Don’t want a knee replacement? These options may help

Knee replacement surgery is one of the most common joint procedures in the U.S. According to the CDC, about 719,000 total knee replacements happen every year, due to arthritis. But sometimes a person either doesn’t want a knee replacement or simply isn’t healthy enough to undergo the surgery.

There are other options, according to orthopedic surgeon Paul Dimond, MD, at the Falmouth Orthopedic Center.

“I operate on a lot of patients, but there are times when patients are just not ready and want to discuss other options,” he said.

Arthritis is the loss of cartilage that causes a flair-up of painful symptoms like fluid on the knee and acute inflammation, Dr. Dimond explained. That’s when patients typically end up in his office. Total knee replacement surgery is one solution, but he also offers other nonsurgical treatment options that may be a better fit for certain patients.

Cortisone Injections

“Patients will come into the office and I’ll typically start out with a cortisone injection,” Dr. Dimond said. “Cortisone injections in this realm can sometimes secure the problem for a significant length of time. In other words, they feel good, they are back doing activities, and their knee doesn’t hurt as bad. Some patients can go years with injections.”

He typically does cortisone injections when his patients have a recurrence of discomfort. If they respond to the injections, he continues to do them from one to three times a year. Once the inflammation goes down, he prescribes physical therapy (PT). 

“Once you get them over that acute kind of inflammatory process, giving them some gentle PT can help settle it back down by strengthening the quadriceps. It stabilizes the joint and prevents those flair-ups from occurring.”

Hyaluronic Acid

If the patient still has pain or difficulty walking, Dr. Dimond gives them a shot of hyaluronic acid, which he calls the “WD40 for the knee.” It is lubricating, eases pain and is an anti-inflammatory. He gives one injection a week for three weeks in a row.

“Some people will do really well and come back once a year for a repeat of the hyaluronic acid,” he said. “Other patients don’t respond as well. It’s such a variable thing, but I’ve used it for a long time and I think patients will find some improvement with it.”

If, after these treatments the patient is still in significant pain, Dr. Dimond recommends a total knee replacement, if they are symptomatic enough to warrant it. If patients are still seeking other non-surgical options or are too old and infirmed for surgery to be safe, he offers the following four options.

Zilretta

Sometimes Dr. Dimond uses an injectable medicine called Zilretta. It is a long-acting steroid that is dissolved in a polylactic acid, which releases the steroid slowly over four months.

“Success is based on the patient’s history, their physical condition, their co-morbidities and their age,” Dr. Dimond said. “At that point it’s a discussion with me regarding what’s next on their continuum of care. If they get relief with that, great. If not, then it’s another discussion about knee replacement or surgical options.”

Platelet-Rich Plasma

If the patient still doesn’t want surgery or is very young (in their 50s), or very old and infirm, Dr. Dimond offers them the option of platelet-rich plasma (PRP).

“It’s a process where we take blood out of the arm, we spin it down and then we inject the joint with the platelet-rich plasma,” he said. “That’s designed to change the chemical environment of the joint. Essentially it calls in new cells to hopefully settle down the arthritic pain process. It doesn’t cure, but it can improve the symptoms.”

Insurance doesn’t cover it so PRP costs $750 out of pocket, which just covers the cost of the kit.

“Typically, patients will find three to six months of 80 percent improvement,” he said. “Again, some people come back in a year and repeat it. Others find they can get enough relief that they can hold off joint replacement.”

Stem Cell Treatment

If a patient finds some relief with PRP, Dr. Dimond offers them in-office stem cell treatments.

“Under ultrasound, we numb the pelvic crest, and we use patients’ pelvic blood, which are osteoprogenitor cells,” he said. “We take this bone marrow, spin it down and inject it back into the knee. The thought process here is that these cells have some pluripotential effect (capable of turning into any type of cell except those that form a placenta or embryo) to maybe start to grow some fibrocartilage. The literature is mixed on this but it can grow some fibrocartilage that may also be protective.”

Like PRP, this treatment is most advisable for the very young or very old and infirm patients.

Stem cell treatment also isn’t covered by insurance and the out-of-pocket expense is $2,500.

Geniculate Artery Ablation

“There are also patients in the elderly population who can’t have surgery who have a lot of fluid in their knee,” Dr. Dimond said. “I can send them to the vascular surgeon and he can do geniculate artery ablation procedures that are designed to try to help prevent chronic swelling in the knee. So that’s kind of last-ditch effort.”

Knee Replacement Surgery

Sometimes surgery ends up being the only good option, Dr. Dimond said.

“There are times when patients have a significantly arthritic knee with very bad ligamentous balance and their knee will collapse on ambulation or they have more malalignment that doesn’t respond to stem cells or things like that,” he said. “They typically need knee replacement because there are arthritic conditions that are so advanced that I would need to operate on it.”