoned off and injected into the affected tissue or joint. Since PRP is derived from the
patient’s own blood, safety concerns are minimal.
Several recent studies have shown that PRP injections perform better than HA injections and placebo
for 6 months after treatment. A 2016 randomized controlled study showed good results with a series
of three PRP injections administered one week apart. Twelve months after the injections, patients
scores on a self-reported functional index improved by 78%.
PRP is not currently covered by insurance and the average cost in the United States is between $500-
$1000 per injection. Skepticism regarding real efficacy for the treatment of knee osteoarthritis is
warranted, but if visco-supplementation has failed, and cost is not a concern, PRP may be worth
trying.
[6,22,26,48,54,58,86,108,133,135,136,137,149,163,164]
Section 32

REGENOKINE

Next stop, Düsseldorf

Regenokine (also known as Orthokine) is a biological injection therapy similar to PRP, but with
some significant differences. The procedure was pioneered by German orthopedist Peter Wehling and
molecular biologist Dr. Julio Reinicke in 1998, and continues to be refined. Blood is drawn from the
patient and incubated in specially designed vials. This stimulates the production of interleukin-1
receptor antagonist (IRAP), a protein which limits inflammation. After centrifugation, the cell-free
serum is injected into the joint. A German study found six injections, given one week apart, reduced
pain and increased function. The shots are part of a multifactorial program which includes improving
sleeping habits, diet, and conditioning.
Professional athletes from the NBA, NFL, and MLB, as well as several top golf and tennis pros, have
made the trip to Dr. Wehling’s clinic in Düsseldorf for treatment. Regenokine is not currently
approved by the FDA for use in this country although it is available “off-label” in Los Angeles, New
York, and Miami. It is not covered by insurance and treatment starts at $5,000 but can be as much as
$10,000 based on the number of injections necessary.
[91,178,179,202]
Section 33

ALPHA-2-MACROGLOBULIN

On the frontier

Alpha-2 Macroglobulin, like IRAP, is another naturally occurring protein found in plasma. The
ability to filter out these molecules may lead to an effective natural injection for the treatment of
osteoarthritis. Currently there are no clinical studies in humans to support their efficacy.
Section 34

STEM CELLS: THE SCIENCE

Regenerative medicine

If you are considering stem cell therapy, it will be an out-of-pocket expense, so it is worth your while
to understand the science.
All cells in the human body develop from a common precursor stem cell. Once the job of building the
body is complete, stem cells continue to do maintenance work, repairing and replacing damaged
tissue. Stem cells have several important characteristics, among them the ability to replicate,
transform into another type of human cell, and control other cells by secreting molecular signal
proteins when activated. With age the vitality of your remaining stem cell population declines.
Research in the field of regenerative medicine has increased exponentially as scientists search for
ways to harness the innate healing powers of the body to cure disease, repair damaged tissue, and
even grow new tissue and organs. In theory, access to robust stem cells would allow regrowth of
normal tissue, including articular cartilage. The challenge is to persuade a stem cell, through the use
of chemical signaling and mechanical and environmental stimulation, to become a functional
chondrocyte capable of restoring the complex architecture of healthy articular cartilage.
[5,23,38,81,139,141,155]
Section 35

STEM CELLS: THE PROCEDURE

A work in progress

Stem cells are typically harvested from bone marrow by inserting a large needle-like device into the
pelvis and extracting bone marrow aspirate. The extract is then spun down in a centrifuge to
separate the stem cells, which are then injected into the target tissue or joint. Stem cells can be
isolated from other tissues, including fat (adipose), peripheral blood, and synovial fluid.
Bone marrow can be aspirated without much difficulty or patient discomfort, however, the optimal
site for harvesting stem cells to be used for the treatment of knee osteoarthritis has yet to be
determined. Adipose-derived stem cells are gaining traction due to easy access and lower harvesting
cost.
The FDA restricts the manipulation of stem cells, so doctors in the US cannot alter the cells before
they inject them into your knee. Outside the US, these restrictions do not apply and the cells are
cultured and expanded, a process which allows the number of cells to be greatly increased and
subsequently produces a much higher concentration of stem cells for injection. In the US the
procedure is not covered by insurance and costs at least $5,000, while abroad, with the addition of
cell expansion, it is significantly more expensive.
Early results for the short-term relief of osteoarthritis symptoms are encouraging, but long-term
efficacy and the ability to regrow articular cartilage have not yet been established. Cellular
therapy holds promise and remains under active investigation, but evidence of significant benefit in
humans and a full understanding of associated risks are currently limited.
[5,23,38,81,139,141,155,216]
Section 36

