Saturday, March 28, 2015

Not So Fast on That Knee Replacement

Here’s a short piece by the New York Times that’s well worth the read if, driven to desperation by pain and a bleak prognosis, you’re considering the ultimate in knee surgery: a total replacement of the joint.

You wouldn’t be alone -- far from it. More than 600,000 of the surgeries were performed in 2012. That’s a big jump from the 250,000 of 15 years ago. But what’s most interesting is where the most rapid growth is: among those 45 to 64 years old, who had triple the number of operations as before.

Are all these surgeries beneficial, especially among younger patients?

Researchers analyzing data from major studies found that people with really bad knees were helped by surgery. “Really bad” in this case means advanced arthritis: in other words, severe pain and impaired physical function, like an inability to climb stairs. But others with less serious arthritis saw only a very small benefit.

The upshot? According to Daniel Riddle, the professor of physical therapy and orthopedic surgery who led the studies:
If you do not have bone-on-bone arthritis, in which all of the cushioning cartilage in the knee is gone, think about consulting a physical therapist about exercise programs that could strengthen the joint, reducing pain and disability.
Amen. Surgery sometimes is the best option. But it’s often the best option when it’s the last option.


  1. Hi Richard,

    Your blog has been a life saver. I am 26 years old; extremely active and have had knee pain in both knees for the past 2 years due to a 25lb kettlebell taking my knee out. I've seen 5 physio therapists, 2 podiatrists, 1 sports med doc, and 1 surgeon - none of them helped, in fact they each made my knees worse to the point where I could barely walk. I read every post and comment on your blog in a weekend, have been following your advice and I am getting relief! Oh, and I also downloaded Doug Kelsey's book. My knees were so bad I thought I'd have to give up my teaching career but that won't be the case thanks to your blog. I might even be hiking this summer! :)

    I love this blog and have been sharing it with anyone who will listen! THANK YOU and many thanks for your continued contributions to this blog! :)

    I realize you have a frequent commenter who also goes by "Anonymous" but I couldn't get it to change to anything else sorry! :)

    1. That's terrific and happy to hear of the good results so far. Drop back in later with an update ... we love to hear success stories.

    2. It is so good to hear that you're feeling relief! I know everyone is different, but would you mind sharing what you have done to feel better?

    3. I agree! Your post is so general. Please, give us some more details. Let us know that you are not a robot!

    4. Basically I'm walking - in moderation. I've had prolotherapy injections and they have given me some relief but no miracle cure. I'm considering trying PRP but we'll see. I have a step counter which I follow and currently 8000 steps per day seems to be the sweet spot. I walk mostly on a treadmill (winter in Canada) so last week it was finally nice out and I decided to hit the pavement....a week later I'm still aching from that walk, so currently I'm feeling a major set back. I still can't go up/down stairs nor am I anywhere near being able to do anything that breaks a sweat. My knees feel stronger but I have a constant ache/burn to them; any advice for that? Physio's gave me the same old prescription: strengthen quads, vmo, glutes which absolutely destroyed my knees! One thing I couldn't get over was them trying to tell me to strengthen quads - mine already where strong! Given the level of activity I was doing and I had been doing significant weight training which I believe is what ultimately wrecked my knees. I had a very difficult time find a doctor who would take my knee pain seriously, and finally after much hassle I had an MRI and was diagnosed with osteoarthritis is both age 26 :( so I'm trying to walk everyday and increase my steps each week. Currently, I've scaled back the steps per day as my I'm mid set back. Has anyone tried PRP injections? Thoughts?

    5. Don't we all have osteoarthritis?! Yes, blood injections will reduce your constant pain for about 30-70%. (no matter PRPs or orthokine )
      I have another interesting thing to share.
      I received my fourth weekly orthokine injection. Again, one in each knee. These were not frozen because I gave my blood earlier that day so there was no need for freezing them. And, wow!!!!!! The next day my afternoon pain almost disappeared!!!!!!!!!!!
      During my first treatment, 15 months ago, only my first injection was not frozen. That one also had by far the strongest effect on the level of constant pain of them all.
      Conclusion: Let them be fresh!

      After injections, I talked with my OS and he told me an interesting theory.
      He said that someone recently drilled hole in patella of one patient with chondromalacia, and took a sample of his patella's subchondral bone.The sample is sent for analysis and it was found that the blood was acidic, although normal blood should be slightly alkaline. Maybe chages in blood pH somehow contribute to the degeneration of cartilage?
      If that is the cause, the cure would be re-establishing the correct blood pH of subhondral bone. Easiest thing to do that is better blood circulation, and again, movement!
      He did a lot of arthroscopies for chondromalacia and says that very often there is no damage. Cartilage is shiny and white, only sometimes a little softer, which can also be totally asymptomatic.
      In maintaining blood pH carbonate buffer has a major role. It makes CO2 and HCO3-. CO2 is generated by metabolism in the cells, and it is normally excreted with lungs, that lowers the pH (more acidic).
      HCO3- increases the pH (alkaline), the concentration is held with kidneys by increasing its excretion in urine (in alkalosis, ie. High pH) or increase its absorption of urine and restore the circulation (with acidosis, ie. Reduced pH). Lungs with acidosis increases ejection of CO2 (hyperventilation, ie, rapid breathing), and in alkalosis less CO2 is expelled. All of these are mechanisms to maintain the pH, or acid-base balance.

  2. Here here, thanks to Richard for the book and maintaining the blog.
    After reading the NYT article, click on "Comments," then "Readers Picks." Interesting insights: Particularly "Kirk" the MD. That is a good criteria for evaluated TKR and of the general state of the orthopaedia.

