Which alternatives to knee replacement deserve a fair try?

What can you change this week?

Cut back any motion that brings a sharp flare, while keeping some easy movement. A shorter walk, a rail on stairs or a cane can lower the load, so you can keep moving without turning a mild ache into a rough evening at home.

One hard session isn't as useful as steady strength work. When extra weight strains the knee, slow weight loss may help.

Which medical choices may ease soreness?

Anti-inflammatory gel isn't taken by mouth, since you rub it on the skin to calm swelling and soreness. Pills may help too, but your kidney, stomach and heart concerns can make them a poor fit.

QC Kinetix provides regenerative choices, including platelet-rich plasma, or PRP, prepared from a small sample of your blood that the clinic spins before its medical providers use the liquid in your joint. There, medical providers are the staff members who examine you and give care.

We don't know as much about relief from PRP and gel as we do about exercise or brief cortisone relief. Before paying, ask about likely relief, cost and how long you'll wait to judge it.

When does replacement become reasonable?

Replacement deserves a talk when lost movement and aching rule the day despite a solid try at other care. It isn't a failure to reach that point.

More delay isn't always safer or wiser. Once your exam, X-ray and daily limits all support surgery, another short-lived treatment may only put off the same hard choice.

What should the next visit settle?

Bring the daily activity you miss most and say what makes it stop. Tell the doctor which care helped, which failed and how long each try lasted.

Then ask what the next choice is meant to change. The reply needs to be plain, including what comes next if your soreness stays.

Sources

1. OARSI 2019 designates arthritis education plus structured land-based exercise (with or without dietary weight management) as CORE treatments for knee OA, and education plus structured land-based exercise as core for hip and polyarticular OA. Topical NSAIDs are strongly recommended for knee OA (Level 1A). Intra-articular corticosteroids and hyaluronic acid are Level 1B/2 for knee OA depending on comorbidity and are NOT recommended for hip or polyarticular OA. Oral NSAIDs are not recommended for people with cardiovascular comorbidity or frailty, and oral and transdermal opioids are strongly not recommended (Level 5).

   Bannuru RR, Osani MC, Vaysbrot EE, et al. — OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis.. Osteoarthritis and Cartilage, 2019. DOI: 10.1016/j.joca.2019.06.011.

2. The 2019 ACR/Arthritis Foundation guideline makes STRONG recommendations for exercise, weight loss in people with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, tibiofemoral bracing for tibiofemoral knee OA, topical NSAIDs for knee OA, oral NSAIDs, and intra-articular glucocorticoid injections for knee OA. Radiofrequency ablation for knee OA, acupuncture, thermal modalities, acetaminophen, duloxetine and tramadol are only CONDITIONAL recommendations.

   Kolasinski SL, Neogi T, Hochberg MC, et al. — 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.. Arthritis & Rheumatology, 2020. DOI: 10.1002/art.41142.

3. At 2 years across two parallel randomised trials (200 patients, mean age 66), total knee replacement plus non-surgical treatment beat non-surgical treatment alone by 18.3 KOOS points (95% CI 11.3 to 25.3), and non-surgical treatment in turn beat written advice by 7.0 points (95% CI 0.4 to 13.5). Among patients eligible for replacement, 16 of 50 (32%) in the non-surgical group had surgery within 2 years - meaning two out of three delayed it for at least two years.

   Skou ST, Roos EM, Laursen MB, et al. — Total knee replacement and non-surgical treatment of knee osteoarthritis: 2-year outcome from two parallel randomized controlled trials.. Osteoarthritis and Cartilage, 2018. DOI: 10.1016/j.joca.2018.04.014.

4. In the only randomised controlled trial to compare total knee replacement directly with non-surgical treatment in patients already eligible for surgery (n=100), the replacement group improved more at 12 months than the non-surgical group (KOOS4 32.5 vs 16.0; adjusted mean difference 15.8, 95% CI 10.0 to 21.5) but had four times the serious adverse events (24 vs 6, P=0.005). Only 13 of 50 patients (26%) assigned to non-surgical treatment alone had undergone knee replacement by 12 months.

   Skou ST, Roos EM, Laursen MB, et al. — A Randomized, Controlled Trial of Total Knee Replacement.. New England Journal of Medicine, 2015. DOI: 10.1056/NEJMoa1505467.

5. The Cochrane review of topical NSAIDs for chronic musculoskeletal pain in adults evaluated randomised, double-blind, placebo- or active-controlled trials meeting stringent quality criteria, searched to February 2016, and is the evidence base underlying the guideline preference for topical over oral NSAIDs in knee osteoarthritis.

   Derry S, Conaghan P, Da Silva JA, et al. — Topical NSAIDs for chronic musculoskeletal pain in adults.. Cochrane Database of Systematic Reviews, 2016. DOI: 10.1002/14651858.CD007400.pub3.

6. The Lancet's osteoarthritis Seminar states that the diagnosis of osteoarthritis is clinically based despite the widespread OVERUSE of imaging methods, that management should be tailored to the individual and focus on core treatments including self-management and education, exercise and weight loss as relevant, and that surgery should be reserved for those who have not responded appropriately to less invasive methods.

   Hunter DJ, Bierma-Zeinstra S. — Osteoarthritis.. The Lancet, 2019. DOI: 10.1016/S0140-6736(19)30417-9.