Knee-replacement

Questioning knee replacement | Is it the wrong operation?

The debate over whether or not to have a knee replacement is not a new on. Back in 2006, the rate of knee replacement failures caused some concern that maybe everyone is NOT a candidate for joint replacement.

Findings at that time published in the medical journal Clinical orthopedics and clinical research suggested 37% operations supported by a significant disorder on magnetic resonance imaging were unjustified.1

That was 2006, certainly things have changed. Eight years later, June 30, 2014, research in the medical journal Arthritis & Rheumatology, suggested more than one third of total knee replacements in the United States were the “inappropriate” treatment.2 Not much changed.

Doctors warn that in the case of chronic knee pain, a thorough examination is imperative in identifying the correct diagnosis. That sounds like common sense, but the truth is that the source of pain is often missed and treatment then will present a significant challenge with less than desired results.

One study sought to understand why up to 20 percent of patients who undergo total knee replacement still have persistent pain and why secondary surgery rates are on the rise.3 Forty-five patients were studied. What the researchers found was somewhat shocking. The pain was not originating in the knee – here is what they said:

“Patients may still be undergoing knee (replacement) arthroplasty for degenerative lumbar spine and hip osteoarthritis. . . We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.”

In other words, patients received a knee replacement when the cause of pain came from the hip and spine.

Researchers at the Graduate School of Medicine, Chiba University published two studies, Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip, and, Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip. In both studies doctors area cautioned to be on the look out for “hip disease masquerading as knee pain or low back pain.” They noted various ways hip pain distributes itself including as groin, buttock and hip pain.” 4,5

In the case of chronic joint pain, a thorough examination is imperative in identifying the correct diagnosis. That sounds like common sense, but the sad truth is that the source of pain is often missed because of misinterpretation of MRI and other imaging scans.

Recently doctors warned patients not to go to low-volume knee replacement hospitals because the risk of complication was greater due to lack of expertise. (The same thing can be said about Prolotherapy – go to a high volume Prolotherapy practice).

Despite this warning about knee replacement complication risks being higher when performed at local low-volume hospitals – patients still choose the local – higher risk option. In fact the researchers called these patients the “vulnerable group.”6


1. Ben-Galim P, Steinberg EL, Amir H, Ash N, Dekel S, Arbel R. Accuracy of magnetic resonance imaging of the knee and unjustified surgery. Clin Orthop Relat Res. 2006 Jun;447:100-4.
2. Riddle, D. L., Jiranek, W. A., & Hayes, C. W. (2014). Using a Validated Algorithm to Judge the Appropriateness of Total Knee Arthroplasty in the United States: A Multi-Center Longitudinal Cohort Study. Arthritis & Rheumatology (Hoboken, N.J.)66(8), 2134–2143. http://doi.org/10.1002/art.38685
3. Al-Hadithy N, Rozati H, Sewell MD, Dodds AL, Brooks P, Chatoo M. Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies? Int Orthop. 2012 Jan 11.
4.  Nakamura J, Oinuma K, Ohtori S, et al. Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip. Mod Rheumatol. 2012 Apr 11.
5. Nakamura J, Oinuma K, Ohtori S, Watanabe A, Shigemura T, Sasho T, Saito M, Suzuki M, Takahashi K, Kishida S. Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip. Mod Rheumatol. 2013 Jan;23(1):119-24. doi: 10.1007/s10165-012-0638-5.
5. Lau RL, Perruccio AV, Gandhi R, Mahomed NN. The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature.BMC Musculoskeletal Disorders. 2012;13:250. [Pubmed] [Google Scholar]

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