AMNIOTIC MEMBRANE PRODUCTS

The potential for fetal-type healing

The amniotic membrane (AM) is a diaphanous tissue that surrounds the embryo. It is collected from
the placenta of volunteers after childbirth; it would otherwise be disposed of. Donors are carefully
screened for infectious disease and the tissue is sterilized with radiation.
Amniotic membrane-derived products have been used in medicine since 1910, but only recently has
their applicability to the treatment of osteoarthritis been explored. The advantages of amniotic
membrane-derived products are significant. They provide access to stem cells and growth factors
without the need to harvest tissue from the patient, while avoiding ethical concerns associated with
embryonic stem cells. In addition, AM is intrinsically anti-inflammatory and anti-microbial, promotes
scar-free healing, and is invisible to the immune system.
One study investigated the use of a single AM injection for the treatment of osteoarthritis in rats and
found a reduction in cartilage degeneration. However, knee injections in humans remain an off-label
use of amniotic tissue and are expensive. In addition, there is no current clinical data available that
establishes efficacy in the treatment of osteoarthritis.
[150,182]
Section 37

ARTHROSCOPY AND ARTHRITIS

A common misconception

Knee arthroscopy is a common orthopedic procedure that allows the surgeon to look and work
inside the knee joint using a camera and specially designed instruments. After inflating the knee joint
with water, an arthroscope (a pencil-shaped camera with a fiber optic light source) is inserted
through a small incision. Water is pumped continuously through the knee, inflating the knee capsule
like a water balloon and providing a clear field of vision. The video captured by the arthroscope is
viewed on a monitor. A second incision is made to allow the introduction of a working instrument.
Knee arthroscopy is a low-risk outpatient procedure carried out with local anesthesia and IV
sedation.
It is a common misconception that osteoarthritis can be “scraped out” or “cleaned out” with an
arthroscopic procedure. In patients with painful arthritis, there is little to no long-term benefit to
arthroscopy.
In some cases, however, osteoarthritis coexists with other problems which are responsive to
arthroscopy, most notably meniscal tears and loose bodies.
Section 38

MENISCAL TEARS AND ARTHRITIS

The most commonly performed orthopedic procedure

Osteoarthritis and meniscus tears often coexist in older patients as a result of wear and tear. When an
MRI shows arthritis plus a tear, the source of the pain needs to be determined. Your doctor will try to
make that judgement based on the nature of your pain, the severity of your osteoarthritis, and the
characteristics of the tear. If the pain is diffuse and achy, it is more likely due to osteoarthritis.
Conversely, mechanical symptoms, which start suddenly and feel like locking or catching of the knee,
are more likely attributed to a meniscal tear and can be relieved with an arthroscopic partial
meniscectomy (removal of the torn tissue).
The results of partial meniscectomy in the setting of an arthritic knee are often disappointing since the
symptoms of osteoarthritis persist.
Section 39

THE LOOSE BODY

A joint mouse

On occasion, a small piece of articular cartilage or bone, a loose body, will detach and float around
the knee. It is analogous to having a pebble in your shoe. In many cases, the fragment will get stuck in
a recess, or in the back of the knee, and go unnoticed. However, if it works itself into a bad spot, a
loose body (aka a “joint mouse”) can cause intermittent catching, locking, and “giving way” of the
knee.
Symptomatic loose bodies can be removed arthroscopically, but symptoms related to the arthritis will
persist.
Section 40

