To operate or not to operate

Although Joint Replacement Surgery is a fairly predictable and cost-effective intervention for severe osteoarthritis of a major joint, it is not necessarily the treatment of choice for everybody. There are issues surrounding the decision-making process for surgeon and patient. Treatment should begin with most basic options and progress to the more involved as not all treatments are appropriate for every patient. Not everybody gets better after a total hip or total knee replacement. An important minority estimated at 10%-20% does not improve or are made worse by surgery. Then there is the population of patients who have associated conditions, co-morbidities, which prevent them from undergoing a surgical procedure without severe medical risks.

Try Nonsurgical Therapy First

While orthopedic surgery is based on allopathic medicine, that is the scientific process; the key to good decision-making about whom should have a joint replacement should be a holistic approach. Weight Reduction is paramount; anything greater than a BMI of 25.5 will result in excess loading of your hip and knee. Activity modification is strongly recommended using a bike and the swimming pool for exercising, Low-impact aerobic fitness, range of motion and flexibility exercises, muscle strengthening, and core strengthening. I find a patellar stabilizing knee sleeve to be very valuable, the one with the hole in the center. Acupuncture, glucosamine and chondroitin sulfate still are homeopathic. While there seems to be a greater than 50% positive response to visco-supplementation in the knee, the American Academy of Orthopedic Surgeons will not endorse this approach. There is no question that intra-articular corticosteroids offer short-term pain relief both in the hip and the knee.

Arthroscopy

Not advised for debridement of an arthritic hip. The same holds in the primary diagnosis of symptomatic osteoarthritis of the knee. On the other hand, there is a place for partial meniscectomy or loose body removal when the primary symptom arises in the presence of osteoarthritis.

Orthobiologics (PRP and Stem Cells)

We do not yet know exactly who may benefit from platelet concentrate or bone marrow concentrate and which factors are most critical in assuring the best possible outcome. Even the exact scientific explanation for how stem cells really work is still in the works. Preoperative severity of arthritic disease is probably most important. At this time, the decision to undergo an ortho-biologic procedure is about balancing potential benefits against potential risks. Given the fact that the biologic is autogenous and confined to a major joint, the significant risk is infection; that’s the risk of any invasive procedure and exceedingly rare to date. The case studies suggest that the new world of stem cells is worth consideration before a joint replacement

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