Is joint replacement surgery necessary?

Non-surgical and minimally invasive surgical options for deteriorating joints may allow some patients to delay or avoid joint replacement surgery.

Evoke™ knee brace. OssKin.

By Kim Waterman, Northwestern Medicine, Orthopedics May 15, 2019

Hip and knee joint replacements are among the most common elective surgical procedures performed in the United States [and Canada] today. However, some patients may be getting these surgeries sooner in life than desired or in situations when they don’t quite have end-stage arthritis of the hip or knee. Non-surgical and minimally invasive surgical options for deteriorating joints may allow some patients to delay or avoid joint replacement surgery.

“A joint replacement should be the last option for joint pain. Emerging treatments such as orthobiologics, advanced hip arthroscopy, cartilage restoration, meniscus transplantation, and osteotomy techniques can help adults and adolescents with pre-arthritic conditions regain full function,” said Brian Chilelli MD, orthopaedic surgeon and co-director of the Northwestern Medicine Hip and Knee Joint Preservation Center at Central DuPage Hospital.

Sanjeev Bhatia MD and Brian Chilelli MD, orthopaedic surgeons and co-directors of the Northwestern Medicine Hip and Knee Joint Preservation Center at Central DuPage Hospital.

The first level of treatment for most joint pain involves rest, activity modification, anti-inflammatory medications and physical therapy. If symptoms don’t improve, injections in the joint, including corticosteroids and hyaluronic acid, may help decrease inflammation and provide lubrication to the impacted areas. Dr. Chilelli says the newer biologic injectables also promote healing.

“One of the more well-studied orthobiologics is platelet rich plasma, or PRP,” said Dr. Chilelli. “The patient’s own blood is spun down in a centrifuge to concentrate the platelets, which is then injected back into the joint. Platelets contain proteins called growth factors which can help regulate joint homeostasis and potentially provide a healing response.”

If non-operative techniques fail, minimally invasive procedures include advanced hip arthroscopy for hip impingement and labral tears, cartilage restoration, meniscus repair and transplantation, and osteotomy techniques for both the hip and knee.

“The type of surgery depends on the location and size of the cartilage damage, the type of pre-arthritic pathology that may be deteriorating the joint quickly as well as the age and goals of the patient,” said Sanjeev Bhatia MD, orthopaedic surgeon and co-director of the Northwestern Medicine Hip and Knee Joint Preservation Center at Central DuPage Hospital. “Most procedures can be done using a tiny camera and scope through small incisions.”

On the hip side, advanced arthroscopic treatments can remove bone spurs that cause painful hip labral tears and accelerated hip cartilage damage through a process called femoroacetabular impingement (FAI), one of the leading causes of hip arthritis in the United States.

“Recent studies have shown that hip arthroscopy performed at tertiary care centers is more effective than conservative management for some patients with symptomatic FAI,” said Dr. Bhatia. “In addition to repairing or reconstructing labral tears, large bone spurs can be smoothed and sculpted during surgery, alleviating their irritation.”

On the knee side, arthroscopic debridement can smooth out loose fragments or flaps for patients suffering from mechanical pain in the knee. Meniscus surgery is aimed at preservation of this structure, given its important role in protecting knee cartilage. If accelerated knee cartilage damage is caused by malalignment, an osteotomy procedure can also be performed to realign the joint. In this procedure, the malaligned bone is cut, realigned and secured with a plate.

For patients with a focal area of cartilage damage, cartilage from a healthy part of the body, or from a cadaver, can be transplanted to the defect. The newest technique, matrix-induced autologous chondrocyte implantation or MACI, can be used to restore knee cartilage in cases of medium to large defects.

“A sample of the patient’s cartilage is taken from a non-weight-bearing part of the knee. This sample tissue is sent to a lab, where cells are embedded in a special collagen membrane that promotes regeneration,” said Dr. Bhatia. “At the time of re-implantation, the new material, called the MACI membrane, is trimmed to the desired size and shape, and secured to the bone.”

Dr. Chilelli says with emerging science and new treatments, it is an exciting time for joint preservation; however, he warns patients to be cautious of false advertising for so-called “miracle” stem cell solutions.

“There is a wide variation in stem cell products and some products out there that claim to be stem cells are not,” Dr. Chilelli. “It is important to do your research and seek out the best evidence-based treatments backed by high-powered studies.”

The Northwestern Medicine Hip and Knee Joint Preservation Center is located at 27650 Ferry Road in Warrenville with surgeries being performed at Northwestern Medicine Central DuPage Hospital in Winfield.

Source Northwestern Medicine

  Further reading
Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? A survey of 194 orthopaedic surgeons who made 3880 predictions, van de Graaf V, Bloembergen CH MD, Willigenburg NW PhD, Noorduyn JCA MSc, Saris D, Harris I, Poolman R; ESCAPE Research Group. Br J Sports Med. 2019 Aug 1. pii: bjsports-2019-100567. doi: 10.1136/bjsports-2019-100567. [Epub ahead of print] Full text. Clinical Trial NCT03462134

Treatment of Articular Cartilage Defects: Focus on Tissue Engineering, Żylińska B, Silmanowicz P, Sobczyńska-Rak A, Jarosz Ł, Szponder T. In Vivo. 2018 Nov-Dec;32(6):1289-1300. doi: 10.21873/invivo.11379. Review. Full text

Bone Marrow Mesenchymal Stromal Cell Treatment in Patients with Osteoarthritis Results in Overall Improvement in Pain and Symptoms and Reduces Synovial Inflammation, Chahal J, Gómez-Aristizábal A, Shestopaloff K, Bhatt S, Chaboureau A, Fazio A, Chisholm J, Weston A, Chiovitti J, Keating A, Kapoor M, Ogilvie-Harris DJ, Syed KA, Gandhi R, Mahomed NN, Marshall KW, Sussman MS, Naraghi AM, Viswanathan S. Stem Cells Transl Med. 2019 Aug;8(8):746-757. doi: 10.1002/sctm.18-0183. Epub 2019 Apr 9. Full text

A Comparison of 2-Year Outcomes in Patients Undergoing Tibiofemoral or Patellofemoral Matrix-Induced Autologous Chondrocyte Implantation, Ebert JR, Schneider A, Fallon M, Wood DJ, Janes GC. Am J Sports Med. 2017 Dec;45(14):3243-3253. doi: 10.1177/0363546517724761. Epub 2017 Sep 14. Full text

Also see
Surgeons Not Good at Predicting Benefit From Knee Operations in Medscape
Why ‘Useless’ Surgery Is Still Popular in The New York Times
Think Twice Before Choosing Knee Replacement in The New York Times
Using stem cells to combat osteoarthritis in Medical News Today
Superstar Athletes Popularize Unproven Stem Cell Procedures in Kaiser Health News KHN

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