SUBCHONDROPLASTY

Patients must be carefully selected

Subchondroplasty takes a novel approach to treating osteoarthritis pain, in carefully selected

patients, by targeting painful bone marrow lesions (BML).
Subchondroplasty® (Zimmer Biomet) is a minimally invasive surgery in which a flowable bone
substitute material is injected into the BML.* This filler sets to a solid, providing support to the
damaged bone. It is usually performed in conjunction with arthroscopy. It is an out-patient procedure,
meaning patients go home the same day. After surgery, crutches are used to limit weight bearing to
50% on the operative leg for 1-2 weeks. The procedure is not recommended for patients with BMI
>40 or severe malalignment of the joint.
Subchondroplasty is not a particularly popular procedure, and it remains to be seen whether it will
gain widespread acceptance.

*AccuFill® Bone Substitute Material (BSM), an injectable calcium phosphate (CaP).

Section 41

OSTEOTOMY

Young patients with isolated osteoarthritis

An osteotomy is a surgical procedure in which the bone is cut, alignment is corrected, and fixed with
a plate and screws, shifting pressure away from the overloaded, damaged compartment to the
relatively well-preserved compartment. After surgery, weight bearing is limited for up to 6 weeks
while the bone heals.
The primary goal of an osteotomy is to buy time prior to knee replacement in patients that are too
young (less than 50 years) and active. It may allow younger patients to continue with high demand,
high impact activities.
The procedure is technically challenging and has a relatively high complication rate, somewhere
between 6-14%, and is not appropriate for older or obese patients. For this subset of patients, it has
largely been supplanted by partial knee replacement.
[3]
Section 42

KNEE REPLACEMENT

Definitive treatment

If all else fails, the joint can be resurfaced with a metal and plastic prosthesis, a procedure known as
a knee replacement or arthroplasty.
If the osteoarthritis is limited to one compartment, a partial knee replacement may be an option.
With more extensive involvement, a total knee replacement is the preferred approach.
Section 43

PARTIAL KNEE REPLACEMENT

Single compartment

The benefits of a partial knee replacement over total include preservation of bone, less surgical
exposure, improved range of motion, better kinematics, shorter operating time, less blood loss, lower
infection rate, shorter hospital stay, faster recovery, and lower cost. Patients report that the knee feels
more normal than with a total replacement.
What is the argument agains a partial replacement? Pain due to undetected or mild osteoarthritis in the
other compartments may persist after surgery. Furthermore, partial knee replacement is a technically
challenging procedure, especially in terms of proper implant positioning. Revision rates reported in
the literature are 2.5 to 3 times higher than for total knee replacement.*
Recently, robot-assisted surgery has been found to improve the accuracy of implant positioning in
partial knee replacement, an important variable that affects the long-term survival of the prosthesis.
Robotic assistance is becoming the standard of care in the US and should significantly improve
outcomes. Recent evidence suggest that revision rates are decreasing, especially when the surgery is
performed in high volume centers by high volume surgeons.
Partial knee replacement is worth considering in younger patients (<60) with true uni-compartmental
osteoarthritis, in the hands of an experienced surgeon with robotic assistance.
* A revision is a surgery performed to replace or correct a failed implant.

[43,53,101,172]
Section 44

TOTAL KNEE REPLACEMENT (TKR)

The definitive treatment

Total knee replacement (TKR) is the definitive treatment for knee osteoarthritis – the only “cure”
currently available. The entire joint is resurfaced.
A well done knee replacement can last for over 20 years and provide excellent pain relief and
restoration of function for the vast majority of patients. It is considered a highly cost-effective
medical intervention.
If any of the following variables are suboptimal, so too is the outcome:
surgeon + patient + pain control + physical therapist + X factor (luck) = outcome
[2,42,90,92]
Section 45

