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Doctor… I Don’t Want a Joint Replacement For my Arthritis. What Are my Options?
- By Nathan Wei
- Published 08/14/2008
- Medicines and Remedies
- Unrated
Nathan Wei
Nathan Wei, MD FACP FACR is a board-certified rheumatologist. For more info: Arthritis Treatment and Tendonitis Treatment Tips
View all articles by Nathan Wei
Arthritis is a growing health concern. The most common form of arthritis-osteoarthritis (OA)- is increasing in prevalence coincident with the Baby Boomer surge into late middle age. It is estimated that OA affects more than 20-30 million Americans. By the year 2030, that number will probably double.
This form of arthritis is also prevalent among the overweight—which describes nearly 65 percent of our nation's adult population.
While the treatment of end-stage OA of weight-bearing joints such as the hips and knees has been enhanced by surgical joint replacement techniques, joint surgery also has its many downsides including complications related to the procedure, complications arising from anesthesia, and the hefty price tag associated with the procedure which is a drag on the healthcare system.
A recent study done by researchers at Florida International University analyzed increases in surgeries and costs between 1997 and 2004. The April 2008 issue of Arthritis Care & Research presents eyebrow raising numbers that conclude with the author’s contention that "the burden resulting from hip/knee joint replacement is not only substantial but also increasing at a steep rate."
Among the findings include:
• In 2004, approximately 431,485 primary knee replacements were performed—a 53 percent increase from the year 2000. 225,900 primary hip replacements were performed in the US—marking a 37 percent increase for the same period.
• In 1997, about 60 percent of primary hip replacements and 69 percent of primary knee replacements were performed on individuals between the ages of 65 and 84 years. Although elderly patients remained the main recipients, the number of joint replacement surgeries among the middle-aged, patients between 45 and 64 years, increased excessively—71 percent for hip replacements and 83 percent for knee replacements—in 2004.
• Between 1997 and 2004, the hospital charges for joint replacements, both primary and revision surgeries, increased faster than the rate of inflation. While Medicare continued to provide the principal source of payment, compared with other sources of payment, the relative burden decreased. The burden on private insurance more than tripled in that 7-year span—from $1.1 billion to $3 billion for hip replacements and from $1.46 billion to $4.64 billion for knee replacements.
According to the research, led by Dr. Sunny Kim, ”if current trends persist, nearly 600,000 hip replacements and 1.4 million knee replacements will be performed in the year 2015.
Dr. Kim and colleagues stressed the need for "public health education …to reduce the proportion of people who are overweight as well as to manage arthritis at earlier stages… the health care community should be prepared for this upcoming demand of surgical loads and its economic burden on government and private insurance systems."
These sobering statistics point towards the need for therapies designed to prolong the life of cartilage and possibly to regenerate new cartilage. While the thrust of research until recently has been to evaluate drugs that might have disease-modifying potential, clinical trial results have been disappointing.
In addition, stop-gap measures such as glucocorticoid (“cortisone”) and viscosupplement (lubricant) injections may not provide long-term relief. In addition, glucocorticoids led to more cartilage deterioration.
However, a new approach- ironically, borrowed from the veterinary sector- shows great promise in the possibility of cartilage regeneration.
Stem cells are pluripotential cells, meaning they are capable of differentiating into any type of cell in the body, given the right circumstances. Orthopedic surgeons have been interested in designing tissue scaffold techniques to help preserve cartilage. However, the procedures are cumbersome and require recuperation periods of between 6 and 12 months.
It is now possible to harvest a person’s own stem cells by using a small gauge biopsy needle inserted into the iliac crest (back of the pelvis). Stem cells are then concentrated in a process termed Bone Marrow Aspirate Concentrate (BMAC). At the same time, platelet rich plasma is obtained from the patient’s whole blood. Platelets are cells in the blood that contain multiple growth and healing factors.
