Back in the early 1970’s, I recall Mr. Keever, a robust, good old family friend sitting in the passenger seat of his parked pick-up truck in our driveway. His wife was inside having a quick catch-up coffee with my mother. When I went out to say hello to him, I found him uncharacteristically leaning on the dashboard close to tears. He pointed to his knees, mumbled “Knee replacements” and added that he was in too much pain to join us. He waved me away. “Wow!” I said to myself. “I hope I never have to have that!”
In fact, in 2003 when I was 47 years old, memories of Mr. Keever came back to me when I was struggling with chronic knee pain. My then tried and trusted orthopedic doctor, Dr. U. cavalierly declared after my umpteenth visit to him: I really wish you would just allow yourself to have a total knee replacement (TKR). They are easy! We implant the metal and the plastic cartilage. When you wear out the plastic, we just pop them out and pop in another set! Admittedly, his confidence and that last line sold me. I later learned I was one of his first TKR patients. He needed the experience as much as I needed a resolution my pain.
Fast forward to early spring, 2018 when my orthopedic surgeon, Dr. B. broke the news to me that ‘popping in and out’ a set of plastic discs was not possible, that I had been fed the wrong information. Instead he enthusiastically described a revision procedure calendar: Yes, there are risks, but let’s assume the (first) revision will last ten years. You will be 72 by that time. You can have another revision then. In fact, you will still have time for another after that assuming you are…you know, still here (alive)!
Deciding to have a total knee replacement and then a total knee revision is more complicated than that and should be more thoughtfully decided – although current and projected numbers suggest otherwise.
TKR AND TKR REVISIONS STATS. THEY MAY SURPRISE YOU.
Various sources have published statistics on long-term primary and revision rates for TKRs. Sources I have found useful over time include:
- Healthline Medical Information: www.healthline.com/health/total-knee-replacement-surgery/revision#4
- The American Academy of Orthopedic Surgeons (AAOS): http://orthoinfo.aaos.org AND www.assos.org
- Adult Stem Cell Therapy: www.regenexx.com
- US National Library of Medicine, National Institutes of Health: http://www.ncbi.nlm.nih.gov/
The Total Knee Replacement (TKR) procedure, in the USA, was developed in the 1970s and then disseminated across referral centers and then community hospitals in the 1980s and 1990s. By 2014, TKR utilization exceeded 650,000 cases annually in the US and many more worldwide (Katz JN, Editorial, Arthritis Rheumatol. 2014 Aug;66(8):1979-81. doi: 10.1002/art.38688).
Healthline conducts their own surveys using Medicare and private pay records as well as data from the U.S Department of Health and Human Services Agency for Healthcare Research and Quality (AHRRQ). They also rely on meta-analyses of worldwide joint registry databases. Healthline data indicates that growth in the use of TKRs has occurred primarily in patients 45–64 years of age. TKR utilization increases dramatically in the age group 50–59 years of age and primarily among women.
To assess revision rates, Healthline analyzed approximately 1.8 million (USA) Medicare and private pay records to find that the rate of revision for all age groups within five years from surgery is about 7.7 percent. The rate increases to 10 percent for those age 65 and older. Healthline also found a somewhat parallel number WORLDWIDE based on a meta-analysis of international joint registry databases (2011): the revision rate is 6 percent after five years and 12 percent after ten years. People are turning to revisions worldwide and the numbers are not decreasing.
Leaping ahead, the American Academy of Orthopedic Surgeons (ASSOS) anticipate that by 2030 projected growth of dependency on TKRs will increase by up to 189 percent, or 1.28 million procedures annually. (The ASSOS clarifies that these numbers are always shifting but not substantially from the pattern set)
Similar gains by 2030 are expected for revision TKRs, growing by 190 percent or 120,000 procedures.
By 2060, primary TKRs are expected to reach 2.60 million (382 percent increase), while revision TKRs s are expected to reach 253,000 (400 percent increase).
The mean age for primary total knees has declined significantly from 68 years to 65.9.
Females continue to make up the majority of patients at 55-62%.
