Knee osteoarthritis treatments that don’t work

This article discusses treatments for 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

In summary, the healing effects of conservative care are uncertain if at all existent.

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

Conservative care failure – NSAIDs

For decades the most commonly prescribed treatment for knee osteoarthritis was oral analgesics (pain-killers). While warnings of pain-killer use persisted for decades, it is only in the last decade that the complexity of managing patients with pain-killers were understood in the context of symptom control with the well documented drug safety concerns.

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.”3 Please see Ross Hauser MD’s article When NSAIDs make pain worse.

Corticosteroid causes more damage in knee osteoarthritis

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.4

Conservative care failure – hyaluronic acid (viscosupplementation)

Viscosupplementation, the intra-articular injection of hyaluronic acid, is widely used for symptomatic knee osteoarthritis.  In one of the largest medical studies examining the benefit of “HA” injections, researchers noted: “In patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events.” 5

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 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. Ross Hauser, MD also explains in the video below:

1 Diehl P, Gerdesmeyer L, Schauwecker J, Kreuz PC, Gollwitzer H, Tischer T. Conservative therapy of osteoarthritis. Orthopade. 2013 Feb;42(2):125-39. [Pubmed]

2. Hameed F, Ihm J. Injectable medications for osteoarthritis. PM&R. 2012 May;4(5 Suppl):S75-81 [Pubmed]

3 Hauser RA. The Acceleration of Articular Cartilage Degeneration in Osteoarthritis by Nonsteroidal Anti-inflammatory Drugs. Journal of Prolotherapy. 2010;(2)1:305-322. [JOP Citation]

JAMA Press release May 17, 2016

5 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]