TKR: INDICATIONS

Strict indications lead to better outcomes

The decision to undergo knee replacement should be based on a realistic understanding of risks and
benefits. Symptoms, rather than the appearance of an X-ray, should determine the need for surgery.
The inability to carry out activities of daily living without pain is the accepted general criterion
for joint arthroplasty, assuming conservative, non-operative treatment options have been
exhausted.
The indication for knee replacement must be individualized. The risk/benefit ratio for a morbidly
obese, diabetic patient with severe arthritis and deformity is much higher than that for a 55-year-old
male with a BMI of 22.
No real consensus on knee replacement candidacy currently exists in the US, and any appropriateness
criteria would be limited by the multifactorial nature of surgical decision-making. A 2014 study found
only 44% of total knee replacements performed at several sites in the US were clearly appropriate,
while 34% were deemed inappropriate.
Pain relief is considered the best reason for knee replacement, and should be the patient’s primary
expectation.
[153]
Section 46

TKR: EXPECTATIONS

Be realistic

Total knee replacement is regarded as a highly effective surgical procedure that can improve the
quality of life for patients with serious osteoarthritis of the knee. The most common expectations for
patients undergoing TKR are pain relief, improved ability to walk, and return to sport.
Establishing realistic expectations before surgery is critical to ultimate patient satisfaction after
TKR. Full recovery may take up to two years in some patients. The prosthesis will not necessarily
restore the feel and function of a healthy, natural knee (about two-thirds of TKR patients report that
their knees feel normal after surgery). Recent studies have shown that 20-40% of patients who
underwent well-performed total knee replacement were dissatisfied with the procedure or had
persistent pain. Another recent study reported a 10% prevalence of chronic pain after TKR. Pain
relief after surgery is expected, but can be slow and inconsistent.
Unrealistic expectations of rapid recovery with a return to a high level of function is becoming an
important issue as the demographic for knee replacement shifts younger. Almost half of patients
undergoing knee replacement in one study expected to be able to perform activities like dance or golf
after surgery, but only 14% met these goals at five years after surgery. The highest rate of
dissatisfaction, as recorded by patients’ self-reported outcomes, seems to be in patients less than 55
years of age, whose expectations of returning to strenuous activities were not met. A return to low
impact activities, such as bowling, golf, and biking is expected, but high-impact sport participation is
discouraged.
A good-to-excellent result after TKR has less to do with range of motion, complete pain relief, and
perfect x-rays, and more to do with met expectations. Managing these expectations before surgery is
an under-appreciated aspect of achieving good outcomes. Psychological health is another important,
and often neglected, predictor of satisfaction and function after surgery. Depression has been found to
be a strong predictor of persistent pain after knee replacement and disappointing improvement in
function.
[35,75,124,157]
Section 47

TKR: EXPECTATIONS FOR WEIGHT LOSS

Unlikely

Many overweight patients with exercise-limiting pain plan on losing weight after knee replacement,
when they can exercise pain-free. A 2013 study found just the opposite. Patients who had a knee
replacement were at increased risk for clinically significant 5-year post-operative weight gain,
especially if they were less than 70 years of age, or intentionally lost a substantial amount of weight
prior to surgery.
Most patients do not lose weight after a hip or knee replacement.
[74,152,154]
Section 48

TKR: COMPLICATIONS

Big surgery, potentially big complications

Complications can happen to anyone – even the healthiest patient in the hands of the best surgeon.
Whenever possible, modifiable risk factors should be minimized.
Obesity, and the medical conditions linked to it (especially diabetes), has a negative influence on
outcomes after total knee replacement. Excess fat makes exposure more difficult and leads to longer
operative time. Morbid obesity seems to be particularly associated with an increased risk of
superficial wound infection after surgery. Percent body fat has been found to be a better predictor of
outcomes after total knee replacement than BMI.
Albumin is produced by the liver and is an important gauge of nutritional status. Malnutrition is
defined as an albumin level < 3.5 g/dL and is an even stronger predictor of serious complications,
especially wound problems, than obesity.* Low albumin levels have been linked to higher mortality
levels and other major complications.
Smoking is probably the single most important risk factor for complications after total knee
replacement. Cutting back or quitting prior to surgery can significantly decrease risk. Each week of
smoking cessation prior to surgery lessens the risk by close to 20%.
Studies have shown that patients who have a cortisone injection before a knee replacement have a
higher likelihood of infection after surgery. The closer the injection is to the surgery, the higher the
risk. An interval of 6 months eliminated the risk.
Early discharge from the hospital, from 0-2 days after surgery, is not associated with increased risk
of major complications following TKA, as compared to standard discharge at 3-4 days.
*Malnutrition and obesity often coexist in the same patient.
[12,34,44,52,59,76,84,98,110,121,168,175,191]
Chapter 5

10 QUESTIONS: TOTAL KNEE REPLACEMENT

Section 1

DO I NEED A KNEE REPLACEMENT?

