Current arthritis treatment is outdated and unacceptable

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You are told you have knee arthritis. The doctor isn't positive why, maybe genetics, maybe that old soccer injury in high school, maybe because a surgeon removed some of the meniscus cartilage. The advice the doctor gives you is to go home, rest your knee, take anti-inflammatory drugs, lose some weight, wait until you are older and then get an artificial knee replacement. This advice is awful.

In the 21st century, wouldn't you think the advice could be: Here is how to fix your problem and, by the way, here is how to use the injury as an opportunity to get fitter than you have been in years?

Why is it that are we still in the outdated "wait, rest, drugs, joint replacement" era? Here is the shocking data.

The dramatic increase in knee injuries in athletes of all ages is leading to a rise in the silent killer of active lifestyles: osteoarthritis. An estimated 27 million Americans age 25 and older have osteoarthritis, up from 21 million in 1990. [1]

If you injure your knee in high school and either you live with it or the surgeon removes a portion of the articular cartilage, the bearing surface of the joint, or the meniscus cartilage, the fibrous shock absorber, you have a more than 80-percent chance of developing arthritis within 20 years.

If you have osteoarthritis and are 20 to 60 years old, the standard of care recommended by the National Arthritis Foundation, National Institutes of Health, and Centers for Disease Control and Prevention and the top 10 hospitals in the U.S. includes 20-plus treatment options. These consist of: 

  • 11 lifestyle changes (lose weight, don't run etc.)
  • 8 drug regimens (over the counter, prescription and injections)
  • 3 surgeries (debridement, lavage and osteotomy)

Once you turn 60, you will be recommended for a knee replacement, the only treatment option to address the underlying cause of the arthritis. The rest of the treatments manage the symptoms, which counterproductively encourage people to resume the activities that further damage the joint.

If you get a knee replacement, you've got a 50-percent chance of still having pain afterwards and impact sports are forbidden.

Every year, 700 thousand knee arthroscopy procedures, where the meniscus cartilage is partially removed, are performed in Ambulatory Surgical Centers in the U.S. More than 20 million people already have knee osteoarthritis. [2]

Yet ways to treat and prevent osteoarthritis are available, just not fully accepted or proven. If your meniscus is torn, it can be repaired or replaced by a donor meniscus replacement.

There are several studies documenting that meniscus replacement in the setting of arthritis can improve patients' pain, function and activity levels provided that the cartilage damage is treated as well [3,4,5,6] with new data promising the ability to participate in sports for over 10 years. [7] Despite this, less than 1 percent of torn meniscus cartilages are repaired and only 1,500 meniscus replacements are performed in the U.S. each year. [8]

Articular cartilage can be repaired. A two-to-twelve-year outcome study combining meniscus replacement with the articular cartilage paste grafting technique demonstrated an 80 percent success rate at improving function and diminishing pain in arthritic patients with a survival of the implants estimated at 9.9 years. [9] A 10- to 20-year outcome study is soon to be reported with similar encouraging results.

Osteoarthritis can be treated, possibly even prevented, and certainly the injuries to the joint that lead to more severe arthritis can be successfully repaired.

So why are so few people treated? Firstly, doctors and insurers demand more of what are called Level 1 studies, which are usually prospective, comparative blind trials where one patient receives the treatment and another receives a placebo. These are extremely difficult to do for patients who have significant knee injuries and are requesting repair, even though the absence of treatment has a certain failure rate.

Additionally, these procedures are technically difficult (few surgeons have extensive meniscus replacement experience). Also, cost and lack of reimbursement are the most frequently cited reasons why the initial injury or the arthritis is not repaired. The insurers of today most likely will not be around to foot the bill of the arthritis you get a decade from now. And finally politics. The Arthritis Foundation is a rheumatology entity that focuses on inflammatory arthritis. Very few people with arthritis have inflammatory arthritis such as rheumatoid arthritis. Most people have osteoarthritis or traumatic arthritis. The disproportionate spending on the minority has led to a neglect of the trauma-induced arthritis that most athletes suffer from.

Stay tuned. Patients are demanding a better level of arthritis care. And the NFL and other sports entities are starting to pay attention to the long-term effects of injury to the knees, not just the concussions we hear about more often. The silent arthritis is soon to be less quiet.

1. Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum 2008;58(1):26-35.

2. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Rep 2009;11:1-25

3. Rue LJ-PPH, Yanke AB, Busam ML, McNickle AG, Cole BJ. Prospective Evaluation of Concurrent Meniscus Transplantation and Articular Cartilage Repair: Minimum 2-Year Follow-Up. Am J Sports Med. 2008;36(9):1770-1778. doi:10.1177/0363546508317122.

4. Farr J, Rawal A, Marberry KM. Concomitant meniscal allograft transplantation and autologous chondrocyte implantation: minimum 2-year follow-up. Am J Sport Med. 2007;35(9):1459-1466. doi:0363546507301257 [pii] 10.1177/0363546507301257.

5. Stone KR, Walgenbach AW, Turek TJ, Freyer A, Hill MD. Meniscus allograft survival in patients with moderate to severe unicompartmental arthritis: a 2- to 7-year follow-up. Arthroscopy. 2006;22(5):469-478. doi:S0749-8063(05)01789-5 [pii] 10.1016/j.arthro.2005.12.045.

6. Stone KR, Adelson WS, Pelsis JR, Walgenbach AW, Turek TJ. Long-term survival of concurrent meniscus allograft transplantation and repair of the articular cartilage: A PROSPECTIVE TWO- TO 12-YEAR FOLLOW-UP REPORT. J Bone Jt Surg Br. 2010;92-B(7):941-948. doi:10.1302/0301-620x.92b7.23182.

7. "Meniscus Allograft Transplantation Allows Return To Sporting Activities," Stone, KR. 9th Biennial ISAKOS Congress, Toronto, Canada, May 12, 2013.

8. Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 2005-2011. Am J Sports Med. 2013;41(10):2333-9. doi:10.1177/0363546513495641.

9. Stone KR, Adelson WS, Pelsis JR, Walgenbach AW, Turek TJ. Long-term survival of concurrent meniscus allograft transplantation and repair of the articular cartilage: A PROSPECTIVE TWO- TO 12-YEAR FOLLOW-UP REPORT. J Bone Jt Surg Br. 2010;92-B(7):941-948. doi:10.1302/0301-620x.92b7.23182.

Posted by Kevin R. Stone, M.D on May 18th, 2014
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