Sunday, June 30, 2024

A shot in the knee?

A lot of us develop osteoarthritis (“wear and tear arthritis” – though the process is not that simple) as we age.

If it is truly disabling, surgery may be the only way to reduce pain and increase mobility, but there are many less invasive options. Do any of them work?

Let’s get one myth out of the way first. Many people see an orthopedic surgeon and are told “your knee(s) are bone-on-bone, and nothing will work but surgery.” This is very often an exaggeration. There may be complete loss of cartilage in a portion of the knee, but rarely does this involve the whole knee. If it is on one edge, a brace may give great relief. The decision to have surgery should almost never be based on an X-ray.

The most time-tested non-surgical approach is an injection of a cortisone-type product into the knee, usually accompanied by a local anesthetic. This injection generally starts working in 2 days, and the effect may last 3-4 months. I had patients who got these shots 3-4 times a year for several years with good relief.

Like any treatment, cortisone shots do not work for everyone, and there is a worry that the drug may hasten deterioration of cartilage. The treatment is universally covered by Medicare and commercial insurance plans.

Hyaluronic acid is a lubricant that mimics the body’s natural joint fluid and injecting it into the knee is another “standard” procedure that is covered by insurance. Since most of the product leaks out of the joint within a few days, it is unclear how it works, and recent studies have suggested that it has largely a placebo effect.

Newer treatments are available that are considered experimental and typically NOT covered by insurance.

One is injection of platelet-rich plasma (PRP), drawn from your own blood, centrifuged to separate the PRP from the rest of the blood and injected into the knee. These seem to work by reducing inflammation and may provide relief for as long as a year. Be prepared to pay several thousand dollars out of pocket if you go this route.

Widely advertised is the use of stem cell injections, which can theoretically grow new cartilage. The jury is still out on this, but most studies show benefit lasting only 3-4 months. The cost, in the thousands, will almost certainly not be covered by insurance.

The newest kid on the block is radiofrequency ablation (RFA) of the pain nerves in the knee. This treatment has been shown to give pain relief for up to six months. It is minimally invasive and has few side effects, but is often not covered by insurance, at least not without prior approval from your insurance company.

Knee replacement surgery is generally, but far from always, successful. If you opt for this surgery, know that you must be committed to doing a lot of physical therapy for many months to get the best result.

Do not forget weight loss! Whether through use of the newer drugs or old-fashioned diet, significant weight loss will usually help your knees.

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