This article discusses treatments for conservative non-surgical knee osteoarthritis that do not work or are in fact detrimental and accelerate the need for knee replacement.
Knee Osteoarthritis Conservative Care Option Problems
With predictions for millions of knee replacements annually on the horizon, researchers are coming to terms with the general failure of conservative, non-surgical treatments to provide a long-lasting alternative to surgery. Further, these conservative treatments are more thought of as “delaying” tactics.
Doctors at the Rostock Medical University in Germany wrote: “In an effort to delay major surgery, patients with knee osteoarthritis are offered a variety of nonsurgical modalities, such as weight loss, exercise, physiotherapy, bracing, orthoses (custom-designed external devices), nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular viscosupplementation or corticosteroid injection. In general, the goals of these therapeutic options are to decrease pain and improve function. Some of these modalities may also have a disease-modifying effect by altering the mechanical environment of the knee. Chondroprotective substances, such as glucosamine, chondroitin sulphate and hyaluronic acid are safe and provide short-term symptomatic relief while the therapeutic effects remain uncertain.”(1)
Doctors at the Department of Physical Medicine and Rehabilitation, Rehabilitation Institute of Chicago published research suggesting that cortisone and hyaluronic acid provided only short-term relief. They found cortisone decreased pain and symptoms associated with osteoarthritis for up to 3 week and hyaluronic acid was most beneficial between 5 and 13 week after treatment.(2) More on this below.
Conservative care failure – NSAIDs
In an article from Ross Hauser MD’s article When NSAIDs make pain worse, Dr. Hauser writes:
At the Veteran’s Affairs of the Connecticut Healthcare System and Yale School of Medicine, a study is underway. The study is titled:
Discontinuing a non-steroidal anti-inflammatory drug (NSAID) in patients with knee osteoarthritis : Design and protocol of a placebo-controlled, noninferiority, randomized withdrawal trial.(3)
The hypothesis of this study, that is what the researchers are confident they will find is that a placebo will be just as effective as meloxicam, a commonly prescribed anti-inflammatory medication.
If the researchers can show this, then they can show, NSAIDs do not offer benefit and the need and way to getting patients to stop using NSAIDs must be explored.
This is from the study: “Knee osteoarthritis is the most common cause of knee pain in older adults. Despite the limited data supporting their use, non-steroidal anti-inflammatory drugs (NSAID) are among the most commonly prescribed medications for knee osteoarthritis.” The use of NSAIDs for knee pain warrants careful examination because of toxicity associated with this class of medications. . .This study is the first clinical trial to date examining the effects of withdrawing an NSAID for osteoarthritis knee pain. If successful, this trial will provide evidence against the continued use of NSAIDs in patients with osteoarthritis knee pain.”
In 2010, Dr. Hauser wrote in the Journal of Prolotherapy: Further, research suggests that the use of this nonsteroidal anti-inflammatory accelerates articular cartilage breakdown in osteoarthritis, and that, “Use of this product poses a significant risk in accelerating osteoarthritis joint breakdown. Anyone using this product for the pain of osteoarthritis should be under a doctor’s care and the use of this product should be with the very lowest dosage and for the shortest duration of time.”4
Corticosteroid causes more damage to the knee
Patients who had an injection of a corticosteroid every three months for two years, had significantly greater cartilage volume loss and no significant difference in knee pain compared to patients who received a placebo injection, according to a study published in the Journal of the American Medical Association, JAMA.
Timothy E. McAlindon, D.M., M.P.H., of Tufts Medical Center, Boston, and colleagues randomly assigned 140 patients with symptomatic knee osteoarthritis with features of synovitis to injections in the joint with the corticosteroid triamcinolone (n = 70) or saline (n = 70) every 12 weeks for two years. The researchers found that injections with triamcinolone resulted in significantly greater cartilage volume loss than did saline and no significant difference on measures of pain. The saline group had three treatment-related adverse events compared with five in the triamcinolone group.