Medicare beneficiaries make up about 60% of the total knee replacement (TKR) population. Between
1991 and 2010, the number of Medicare patients undergoing TKR increased by 160%, while the per
capita utilization doubled from 31 procedures per 10,000 patients to 62. The rapid increase in the
number of procedures being performed is, in large measure, a reflection of the success of total knee
replacement in improving health-related quality of life and functional status. If most patients weren’t
happy with their results, word would get around.
This rapid growth has led some to ask whether TKR is over-utilized – are some procedures
unnecessary? Determining appropriateness is difficult since guidelines for surgery are somewhat
subjective.
Symptoms, rather than the appearance of an X-ray, should determine the need for surgery. If you
have severe functional limitations and cannot carry out activities of daily living without pain, and
have failed conservative, non-operative management, you are a candidate. A desire to return to
sport is not a good reason to have a knee replacement.
[67]
Section 2

AM I TOO OLD OR TOO YOUNG?

As knee replacement techniques and outcomes have improved, the indications for the surgery have
expanded to include younger, active patients as well as the elderly and frail. In particular, the last
decade has seen a disproportionate growth in the rate of total knee replacement in “middle-aged”
patients, those between the ages of 45-64. This trend is likely to continue. The average age of a knee
replacement patient between 2000-2010 was 66 years.
The perception that a younger group of TKR candidates consists mostly of aging weekend warriors is
inaccurate. In fact, they are more likely to be heavier and have more medical issues. A recent analysis
found that 55% of patients 65 and younger having knee replacement were obese (with an average
BMI of 33), as opposed to 43% of those older than 65.
The surge in the elderly population is leading to an increased demand for knee replacement. Although
the risk of complication is higher in patients over the age of 80, outcomes and pain relief are
comparable to younger patients. Many patients in their eighties remain healthy and fit enough to
undergo the procedure, recover, and benefit from enhanced mobility.
Knee replacements generally last 15-20 years, but this range can vary considerably as a consequence
of patient characteristics like weight and activity level. About 90% of replacements last 10 years,
85% last 20 years. For younger candidates, implant survivorship should be a factor in decision
making.
The upper age limit for knee replacement is a function of physiologic age rather than
chronological age alone. Age less than 55 could be considered a relative contraindication to TKR.
In young patients who are fitter and have high functional demand, satisfaction scores tend to be lower
after TKR, most likely because the operation did not meet their expectation of return to their preferred
activities.
[21,31,39,113,183,197]
Section 3

DOES VOLUME MATTER?

Several studies have demonstrated that surgeons and hospitals that perform a larger number of hip and
knee replacements have lower complication rates, lower re-operation rates, shorter hospital stays, a
higher likelihood of being discharged directly home, and better overall outcomes.
Although there is no formal criteria for low vs. high volume hospitals, the parameters in the chart
above were used in a recent review in which outcomes were used to determine risk thresholds. It is
important to note that an analysis of patients at different hospitals would likely yield slightly different
numbers, but this chart is instructive as a general guide.
The concept that “busier is better” should inform your choice of surgeon and center, and supports
increased physician and hospital specialization.
[20,97,193]
Section 4

DOES KNEE REPLACEMENT REQUIRE A HOSPITAL STAY?

