Alternatives to Knee Replacement Surgery

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Sports Medicine Expert Dr. Kevin Plancher on less expensive and less invasive options

Nearly one in five Americans experiences chronic arthritis pain, which can be debilitating physically and financially. According to the most recent statistics from the Centers for Disease Control and Prevention (CDC), arthritis was the reason for most of the 450,000 total knee replacement surgeries performed annually in the United States.

With osteoarthritis of the knee, prevention is more than the best medicine – it’s often the most economical option. For the uninsured, a total knee replacement can cost at least $35,000. If a patient has insurance, out-of-pocket expenses can range from hundreds to several thousand dollars.

However, there are less expensive and less invasive alternatives to surgical knee replacement, according to Dr. Kevin Plancher, a leading sports orthopaedist in the New York metropolitan area and an official orthopaedic surgeon for the U.S. Ski & Snowboard teams.

For younger patients whose arthritis is not severe or for those who can’t take oral medicine for the pain, viscosupplements may be a viable option. With arthritis, there is a decrease in the concentration of hyaluronic acid, a natural component of the fluid that lubricates joints. This acts normally as a shock absorber that should prevent bones from bearing the full force of impact when walking.

Viscosupplements, or injections of hyaluronic acid, add to the joint’s natural supply of the fluid. Since the knee works like a hinge joint, lubrication reduces friction and pain. Effects are felt within days; on average, patients receive three shots spaced a week or more apart.

The Orthopaedic Foundation for Active Lifestyles (OFALS), a non-profit foundation started by Dr. Plancher, recently completed several investigative trials studying novel hyaluronic acid products. Instead of receiving current viscosupplement medications consisting of three injections given one week apart, a new single injection to the knee was administered. Anecdotal results seem to be very positive and the product is pending FDA approval.

In this study patients must avoid excessive weight-bearing activity for one or two days after injecting but can resume normal activities. According to some studies, pain relief lasts up to six months or a year. Although the injections offer relief from symptoms, they are not considered a cure that will stop the disease. Most insurance companies cover hyaluronic acid injections

Proper doses of diet and exercise can also play a leading role in avoiding knee replacement surgery. For older adults with knee osteoarthritis, moderate physical activity at least three times a week can reduce the risk of arthritis-related disability by 47 percent. Losing as little as 11 pounds reduces the risk of developing knee osteoarthritis among women by 50 percent.

Microfracture is another popular alternative to knee replacement because it is minimally invasive and offers a quicker and more comfortable recovery. This outpatient procedure uses a marrow stimulating technique by creating tiny fractures in the bone where cartilage has been worn away. The immune system perceives an injury and rebuilds the cartilage. Blood and bone marrow, full of stem-cells, seep out of the fractures to form clots that release cartilage-building cells.

“Microfracture is an excellent choice for active patients under the age of 45 with specific areas of cartilage degeneration in the knee because it allows them to return to sports confidently and more quickly than the alternatives,” says Dr. Plancher, whose training included a fellowship to study with the doctor who developed Microfracture in the late 1980s.

Microfracture takes an enormous amount of time in the operating room. The healing and rehabilitative process requires approximately four to six months. “Depending upon the location and the size of the area being treated, passive range-of-motion exercises might be initiated immediately because gentle motion will actually stimulate the development of the fibrocartilage,” says Dr. Plancher. Motion exercises can be done by the patient, a physical therapist, or with a passive motion machine (most people use a CPM machine nightly during sleep to speed the cartilage-building process). Weight-bearing, however, is usually limited for 4- 6 weeks after the procedure because pressure on the joint could possibly harm the regenerating cartilage.

A number of high-profile professional athletes have opted for Microfracture to facilitate a quick comeback. “Many of them – such as Jason Kidd of the New Jersey Nets and Steve Yzerman of the Detroit Red Wings – have returned to play at or near their peak performance levels,” says Dr. Plancher. Olympic Bronze medal winner and NBA Rookie of the Year Amar'e Stoudemire underwent Microfracture in 2005. The Phoenix Suns’ forward bounced back to stellar performances in all 82 games of the 2006-2007 season, including the NBA All-Star game.

Most clinical studies show improvement in knee function in about 85 percent of patients (the procedure is less effective in treating older or overweight patients). Other studies have shown a continuation of positive results for up to seven years. Microfracture is a good first-line option because it doesn’t prevent the application of other cartilage repair procedures in the future.

Following its success managing knee osteoarthritis, Microfracture is being evaluated for its applicability to other joints, including the shoulder, hip, and ankle; the OFALS clinical studies are underway.

About Dr. Plancher: Kevin D. Plancher, M.D., M.S., F.A.C.S., F.A.A.O.S., is one of the nation’s leading orthopaedic surgeons and sports medicine experts, specializing in the treatment of knee, shoulder, elbow and hand injuries. He is Associate Clinical Professor in Orthopaedics at Albert Einstein College of Medicine in New York City and the Head Team physician for the professional lacrosse team, the Long Island Lizards. Dr. Plancher served on the editorial review board of the Journal of the American Academy of Orthopaedic Surgeons from 1994-2010. In 2007, 2008, 2009, and 2010 Castle Connolly Medical Ltd., a New York City research company, named Dr. Plancher America’s Top Doctor in Sports Medicine in the U.S.. Every year from 2001 to 2010 he has been included in Castle Connolly’s list of Top Doctors in the New York Metro area, as published in New York Magazine's yearly "Best Doctors" issue.

Dr. Plancher received his M.D. degree (cum laude) and an M.S. degree in physiology from Georgetown University in Washington, DC. He completed his residency at Harvard University’s orthopaedic program and a fellowship at the Steadman-Hawkins Clinic in Vail, Colo., where he studied shoulder and knee reconstruction and served as consultant to the clinic for six years. He has been team physician for more than 15 high school, college and national championship teams.

An attending physician at Beth Israel Hospital in New York City and Stamford Hospital in Stamford, CT, he maintains offices in Manhattan and Greenwich, CT, http://www.plancherortho.com. Dr. Plancher lectures Internationally and here in the U.S. on issues related to orthopaedic procedures and injury management and to halting the process of arthritis. He also has been named to the sports medicine arthroscopy program subcommittee for the American Academy of Orthopaedic Surgeons. Dr. Plancher has been awarded the Order of Merit (magna cum laude) for distinguished philanthropy in the advancement of orthopaedic surgery by the Orthopaedic Research and Education Foundation. In 2001, he founded The Orthopaedic Foundation for Active Lifestyles, a not-for-profit foundation focused on maintaining and enhancing the physical well-being of active individuals through the development and promotion of research and supporting technologies, http://www.ofals.org.

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MELISSA CHEFEC
MCPR Public Relations
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