So you think you need knee replacement surgery?

Joint replacement, or ‘arthroplasty’ as doctors term it, is justifiably regarded as miracle surgery. Like hip replacement surgery, medicine offers knee replacement surgery as the inevitable next step when pain and immobility become too great. According to a study presented at the American Academy of Orthopedic Surgeons in 2006, knee replacement has become so commonplace and popular that the number of annual surgeries is expected to rise by 673 per cent over the next 20 years.

In the operation, the surgeon removes damaged cartilage (the soft tissue lining of the joint) plus a small amount of bone. An artificial joint made of metal and polyethylene is then cemented into place. A patient with no complications usually spends around five days in the hospital and a month recuperating at home, returning to normal activity over the course of two to three months.

The medical research paints a glowing picture of knee replacement, claiming that 95 per cent of knee operations using cement are successful – that is, with no complications – for at least a decade. According to a review by Indiana University School of Medicine of 130 studies, 89 per cent of knee replacements have a good outcome over an average follow-up period of more than four years, and the majority of knee replacements remain functional for at least 10 years.1

But this sterling track record refers simply to the knee replacements that ‘take,’ and omits all the problems that could arise. Here’s what you should think about before you have your knee replaced.

You may not need it. Perhaps dazzled by the success rate of this cutting-edge technology, doctors are too quick to replace knees. As a recent study discovered, approximately one-third of knee replacements in arthritis sufferers shouldn’t have happened in the first place. Only 44 per cent of procedures are fully justified, say researchers from the Virginia Commonwealth University in the US, after analyzing 205 cases of total knee replacements.2

In fact, the need for such surgery was “inconclusive” in a further 22 per cent of cases and “inappropriate” in 34 per cent, which suggests that more than half of all total knee replacement procedures are dubious.2 As approximately 600,000 knee replacements are done in the US alone every year, more than 200,000 could be unnecessary if these findings are to be believed.

Serious complications are more frequent than reported. The Indiana University review came up with an overall mean complication rate of 18 per cent among the studies that reported on complications, including superficial and deep infections, pulmonary embolism (a blockage in a vein in the lung), deep venous thrombosis (blood clot in a vein) and nerve damage to a limb.

The operation may be associated with a risk of death. The Indiana researchers also noted a mean mortality rate of 1.5 per cent per year. Of nearly 10,000 patients enrolled in all the studies they reviewed, this translates to 148 deaths each year of the four years of follow-up, or nearly 600 deaths in total.

Unless you’re very old, the knee will wear out. In the Indiana study, nearly one in 25 – more than 375 people – had to undergo knee operation ‘revisions’, which meant having the artificial knee replaced with a new knee joint. This occurred after less than four years in those affected.

In fact, an artificial knee will only last about a decade before wearing out, at which point, you’ll have to replace the replacement – a much more formidable operation, with far more bone loss, removal of scar tissue and a considerably poorer success rate. So if you’re under age 60, you’ll face having to undergo several more ‘revisions’ in your lifetime.

Artificial knees often come loose. A Finnish survey of 33 studies discovered that joint loosening was the main reason for revision and also its main complication. Another common problem they found was bacterial infection.3

If a second knee joint doesn’t take, there aren’t many other options. “Procedures for repeat surgery following the failure of a reimplanted joint have so far yielded doubtful results,” say Czech researchers.4

You also face other potential complications. There are (admittedly small) risks of other nerve or artery injury, permanent foot injury or – the worst-case scenario – loss of the limb. Complications can mean the patient is in hospital for a longer period of time and may even be subject to repeated operations.

The technology behind artificial knees still needs further improvement. Since the 1980s, there have been attempts to fix knee implants biologically to bone via little metal beads or a mesh. But these ‘uncemented porous-coated’ knee replacements have yet to prove as successful as cemented joints. In one study, out of 96 patients undergoing 108 replacements, about a fifth had failed owing to problems with the lower leg component. After seven years, more than half of these replacements were recommended for revision.5

Other complications include blood loss, which is significantly higher in cement-free knees, the beads coming loose and the tibia (shinbone) knee component being more likely to subside, so leading to loosening.6

But a few scientists have reported fewer problems with the latest technology using cementless ‘porous tantalum’, a new biomaterial mimicking natural bone used to address the problem of subsidence
and loosening.7

Nevertheless, when the Cochane Collaboration carried out one of the few pooled analyses of studies comparing cemented, cementless and ‘hybrid’ knees (using a prosthesis combining the two types), they found that, while both the cemented and cement-free varieties loosened and slipped out of place within two years, the cemented versions were actually at greater risk of this happening.8

The knee will never be as good as new. While such an operation may (or, equally, may not) end chronic pain and enable you to move ‘normally’, doctors recognize that nothing artificial can match the versatility of a human joint. This suggests that anyone suffering from the debilitating pain of arthritis (whether rheumatoid or osteoarthritis) should consider knee replacement only after non-surgical approaches have failed.