It is interesting to note that a study in Europe found approximately 20% of all TKRs were judged to be inappropriate when using a combination of assessments including a formalized Osteoarthritis Index pain and physical function scores, radiographic features, knee motion and laxity measures, and age factors from patient pre-surgery histories. The same research was completed in the USA and found that one-third of TKR procedures were deemed unnecessary. (Riddle DL, Jiranek WA, Hayes CW. Arthritis Rheumatol. 2014 Aug;66(8):2134-43. doi: 10.1002/art.38685).
[In an editorial rebuttal to the above study, it was pointed out that, because a universally shared set of assessment criteria has not yet fully been developed and therefore not shared, the findings should not be considered conclusive. (Katz JN, Ibid)]
OK, THOSE ARE THE STATS. NOW WHAT?
How do we, the clients, make sound decisions about our health before we become the patients? We can begin by exploring our true options. They tend to be wider than the traditional orthopedic community is able, or in some cases willing, to lead you to think. Knees are connected to hips and spines, core muscles, ankles, shoulder blades. They are responsive to climatic humidity and emotional highs and lows, diets and/or lack thereof. Cells have memory. What is a flinch? A shudder? Anxiety, but a physical response to deep empathy or remembering trauma or disgust. What your body is struggling with is an ecosystem full of important issues we, as body stewards, have to understand before we sign off on an irremediable change in our lives and in our lifestyles.
YOUR PERSONAL CHECK LISTS
Consider the below unofficial checklists following your first round of traditional x-rays.
A. You have chronic pain but your Scans show NO structural changes to the joint:
- Test for rheumatoid arthritis, bursitis, fibromyalgia, lupus etc.
- See Osteopath for body alignment issues and corrections
- See Podiatrist for foot/ankle/knee issues and corrections
- See a Physical Therapist for muscle strengthening and additional alignment exercises
- Meet w/ Stem Cell Orthopedic Specialist to assess options (For trained doctors in your area go to http://www.regenexx.com)
- Soften or remove high impact physical activities, incorporate core muscle exercises
- Add-in alternative low-impact activities
- See Acupuncturist for pain management
- See Dietician for nutritional assessment
- Lose weight for joint health
- Adapt home layout for easier movement
- Consider replacing manual car with an automatic one
B. You have chronic pain and your Scans SHOW structural changes to the joint:
- Accept that lifestyle changes must be made
- Assess Orthopedic options
- Assess Stem Cell Orthopedic options (For trained doctors in your area go to http://www.regenexx.com)
- Incorporate all healing activities (Osteopath, Nutritionist, Podiatrist, Physical Therapist) listed above
- Replace all high impact physical activities with leg/core muscle strengthening exercises
- Lose weight
- Adapt home layout for easier movement
- Replace manual car with an automatic.
- Then decide on joint repair options and /or continue with modified lifestyle
Full body scans, if affordable, can be considered for assessing bone on bone relationships not only in the knees but elsewhere in the body that affects your ergonomic stature. Osteopathic medical doctors offer holistic points of view on these scans and accompanying strategies. Changing your physical patterns of behavior may be critical to your long term joint life: does an afternoon of downhill skiing really need to be on your agenda? What about the pleasures of simple yoga, swimming or isometrics? If limited knee flexion and instability prove to be the outcomes of arthritis does a change in diet, strengthening of your core muscles and use of acupuncture help, for now? Remember, certain kinds of (older) manual cars automatically (pun intended) create a persistently odd hip/knee/ankle alignment. Can you exchange cars for your long term mobility’s sake?
Does fear of chronic pain veil periods of painlessness? Does the undesirable demand to change personal behavior first cave to the desire for a professional, aka legitimate and immediate ‘fix’ now – when, in the back of your mind, might be the nudge to wait? In the end, do the gains (from surgery) outweigh the harms now and into the future?
The more boxes you tick off that complete a full scan of honest mind/body/ environmental concerns, the more confidence you will have going into your total knee replacement, if that is the final solution. The same absolutely applies for when you assess the need for a revision of your knee – though by then the evidence tends to be unquestionable. The emotional collateral that you amass on your journey to the operating theater is the collateral you will rely on during the repair phase, both times. Protecting yourself from undue joint replacement is worth the effort and the money and the time since once you start on this path there is no turning back. Take it slow if you can. For now, you can be the client, not the patient, looking for answers that are right for you.
This is a big topic. More can be said. What do you say?