Severe Osteoarthritis, Symptoms and X ray finding

[Aaron Hartman]

I have a patient in my functional medicine practice in her late 60’s who is quite healthy but her knees look terrible on x-ray. There is almost no joint space and severe varus deformities, HOWEVER she is still able to do what she wants. Her ortho says she needs bilateral knee replacement. I disagree.

I’m wondering how some of the orthopedic surgeons in the group would address this patient, who has seen a surgeon who says she needs surgery. We seem to talk about it at every visit.

Thanks

Aaron Hartman

[Kristelle Reyes]

Hello @byurthgmail-com and @drkriswyahoo-com, would love to have your insights here.

Thank you! 🙂

[Kristelle Reyes]

Hello  Dr. @hartmanangmail-com,

Here’s a video response from Dr. Seeds’ SSRP Office Hours 9/21/21 at 21:49, please watch below:

Thank you! 🙂

[Kristelle Reyes]

Claim your CME here: https://earnc.me/GtsCfq

[William Curtis]

Summary by Dr. Seeds (transcription edited for readability):

 

The approach to somebody who is contemplating joint replacement is a great question. If you have someone who is in pain that is not controlled by some type of pain control, whether it’s peptides, molecules, whatever, if you’re not able to control their pain, and it’s affecting their daily living activities, and they’ve had enough of it, that kind of meets that criteria of improving their quality of life. Because it’s all about quality of life.

If they’re functional and they’re able to do all the things they want to do, and I have plenty of patients like that, that don’t come in and complain of pain, and have varus knees, and have terrible x-rays, and they’re not even there to see me for their knees. They’re there to see me for something else, and I’ll look at them, and say, oh, my gosh. I used to, a long time ago, I used to ask people if I could x-ray that and look at it, because I’d like to show it to my residents or it was a great teaching tool to show you, look, this person has (problems) mechanically, they are pretty bow legged like they just got off a horse, right? And they’re not in any pain, but you look in the x-ray and they’ve got severe disease in the medial compartment. The have varus deformity , but yet there are no pain and they’re functioning fine .

So, I think you’re right on track with the discussion with the doc, with the patient. Hey, we’re managing this. What, what are we thinking about surgery right now? Because the knee, you know, as orthopedic surgeons, the surgical procedure is pretty advanced to where no matter how bad that knee gets, we’re in a good position to correct it. So, I think it’s much better to weigh on the conservative side and continue to encourage your patient to be active, because that activity is what’s keeping that patient going. The activity is what’s producing the anti-inflammatory environment in the joint. So, just based on the information you’ve given me, just going off what you’ve told me, I would say, I agree 100% with you.

And I think it’s a good conversation to have because there are many downsides to surgery. If it doesn’t go right.  And it just takes that one person to have something where it doesn’t go right. So, you always must have that conversation. So, it comes down to quality of life, and what are the benefits on each side of this, and it sounds to me, from what you’re saying, this patient is totally, perfectly functional. If that’s true, my recommendation would be to continue the conservative treatment. That’s how I approach it in my office. So, that’s a really good question and a great conversation to have with your patient.

(Keren)I’ve noticed that patients lately, using my last few months of shadowing doctor Seeds, they don’t really want to go into surgery.

You know, that’s a good question too It depends, it depends on where the patient is in their life and how much it’s affecting them. Most of the people we see seek us out because they know there’s may potentially be other options. There are patients that surgery is a good option at that time for them. That’s why it’s a good discussion to have. So, there’s a great question.

Don’t get me wrong, either.  I’m a surgeon. I love to fix things.  I’m all about fixing joints because I can make them look good. I’ve been doing this long enough to know that even if we think something might be better for someone, we’re not always right, and even if we could do it well, we’re not always right . So, you’ve really got to weigh it into your decisions and see where that patient is and let them make the decision.

[Trevor Turner]

@hartmanangmail-com should also note that intraosseous BMAC for knee OA (note some of these were Grade 4 OA):

 

There is an increasing number of reports on the treatment of knee osteoarthritis (OA) using mesenchymal stem cells (MSCs). However, it is not known what would better drive osteoarthritis stabilization to postpone total knee arthroplasty (TKA): targeting the synovial fluid by injection or targeting on the subchondral bone with MSCs implantation.

Methods

A prospective randomized controlled clinical trial was carried out between 2000 and 2005 in 120 knees of 60 patients with painful bilateral knee osteoarthritis with a similar osteoarthritis grade. During the same anaesthesia, a bone marrow concentrate of 40 mL containing an average 5727 MSCs/mL (range 2740 to 7540) was divided in two equal parts: after randomization, one part (20 mL) was delivered to the subchondral bone of femur and tibia of one knee (subchondral group) and the other part was injected in the joint for the contralateral knee (intra-articular group). MSCs were counted as CFU-F (colony fibroblastic unit forming). Clinical outcomes of the patient (Knee Society score) were obtained along with radiological imaging outcomes (including MRIs) at two year follow-up. Subsequent revision surgeries were identified until the most recent follow-up (average of 15 years, range 13 to 18 years).

Results

At two year follow-up, clinical and imaging (MRI) improvement was higher on the side that received cells in the subchondral bone. At the most recent follow-up (15 years), among the 60 knees treated with subchondral cell therapy, the yearly arthroplasty incidence was 1.3% per knee-year; for the 60 knees with intra-articular cell therapy, the yearly arthroplasty incidence was higher (p = 0.01) with an incidence of 4.6% per knee-year. For the side with subchondral cell therapy, 12 (20%) of 60 knees underwent TKA, while 42 (70%) of 60 knees underwent TKA on the side with intra-articular cell therapy. Among the 18 patients who had no subsequent surgery on both sides, all preferred the knee with subchondral cell therapy.

Conclusions

Implantation of MSCs in the subchondral bone of an osteoarthritic knee is more effective to postpone TKA than injection of the same intra-articular dose in the contralateral knee with the same grade of osteoarthritis.

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