“These findings do not support this treatment for patients with symptomatic knee osteoarthritis,” the authors write.(5)
Conservative care failure – hyaluronic acid (viscosupplementation)
Lisa A. Mandl, MD, MPH, Assistant Professor of Research Medicine and Public Health and Elena Losina, PhD, Professor of Orthopedic Surgery from Harvard Medical School wrote a fascinating article on knee osteoarthritis injections in the Annals of internal medicine. In their researsearch they suggest:
- “In patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events.”(6)
Once you decide on Hyaluronic Acid Injections, you have decided on knee replacement:
- A study from the University of California Los Angeles (UCLA) agrees with the current beliefs that Hyaluronic Acid Injections are a treatment best used to help delay inevitable total knee replacement.(7)
- In contradiction is a study which suggests that Hyaluronic Acid Injections that delay inevitable knee replacement are a waste of time, money, and resources. Some patients should proceed directly to the knee replacement. The research from the journal American Health and Drug Benefits suggest that patients over the age of 70 should proceed to total knee replacement as opposed to intra-articular injections of steroids or hyaluronic acid to save on national health care costs.(8)
In the first study from UCLA on the benefits of delaying surgery with Hyaluronic Acid Injections doctors found:
- Patients who did not receive Hyaluronic Acid Injections went on to knee replacement by 114 days post-diagnosis of knee osteoarthritis
- Patients who only had one course of Hyaluronic Acid Injections, the mean time to Knee Replacement was 1.4 years – a delay of about 1 year
- Patients who received more than 5 courses of Hyaluronic Acid Injections courses delayed Knee Replacement by 3.6 years.
Overuse of failed treatments lead to staggering costs and knee replacement
In the year prior to total knee replacement surgery, almost one-third of the costs for treatment of arthritis symptoms went toward strategies not recommended by the American Academy of Orthopaedic Surgeons (AAOS), according to research presented at the 2017 AAOS Annual Meeting (March 14, 2017). Costs could decrease by an estimated 30 percent if treatments that are not recommended are no longer utilized.
“As we transition to an era of value based health care, it will be important to consider both the quality of our interventions as well as the cost associated with that care,” said study author Nicholas Bedard, MD, an orthopaedic surgeon at the University of Iowa Hospitals & Clinics.
Researchers reviewed Humana Inc. insurance information (both private and Medicare Advantage plans) from 2007 through 2015 on more than 86,000 patients diagnosed with osteoarthritis of the knee, who went on to have total knee replacement within one year.
The costs were specifically related to reimbursement for hyaluronic acid or corticosteroid injections, physical therapy (PT), braces and wedge insoles, pain medication and non-steroidal anti-inflammatory drugs (NSAIDs). Only three of these treatments—physical therapy, NSAIDs, and the drug tramadol (short-term for severe pain)—are recommended in the AAOS clinical practice guideline (CPG): “Non-arthroplasty Treatment of Osteoarthritis of the Knee.” Please refer to this article on Prolotherapy.org Why patients do not seek medical care for painful osteoarthritis.
The top three most costly treatments were HA injections, CS injections and PT, accounting for 52.6 percent of expenses (excluding hospital or inpatient), total costs of knee osteoarthritis in the year prior to total knee replacement.
The AAOS recommended treatments—PT, NSAIDs and Tramadol—represented just 11 percent of the total costs; in contrast, 29 percent of the costs were for interventions with strong or moderate recommendations against their use in the AAOS knee CPG.
“We hope that research such as this highlights the high prevalence of low-value interventions in the management of knee osteoarthritis and helps to motivate a transition to higher value care,” said Dr. Bedard.
In an article on this site: Patients not informed of non-surgical knee replacement options, Prolotherapy injections are discussed. Prolotherapy is a rarely discussed option with patients despite many research papers from leading medical universities and hospitals. You can read research on the use of Prolotherapy for knee osteoarthritis.
Questions about Knee osteoarthritis treatments?
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3 Goulet JL, Buta E, Brennan M, Heapy A, Fraenkel L. Discontinuing a non-steroidal anti-inflammatory drug (NSAID) in patients with knee osteoarthritis: Design and protocol of a placebo-controlled, noninferiority, randomized withdrawal trial. Contemporary clinical trials. 2018 Feb 28;65:1-7. [Google Scholar]
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6 Mandl LA, Losina E. Relative Efficacy of Knee OA Treatments: Are All Placebos Born Equal? Annals of internal medicine. 2015;162(1):71-72. [Pubmed]
7. Altman R, Lim S, Steen RG, Dasa V. Hyaluronic Acid Injections Are Associated with Delay of Total Knee Replacement Surgery in Patients with Knee Osteoarthritis: Evidence from a Large U.S. Health Claims Database. PLoS One. 2015 Dec 22;10(12):e0145776. doi: 10.1371/journal.pone.0145776. eCollection 2015.[Google Scholar]
8. Pasquale MK, Louder AM, Cheung RY, Reiners AT, Mardekian J, Sanchez RJ, Goli V. Healthcare Utilization and Costs of Knee or Hip Replacements versus Pain-Relief Injections. Am Health Drug Benefits. 2015 Oct;8(7):384-94.