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Why is it that are we still in the outdated "wait, rest, drugs, joint replacement" era?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: arthritis. An estimated 27 million Americans age 25 and older have osteoarthritis, up from 21 million in 1990.
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 arthritis 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.), eight drug regimens (over the counter, prescription and injections) and three 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, there are 1.4 million knee arthroscopy surgical procedures in the U.S. where the meniscus cartilage is partially removed. More than 20 million people already have knee arthritis. We are creating an enormous pool of injured people without recommending treatments that actually fix the disease.
Yet ways to treat and prevent arthritis 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 now documenting that meniscus replacement in the setting of arthritis returns the patient to sports without pain and the benefits last more than a decade. 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.
Articular cartilage can be repaired. A two- to 12-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. A 10- to 20-year outcome study is soon to be reported with similar encouraging results. Arthritis 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 osteo 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.
Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco. He pioneers advanced orthopedic surgical and rehabilitation techniques to repair, regenerate and replace damaged cartilage and ligaments. For more info, visit www.stoneclinic.com.