It may feel like surgery is the only way to fix that aching joint, yet there are many solutions before a person heads to the operating room. Discover a few ways to relieve pain, retrain joints and return to an active lifestyle that’s free from pain.
Dr. A.P. Rosche was certain the pain he felt in his knee recently was similar to that of an injury he suffered in high school – a torn meniscus.
As a doctor and knee specialist, he was devastated when he learned his self-diagnosis was incorrect.
“I went and got an MRI, and the worst possible result happened: it’s just an old knee,” says the interventional pain specialist at Beloit Health System. “There’s nothing to fix.”
Joint pain – appearing where two or more bones meet – affects more people than you may imagine. Rosche believes more than one-third of people older than 30 have issues with joints.
He’s probably pretty accurate.
The CDC says a quarter of adults with arthritis – 15 million people – experience severe joint pain related to arthritis. Half of those individuals have persistent pain.
“Many people over the age of 50 start having knee pain that is related to degenerative joint disease, or DJD,” says Rosche. “It’s a very common diagnosis.”
DJD is another name for osteoarthritis, the most common form of arthritis. “What that really means is the integrity of the joint is diminished,” Rosche says. “The slippery surfaces on the inside of the knee quit providing lubrication, and there tends to be some rubbing of soft tissue or cartilage on cartilage that starts to degrade the low-friction surfaces of the interior of the joint.”
Many patients who see orthopedic surgeon Dr. Andreas Fischer, at OSF HealthCare Saint Anthony Medical Center in Rockford, want a solution for arthritis.
“They typically come and ask, ‘How do I get rid of it?’” says Fischer. “You can’t get rid of arthritis; we don’t have the means.”
There are, however, steps that will improve joint pain, but if those remedies don’t work, joint replacement surgery is a final option.
For knees, that involves removing the damaged surfaces of the knee joint and resurfacing them with new components, which typically include a tibial (shin bone) component; femoral (thigh bone) component; and patellar (kneecap) component.
Similarly, in a hip replacement, the damaged bone and cartilage are replaced with artificial components to re-create the ball and socket of the joint.
The two biggest causes of arthritis are genetics and injury, says Dr. Greg Dammann, an orthopedic surgeon at FHN in Freeport. Healthy habits can help to prolong the question of surgery.
“Exercising, keeping your quads and legs strong, keeping your weight under control, staying active – those are the best ways to avoid knee replacement,” he says. “If it’s genetic, it’ll get you at some point.”
Before Surgery
As a pain management specialist, Rosche considers physical therapy, strengthening of the joint and re-training the joint as a first line of treatment.
“This increases the likelihood that a patient will not need joint replacement, because they will get through their acute pain phase and get to the joint-toughening phase,” Rosche says. “Frequently, patients can tolerate a lot of wear and tear once the joint is stronger. As the joint is degrading, it hurts. But once it’s gone, the bones polish up and harden and the pain improves naturally; not in everyone, but it’s common enough for me to use that possibility as one of the goals of therapy to avoid complete knee replacement.”
If those methods don’t work, there are many good, non-addictive pain medications that help patients better tolerate their pain, Rosche adds. As a last option, Rosche can turn to interventional pain procedures, such as injections.
“If they get though that type of therapy and medication and still have significant joint pain, injections of joint-lubricating substances, primarily sodium hyaluronate, can replace the natural joint lubrication and diminish joint pain as well as encourage soft tissue repair,” Rosche says.
The vast majority of painful knees are treated “successfully” with knee injections into the joint, Rosche adds, noting he performs more than 500 joint injections each year.
A “successful” injection provides 80% pain relief for six to seven weeks or more.
“It was a success for that procedure and that injection, but we can’t wind back the clock on old knees,” he says. “It’s a matter of time and mileage, and neither one of those can be reversed, unfortunately.”
If an injection doesn’t help, patients can try further interventional procedures like lower back steroid injections or advanced pain procedures like radio frequency ablation, a minimally invasive procedure using radiofrequency waves to interrupt pain signals to the brain.
There are four main nerves that provide pain signals from the knee to the brain, Rosche says. Pain specialists can first block those signals with lidocaine or other local anesthetics, similar to what a dentist would do to a patient’s jaw.
“If that makes the knee pain-free and is reproducible, we can do radiofrequency ablation on those nerves, which lasts for up to six months,” Rosche says. “This can be done prior to joint replacement and after a joint replacement if there is significant knee pain that exists three months after surgery.”
From Rosche’s perspective, these treatments are considered a non-damaging form of pain management.
“They’re not risky; they’re not even really experimental,” he says. “They are effective when they’re effective, and they’re safe otherwise.”
Surgery – What Does It Entail?
If no alternative treatments take away persistent joint pain, patients may consider joint replacement surgery.
The American Joint Replacement Registry (AJRR) now reports more than 2.55 million primary or revision hip or knee replacement surgeries took place between 2012 and 2021, according to the American Academy of Orthopaedic Surgeons (AAOS). That number continues to rise.
If there’s a positive side to having surgery, it’s that there’s always advancements in the knee components themselves, says Fischer, of OSF HealthCare.
The main issue is the bearing surface, he says. If it’s made of high-density plastic, medical manufacturers strive to make that plastic more durable.
“The mode of failure is that plastic wearing out, which causes the components to loosen,” Fischer says. “There’ve been advancements in processing that differently, molding it differently, even adding vitamin E so the plastic doesn’t break down as quickly.”
Other bearing surfaces include cobalt chrome, which rides on plastic, or ceramic.
