What to believe when knee claims sound certain

What to ask when the scan sounds final

The X-ray may show wear, bone loss, or less room between the bones. It doesn’t measure your sleep, balance, strength, or the distance you can manage. Severe wear with workable days differs from the same wear with rest soreness and lost motion.

Ask how well the image matches what the knee is doing. Your exam and history help answer that. If someone moves from “bone on bone” straight to surgery, you can ask what other findings support the advice.

One phrase shouldn’t make the whole decision.

What to expect from a knee procedure

A knee procedure may ease soreness for a time, but it can’t rebuild the joint. PRP, short for platelet-rich plasma, is used during a clinic visit; it’s made by drawing and spinning some of your blood to gather more platelets before the concentrate is placed into the knee.

Some studies report help and others don’t. In the largest study, people received either PRP or sterile salt water without knowing which one. After twelve months, PRP hadn’t eased soreness more than the salt water. Clinics can make PRP in different ways, so ask exactly what will be used, what it costs, and when relief will be checked.

Time and money belong in the choice.

What to remember when surgery is discussed

Knee replacement can bring strong relief for the right person, but it doesn’t end soreness for everyone. Research that followed patients over time found about one in five still had troubling soreness long after surgery. Surgery also brings hard recovery work and a chance of serious problems.

Waiting isn’t always safer. If sleep, walking, and chores keep getting worse after exercise, medicine, and other non-surgical care, another delay may prolong those hard months. Ask what surgery may improve, what can go wrong, and what more waiting may cost you.

Honest advice covers relief and risk.

Sources

1. The Lancet's osteoarthritis Seminar states that the diagnosis of osteoarthritis is clinically based despite the widespread OVERUSE of imaging methods, that management should be tailored to the individual and focus on core treatments including self-management and education, exercise and weight loss as relevant, and that surgery should be reserved for those who have not responded appropriately to less invasive methods.

   Hunter DJ, Bierma-Zeinstra S. — Osteoarthritis.. The Lancet, 2019. DOI: 10.1016/S0140-6736(19)30417-9.

2. A 2021 JAMA review states that osteoarthritis affects an estimated 240 million people worldwide including more than 32 million in the US, that 33% of people older than 75 have symptomatic and radiographic knee OA, that diagnosis is clinical despite widespread overuse of imaging, that people with OA are more sedentary and carry a 20% higher age-adjusted mortality, and that the cornerstones of management are exercise, weight loss where appropriate and education, complemented by topical or oral NSAIDs, with opiates to be avoided.

   Katz JN, Arant KR, Loeser RF. — Diagnosis and Treatment of Hip and Knee Osteoarthritis: A Review.. JAMA, 2021. DOI: 10.1001/jama.2020.22171.

3. A systematic review of prospective studies in unselected osteoarthritis patients found that the proportion reporting an unfavourable long-term pain outcome ranged from about 7% to 23% after hip replacement and 10% to 34% after knee replacement; in the best-quality studies, 9% or more after hip and about 20% after knee replacement.

   Beswick AD, Wylde V, Gooberman-Hill R, et al. — What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients.. BMJ Open, 2012. DOI: 10.1136/bmjopen-2011-000435.

4. A BMJ Rapid Recommendations panel issued a clinical practice guideline on arthroscopic surgery for degenerative knee arthritis and meniscal tears, published in The BMJ in 2017 and republished in the British Journal of Sports Medicine in 2018.

   Siemieniuk RAC, Harris IA, Agoritsas T, et al. — Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline.. BMJ, 2017. DOI: 10.1136/bmj.j1982.

5. The RESTORE trial randomized 288 adults aged 50+ with symptomatic mild-to-moderate medial knee OA to three weekly leukocyte-poor PRP injections or saline placebo. At 12 months, pain change was -2.1 vs -1.8 points (difference -0.4; 95% CI -0.9 to 0.2; P=.17) and medial tibial cartilage volume change was -1.4% vs -1.2% (P=.81). 29 of 31 prespecified secondary outcomes showed no significant between-group difference. The authors concluded the findings 'do not support use of PRP for the management of knee OA.'

   Bennell KL, Paterson KL, Metcalf BR, et al. — Effect of Intra-articular Platelet-Rich Plasma vs Placebo Injection on Pain and Medial Tibial Cartilage Volume in Patients With Knee Osteoarthritis: The RESTORE Randomized Clinical Trial.. JAMA, 2021. DOI: 10.1001/jama.2021.19415.

6. A BMJ meta-analysis of 169 trials (21,163 participants) found viscosupplementation (hyaluronic acid injection) reduced knee OA pain by SMD -0.08 (95% CI -0.15 to -0.02) in the 24 large placebo-controlled trials — about 2.0 mm on a 100 mm scale, far below the prespecified 0.37 SMD minimal clinically important difference — and increased serious adverse events (RR 1.49, 95% CI 1.12 to 1.98). Trial sequential analysis showed conclusive evidence of clinical equivalence to placebo has existed since 2009.

   Pereira TV, Juni P, Saadat P, et al. — Viscosupplementation for knee osteoarthritis: systematic review and meta-analysis.. BMJ, 2022. DOI: 10.1136/bmj-2022-069722.

7. In a placebo-surgery-controlled trial of 180 patients with knee OA, neither arthroscopic debridement nor arthroscopic lavage outperformed placebo surgery at ANY time point over 24 months on any of five self-reported pain/function scales or an objective walking and stair-climbing test.

   Moseley JB, O'Malley K, Petersen NJ, et al. — A controlled trial of arthroscopic surgery for osteoarthritis of the knee.. New England Journal of Medicine, 2002. DOI: 10.1056/NEJMoa013259.

8. FDA states verbatim: 'None of these products have been approved for the treatment of any orthopedic condition, such as osteoarthritis, tendonitis, disc disease, tennis elbow, back pain, hip pain, knee pain, neck pain, or shoulder pain.' The only FDA-approved stem cell products in the United States are blood-forming (hematopoietic progenitor) cells derived from umbilical cord blood, approved only for disorders of blood production. There are currently NO FDA-approved exosome products.

   U.S. Food and Drug Administration — Consumer Alert on Regenerative Medicine Products Including Stem Cells and Exosomes. FDA (Center for Biologics Evaluation and Research), 2020.