The bottom line is this: surgery can help elderly people regain mobility when there’s no other alternative to a wheelchair.

But for everyone else, it makes sense to do everything possible to avoid going under the knife because, in so many instances, surgery is no better than a placebo.

Healing thoughts

Consider the work of Dr Bruce Moseley, a specialist in orthopaedics at Baylor College of Medicine in Houston, Texas, who divided 180 patients with severe osteoarthritis of the knee into three test groups.

One group underwent arthroscopic debridement, where damaged tissue was trimmed and smoothed, and the debris washed away through a tiny tube inserted into the joint. The second group underwent just the lavage, while the third group was given a sham operation: patients were surgically prepared, placed under anaesthesia and wheeled into the operating room; incisions were made in their knees, but no actual procedure was carried out.

Over the next two years, with none of the patients knowing who’d received the genuine procedures and who’d received the sham treatment, all three groups reported moderate improvements in pain and function. In fact, the placebo group reported better results than some of those who’d received the actual treatment.

The mental expectation of healing was enough to marshal the body’s healing mechanisms. The intention, brought about by the expectation of a successful operation, produced the physical improvement, not the surgery.9

What to do instead

Modify your diet, and identify any hidden allergies or parasites. Increasingly, connections are now being made between the state of your gut and the
amount of inflammation in your joints.

Consider stem-cell therapy. In this increasingly popular procedure, a patient’s stem cells are extracted, cultured and then reinjected into the damaged knee.

Opt for a procedure that uses mesenchymal stem cells (MSCs), says Dr Chris Centeno of the Centeno Schultz Clinic, which pioneered the procedure. MSCs are considered superior because they are already partially committed to becoming bone, muscle, ligament or tendon; they are also easily harvested from bone marrow and reproduce rapidly, making them ideal candidates for repairing those very structures. There’s also evidence they may protect against inflammation-related tissue damage and might be able to modulate autoimmune responses too.1

Don’t ignore the power of glucosamine/chondroitin. Glucosamine, the major building block of proteoglycans, is the large molecule in cartilage that makes it elastic and protective, maintaining joint lubrication and flexibility by trapping water in the cartilage matrix. Chondroitin, an even larger cartilage molecule, helps to maintain joint fluidity, while slowing cartilage damage and helping to repair it.

According to a review of 54 trials involving nearly 16,500 patients, glucosamine and chondroitin, either alone or together, significantly improved joint function and markedly increased the narrowed knee joint space characteristic of osteoarthritis.2 Chondroitin can also reduce cartilage loss.3

Consider acupuncture for pain relief. When Danish doctors looked at acupuncture patients who were scheduled for surgery because of severe knee osteoarthritis, they discovered that, even in the most advanced cases, monthly acupuncture relieved as much as 80 per cent of the pain – and significantly increased knee movement too.4

This effect may even be magnified when acupuncture is combined with bee venom to deliver venom compounds directly into an acupoint. Four weeks of bee venom acupuncture has proved more effective at relieving pain than traditional needle acupuncture in patients with osteoarthritis of the knee.5

Try supplementing with hydrolyzed collagen and MSM. In lab studies, collagen hydrolysate was found to stimulate the synthesis of collagen in cartilage tissue,6 while a a study of osteoarthritis sufferers found that 3 g twice daily of methylsulphonylmethane (MSM) improved pain
and function over the 12-week trial.7

Investigate electromagnetic therapies. Pulsed electromagnetic field (PEMF) generators are particularly promising for patients suffering from chronic pain. PEMF generators – which include wearable devices designed for virtually continuous use as well as high-powered machines meant to be used several times a day – can help osteoarthritis sufferers.8 PEMFs have well-documented physiological effects, including increasing levels of glycosaminoglycans, a main component of connective tissue, and reducing inflammation.9

Cranial electrotherapy stimulation (CES) is also promising for chronic pain conditions. It’s thought to bring about changes in certain brain chemicals, including serotonin and norepinephrine, resulting in positive effects on pain. Certain types of CES can smooth out brain patterns, levelling out the peaks usually seen in pain patients.10

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