“Outpatient surgery” in the context of total knee replacement is typically a 23-hour stay in a hospital
outpatient center or private outpatient surgical facility. A 23-hour stay allows the patient to stay
overnight until the next morning. As recently as a few years ago, this concept was considered
irresponsible and unsafe. But economic forces, together with improved pain management and
decreased blood loss during surgery, are redefining recovery protocol and making outpatient, 23-
hour-stay more and more common.
For most patients, outpatient total knee replacement is not an option – medical considerations dictate
that the surgery be performed in a traditional hospital setting. Furthermore, Medicare does not
currently reimburse for outpatient joint replacement and requires that TKR be performed as an
inpatient procedure, which automatically disqualifies most patients age 65 and above. The good news
is that inpatient hospital stays are becoming dramatically shorter, with discharge typically in 1-2 days
directly to home. (Under new Medicare rules and bundled payment plans, hospitals are incentivized
to discharge patients home, with home health care if necessary, rather than to inpatient rehabilitation
or skilled nursing facilities.)
For select, carefully screened patients, however, outpatient TKR is an option, and an increasingly
popular one. In well-designed settings and in the hands of good surgeons, it is safe, effective, and
cost-efficient.
Patient and caregiver education are important prerequisites to successful outpatient TKR. Many of the
problems and questions easily addressed by a nurse in a hospital setting provoke anxiety when the
patient is home, so a high-quality home health agency is an essential component of an outpatient
program.
[8,114,191,217]
Section 5

SHOULD A ROBOT DO MY SURGERY?

Partial knee replacement, yes. Total, not necessarily.

Robotic-assisted partial knee replacement has demonstrated improved accuracy with respect to
implant positioning as compared to the conventional surgical technique. The role of the “robot” is to
ensure proper placement of the prosthesis, which can be more difficult in partial replacement than
total.
Robotic systems for total knee replacement have been cleared for use by the FDA and will be widely
available to surgeons by 2017. Robot-assist will likely become the standard of care for both partial
and total knee replacements in the near future. Set up for the robot adds operative time, however, and
in the hands of experienced surgeons performing total knee replacement, may not add value.
A number of “improvements” to the standard knee replacement are advertised by doctors and
hospitals, which include gender and patient-specific prostheses, as well as improved biomaterials.
These enhancements add cost and have not demonstrated better outcomes.
[11,199]
Section 6

WHAT IS A KNEE REPLACEMENT MADE OF?

The hot and highly oxygenated human body is not a particularly hospitable environment for a metallic
implant. Metal placed in a biological system undergoes electrochemical oxidation, or corrosion.
Orthopedic implants are manufactured and treated in a number of ways to minimize this problem.
Most orthopedic implants are stainless steel, cobalt-chrome alloys, or titanium. The metallic
components of a knee replacement are usually made of cobalt-chrome. In addition, there are two
plastic pieces – an insert which sits between the femur and the tibia, and a button which is cemented
into the patella. The plastic, ultra-high molecular weight polyethylene, is engineered to resist wear.
Over 10 years ago, a novel bearing surface, Oxinium, was developed to better resist scratching and
decrease friction. Results of a five-year comparison with cobalt-chrome knee implants showed no
significant difference in clinical outcomes. Oxinium implants are more expensive than cobalt-
chromium, so the additional cost is best justified in patients with metal sensitivity.
[63,64,73,94]
Section 7

WHAT IS THE COST OF A KNEE REPLACEMENT?

The total cost of a joint replacement includes the following variables: surgeon’s fee, hospital and
operating room fee, prosthesis cost, and physical therapy and home health agency expense.
Surveys have shown that patients estimate their surgeon’s fee for a total knee replacement at about
$12,000. On average, insurance pays your surgeon much less than that – $1,300 for a total knee
replacement including 90 days of follow-up (hospital and office visits) after surgery. As an example,
in Connecticut, Medicaid’s surgeon reimbursement is $900 and Medicare pays approximately $1500.
Cost can vary tremendously by hospital or by region. In 2015, the average facility cost for a TKR in
64 markets was $31,000. Extreme variation was observed between, and within, markets. In Dallas,
the range was $16,000 - $61,000. The highest average cost in a market was in New York City at over
$60,000, while the lowest was in the Montgomery, Alabama, market.
[16,30,50,132,185]
Section 8

SHOULD I HAVE BOTH KNEES DONE AT ONCE?