“From my perspective, the knees are all the same,” Fischer says. “The current design I use has been around for 20 years. It has the market share of the world, so I don’t see a reason for shifting.”
While Fischer appreciates new technology, he cautions patients to make sure they understand the possible risks that come with it.
“Something happened recently in hip replacement: there was a push for metal-on-metal hip replacement, with the thinking that it was better bearing surface,” he says. “In the past, we tried doing metal on metal. They were dramatic failures; they fell out of favor. It came back 10 years ago because we thought the tolerances of the metal and metal components could be machined better. But they have issues with particulate debris. The body recognizes it; white cells try to eat the debris, which comes from hip replacement. That can form pseudo tumors, which can loosen the components.”
One of the buzz phrases in medical procedures these days is “minimally invasive,” which most often translates to small incisions.
While joint replacement is a major surgery, better-designed instrumentation can help keep incisions smaller, as can the approach used by the attending surgeon.
About five years ago, hip surgeons started using an anterior (frontal) approach, which allows them access to the hip joint without going through any muscles, Fischer says. But posterior and lateral approaches are also well-known and liked by many surgeons, he adds.
“From my perspective, orthopedic literature recommends doing what is most comfortable for you,” he says. “I’ve been in practice for 25 years; I go through the side, an anterior lateral approach. There are pros and cons to all different approaches. And in the conferences we go to, they all have similar results in the long term.”
Patients don’t need to have a full understanding of joint replacement surgery before seeing a specialist; surgeons will walk each patient through the procedure. However, there are some questions patients should be ready to ask.
“They should ask, ‘How many have you done? What’s your complication rate? Do you have post-operative infections? Are your patients happy?’” says Fischer. “Those are good questions to not only be comfortable with your surgeon but also know they’re well experienced in doing the procedure.”
Fischer always makes sure his patients understand the risks of having joint replacement surgery.
“Infection is always No. 1 in my mind,” he says. “That could mean more surgery; it could mean limb loss. We want to make sure that they don’t have any rotten teeth or any poorly controlled diabetes – those are things we can control before the surgery to minimize the risk of infection.”
Fischer also tries to provide realistic expectations for post-surgery.
“I wish patients would understand that having a knee or hip replacement doesn’t mean you’re going to be normal. That’s not what happens,” he says. “You won’t go back to being 16; it’s not a normal knee or hip. But it also doesn’t mean you can’t do things you used to do. If you were a skier, yeah, you can still ski, but you can’t do the moguls anymore. If you water skied and were proficient at it, you can still do it, but you’re not going to be 100%.”
A Newer Method
Technology for knee replacements continues advancing. Within the past five years, there’s been increasing attention on TruMatch, a CT-based system that takes a scan of the knee before surgery and specifically designs the cutting instruments for that particular knee.
“That was really good,” says Dammann, of FHN. “The problem is, insurance companies said it was experimental, so they’re not paying for the CAT scans.”
A similar computer navigation system, OrthAlign, uses sensors to find the center of the ankle joint or hip joint and helps surgeons guide their cuts.
Dammann has been most impressed with robotic-assisted solutions, which have been picking up steam, he says.
“Ten to 15% of knee replacement people don’t like their knee replacement – that’s standard nationwide, for whatever reason,” he says. “I’m always trying to find ways to decrease that percentage, and over the past couple of years, robotic solutions have gained traction.”
About 12% of elective primary total knee replacements now use robotic assistance, according to the AAOS.
Following that knowledge, FHN has purchased a VELYS Robotic-Assisted Solution, and Dammann and his team have already completed more than 100 knee replacements with it. VELYS is a computer with a camera system attached to it, as well as a robotic arm with a saw to make cuts for a knee replacement.
What makes VELYS so helpful to surgeons is that it helps find the balance of the joint, Dammann says.
VELYS puts sensors on the part of the thigh bone just above the knee joint and at the end of the shin bone. The system follows those touchpoints as the knee is put through a range of motion, which helps determine if the joint is tight or loose.
“We can make six different adjustments on the cuts we’re going to make with the computer,” Dammann says. “Once you’re happy that knee is going to be really good and balanced, then the robotic arm comes in and, based on the data we’ve told the computer we want to make the cuts, the robot guides the cut. I still run the saw.”
Dammann has found the VELYS system has made cuts more accurate. Many surgeons use metal cutting guides, where a saw is placed into the guide, but there’s always the chance of getting metal debris in the knee, he says.
“The other thing I’ve found is, now, we have to do much less soft tissue direction to balance the knee better,” he says. “Traditionally, we were taught to cut the knee at a 90 degree angle, perpendicular, straight up and down. When you were born, you may have been bowlegged or knock-kneed. If I make you completely straight up and down, maybe that’s why you don’t love your knee replacement. Now, I can dial in a degree or two to compensate for your knock knee. The hope is that it gets your knee to function better and leads to more patient satisfaction.”
Dammann doesn’t have hard data to support the theory that robotic systems provide better results. But anecdotally, he finds patients recover faster, spend less time in therapy, take fewer narcotic medications and have a greatly improved same-day discharge rate.
“I think it’s definitely useful technology,” Damman says. “I would encourage people to seek out technology just to improve that 10 to 15%. They may trust their doctor, and they don’t use a robot, and that doesn’t mean it’s bad. I just think it’s worth it to look. We’ll have more data coming out from the robot, and it’ll be interesting to watch the research of bigger institutions and their experience with robots, so it’s not just anecdotal.
“There’s a lot of stuff going on,” he adds. “If you’re somebody who’s embracing technology, it’s a pretty exciting time to see what’s going on.”