  3. Interesting article. I've heard good and bad stories about knee replacement. My father could be a candidate but doctor told him that he has to loose a lot of weight before going to surgery otherwise it will be very difficult to recover. He had pain for a while, he lost some weight (nothing amazing, just a few kgs) and now he has almost no pain, so he started eating again...
    I'd be very afraid of going through surgery although sometimes if pain is unbearable you see surgery as the only possibility to improve... It's a difficult decision. But I'll give PT a go, maybe a couple of years and see how it goes.
    Anyhow I hope I don't have to make that decision never haha fingers crossed.
    I am now suffering a flare up on my left knee (the one I was relying more on) ... however my right knee is awesome, all my symptoms have gone away. I'm happy for that but worried about the left knee. It doesn't seem to improve :( been like this for 3 weeks.

    1. Is it the right knee you applied PRP injections?
      I started my second treatment with orthokin injections. I received one in each knee. That was on Thursday. For now there is no change in pain level. My Orthopaedist also offered me a PRP injections that cost 30% less. I asked him which injections are better. He replied that orthokin is better and that's the most I can do for my knees at the moment. He also said that I must maintain my muscles, and maybe with time, my knees could possibly be better, but that no surgery, arthroscopic or any other will improve my condition.

    2. I had PRP in both knees. 3 injections. Had them at the end of Dec.
      My left knee has always been less painful, so not sure what's going on now! I think that apart from the chondromalacia there is some trigger point issue going on as well. That's what we suspect. Already going through dry needling, we'll see if it improves/changes anything. Knee range of motion has improved and tendons as well (I have patellar tendonitis). Walking is also better than before, the problem is when squatting. Anyway, I think PRP has helped because my right knee was really bad and in 2 months has improved a lot.
      Haven't heard of orthokin, what is that exactly? is it like prolotherapy?


    4. "The price came to 6,000 euros, or about $7,400, out of her own pocket"

      PRP here in Oz cost me just AU$110 per knee.

      I note Wehling heats the blood after extraction, which is claimed to be novel and improve the anti-inflammatory properties of the mixture, but how can that turn $100 into $7000? Electricity in Germany is not that expensive is it?

      US$7,400 for a modified PRP treatment is right up there with the AU$9,000 they charge here for stem cell therapy on a knee.

      Interesting times.

  4. Unfortunately, Orthokine or Regenokine is a expensive commercial franchise. In Germany, as I had read, treatment is covered through health insurance. My country health sistem doesn't cover costs, but, on the other side, treatmant is much cheaper here. When the country is poorer, prices are lower. That goes for everything that includes high percentage of patented know-how in cost structure. I recently read Peter Wehling's (inventor of orthokine-regenokine treatment) book "The end of pain". Even the book is expensive. Although the book is, indeed, one expensive commercial (critical review of one of the readers on amazon kindle), I find it interesting. My wife is a biochemistry specialist and she said the procedure is very simple except for small glass beads which are new thing. I'm going through my second time procedure myself, and for me it works. Like I said before, 70% less pain! Works for Kobe Bryant too. Maybe Kobe loves German alps. I don't know. I will continue to share my objective, inside perception of orthokine-regenokine treatment.

    1. And no doubt the Vatican paid for the Popes treatment in Germany.

      I detect a whiff of German price gouging.

      Australia is hardly a poor country - Sydney house prices are ridiculous - but if you shop around you can get a PRP shot for $110. The price gougers here will charge $500, but that pales into insignificance against Wehling's $7,000.

      I'd say my standard PRP treatment gave me 50-70% less pain within 3 days too. And I suspect has accelerated the path to long-term healing.

      Having said all that, yes keep sharing your experiences with the treatments, it is good to have first hand accounts objective accounts of these things.

  5. As I mentioned before, I am going through my second orthokine treatment. First was 15 months ago, So far I have received three of five weekly shoots in each knee. Complete treatment will cost me around 1500€.
    This time results are not so bright as they were the first time. Altought I feel my knees are a little calmer, improvement is not so significant. Maybe a 20-30% less pain. But I have to say that my knees were in much worse condition last year.
    However, as TriAgain has intrigued me, I contacted a Orthogen company in Germany. My questions were related to the difference between orthokine and regenokine treatment, as well as the price of the treatment.
    Orthogen employee told me that Regenokine is new, improved treatment. Orthokine was first generation. She asked me for some of mine MRIs and x-rays.
    Who wants to take a peek at my knees, feel free to do it at:
    She respond that I am a good candidate and that my knees aren't so bad. Price will be around 3000-3500€ for both knees. That includes five daily shots in each knee, doctors fee and produce biologicals.

    1. Seems the price has dropped a lot from that stated in the article above.

      I did not download the MRIs but what was the conclusion from them? Where is the damage - in the meniscus or the cartilage on the back of the patella?

    2. MRI conclusions:

      Left knee:
      Chondromalacia patella. 12x9 mm lesion on the upper inner side of the patella with edema. The degree is not defined. Everything else is fine

      Right knee:
      Some signs of enthesopathy on ACL.
      Discrete horizontal rupture of the medial meniscus. Discrete chondromalacia patella with minimal lateral position of patella.

  6. It seems to me there is the common garden variety chondromalacia patella which responds well to a little rest and perhaps some strengthening exercises, then another kind which becomes chronic, widespread and very difficult to treat. It's almost as if the entire patella cartilage becomes soft and weak, rather than just a particular focused point of damage. As if some threshold is passed where the damage becomes systemic, and the resulting pain is almost constant abd quite debilitating.

    1. Yes, that's it! Look at this nice pictures. Especially the third one:

  7. If someone walks without major problems and if the pain is bearable, operation is not an option. If not the case surgery should be considered.