Probably not.
Replacing both knees at the same time, bilateral knee replacement, is usually performed by one
surgeon who does one knee, then turns his attention to the next while an assistant closes the first
incision. Bilateral knee replacement accounts for about 5% of TKRs performed annually in the United
States.
Many orthopedists will not offer bilateral surgery to any of their patients. Quite simply, the risk of a
complication, including death, after bilateral knee replacement is greater than having the procedures
staged at least 3 months apart. This is especially true for patients age 70 and over or with other
medical conditions. Having the second procedure within the following week, an accelerated staged
approach, is associated with the same risks as bilateral surgery.
A bilateral knee replacement is cost-effective, estimated at about $43,000 vs. $72,000 for two
separate, staged procedures. Those opting to have both knees done in the same sitting should be
healthy, fit, and less than 75 years old.
[95,106,128,129]
Section 9

WHAT IS THE PREFERRED METHOD OF ANESTHESIA AND

PAIN MANGEMENT?

Failure to adequately control pain after total knee replacement increases the risk of complications and
decreases long-term patient satisfaction. The current approach is multimodal, combining distinct
methods of anesthesia to better control postoperative pain. The goal of multimodal anesthesia is to
minimize or even eliminate the use, and subsequent side effects, of opioids by blocking pain at
different levels of the sensory pathway.
Multimodal protocols begin with preemptive oral pain medication, which is given 1-2 hours before
surgery. The goal is to prevent the body from releasing pain producing molecules in response to the
stimulus of surgery.
An injection of spinal and/or epidural anesthetic is administered around the spinal cord, numbing the
legs. Either is preferable to general anesthesia, which has a higher complication rate.
Peripheral nerve blocks selectively numb nerves that supply sensation to the knee. The most
commonly used are femoral nerve blocks and adductor canal blocks. Femoral nerve blocks
transiently weaken the quadriceps muscle, which can lead to buckling of the knee, and increase the
risk of falls in the immediate post-operative period. Adductor canal blocks are more selectively
sensory with less quadriceps weakening, and are therefore increasing in popularity over femoral
blocks.
Periarticular injection is a new approach in which a long-lasting anesthetic is injected during the
procedure in the tissue around the surgical site. Exparel is a local analgesic packaged in a lipid foam
that slowly dissolves, providing a sustained release over 2-3 days. Studies have shown decreased
narcotic use after knee replacement with Exparel injection, without any increase in adverse events.
[99,119,201]
Section 10

WHAT IS IT LIKE TO LIVE WITH A TKR?

Patients’ preoperative expectations, as well as their physical and mental health, are important
components of patient satisfaction, an outcome measure increasingly cited as a measure of healthcare
quality and value.
Total knee replacement can provide pain relief and improve quality of life. Recovery can be slow,
inconsistent, and unpredictable. Functional levels often do not return to pre-arthritic levels or those of
age-matched controls. About two-thirds of patients report that their knees feel somewhat normal after
full recovery, but a significant number do not achieve their desired levels of function. Kneeling,
squatting, and negotiating stairs can be problematic even a year after surgery in over half of patients
with well-functioning TKRs.
After knee replacement, return to sports is limited to low-impact, low-demand activities. In fit and
healthy patients, return can be as soon as three months after surgery, although the range is wide.
Return to driving is typically allowed once quadriceps control has been re-established and pain
medications discontinued. Braking time returns to preoperative levels after about 6 weeks, on
average.
At airports with traditional walk-through metal detectors, hip and knee replacements will be detected
approximately 90% of the time, requiring additional screening and pat down. With body scanners,
artificial joints are easily detected, requiring only a limited, local pat down. A doctor’s letter or card
is of no use.
[82,103,142,144]
Chapter 6

COPYRIGHT
COPYRIGHT

© 2017, J. Albert Diaz MD

All rights reserved. This book, or any portion thereof, may not be reproduced or used in any
manner whatsoever without the express written permission of the publisher, except for the use of
brief quotations in a book review.

For information, email albertdiazmd@gmail.com

Published by J. Albert Diaz, MD., Figures & Tables by J. Albert Diaz, MD

This book is intended to supplement the treatment advice of your physician whom you should
consult regarding your individual medical condition. Each case is unique, and management
decisions should be personalized.
Chapter 7

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