A medium gauge needle is then inserted into the hip or knee and used to “irritate” the cartilage and adjacent tendons to stimulate an inflammatory response. Inflammation is the body’s response to injury and is the first stage of healing. The stem cells and platelet rich plasma are then injected into the joint and the patient is placed at limited weight-bearing for one week.
Follow-up imaging studies including magnetic resonance imaging and diagnostic ultrasound have confirmed the re-growth of cartilage in small uncontrolled studies. These observations are consistent with the larger scale controlled studies seen in the veterinary literature.
Patient selection is important in that patients over the age of 60 tend to have “senescent chondrocytes.” This means their cartilage cells are older and less responsive to stem cell stimulation. That is not meant to entirely exclude patients in their 660’s. A patient who is physically active, at ideal weight, and is interested in remaining so, might be a much better candidate than a 50 year-old couch potato.
The added attraction is that this procedure can be done in an outpatient facility at a fraction of the cost of a joint replacement!
This form of arthritis is also prevalent among the overweight—which describes nearly 65 percent of our nation's adult population.
While the treatment of end-stage OA of weight-bearing joints such as the hips and knees has been enhanced by surgical joint replacement techniques, joint surgery also has its many downsides including complications related to the procedure, complications arising from anesthesia, and the hefty price tag associated with the procedure which is a drag on the healthcare system.
A recent study done by researchers at Florida International University analyzed increases in surgeries and costs between 1997 and 2004. The April 2008 issue of Arthritis Care & Research presents eyebrow raising numbers that conclude with the author’s contention that "the burden resulting from hip/knee joint replacement is not only substantial but also increasing at a steep rate."
Among the findings include:
• In 2004, approximately 431,485 primary knee replacements were performed—a 53 percent increase from the year 2000. 225,900 primary hip replacements were performed in the US—marking a 37 percent increase for the same period.
• In 1997, about 60 percent of primary hip replacements and 69 percent of primary knee replacements were performed on individuals between the ages of 65 and 84 years. Although elderly patients remained the main recipients, the number of joint replacement surgeries among the middle-aged, patients between 45 and 64 years, increased excessively—71 percent for hip replacements and 83 percent for knee replacements—in 2004.
• Between 1997 and 2004, the hospital charges for joint replacements, both primary and revision surgeries, increased faster than the rate of inflation. While Medicare continued to provide the principal source of payment, compared with other sources of payment, the relative burden decreased. The burden on private insurance more than tripled in that 7-year span—from $1.1 billion to $3 billion for hip replacements and from $1.46 billion to $4.64 billion for knee replacements.
According to the research, led by Dr. Sunny Kim, ”if current trends persist, nearly 600,000 hip replacements and 1.4 million knee replacements will be performed in the year 2015.
Dr. Kim and colleagues stressed the need for "public health education …to reduce the proportion of people who are overweight as well as to manage arthritis at earlier stages… the health care community should be prepared for this upcoming demand of surgical loads and its economic burden on government and private insurance systems."
These sobering statistics point towards the need for therapies designed to prolong the life of cartilage and possibly to regenerate new cartilage. While the thrust of research until recently has been to evaluate drugs that might have disease-modifying potential, clinical trial results have been disappointing.
In addition, stop-gap measures such as glucocorticoid (“cortisone”) and viscosupplement (lubricant) injections may not provide long-term relief. In addition, glucocorticoids led to more cartilage deterioration.
However, a new approach- ironically, borrowed from the veterinary sector- shows great promise in the possibility of cartilage regeneration.
Stem cells are pluripotential cells, meaning they are capable of differentiating into any type of cell in the body, given the right circumstances. Orthopedic surgeons have been interested in designing tissue scaffold techniques to help preserve cartilage. However, the procedures are cumbersome and require recuperation periods of between 6 and 12 months.
It is now possible to harvest a person’s own stem cells by using a small gauge biopsy needle inserted into the iliac crest (back of the pelvis). Stem cells are then concentrated in a process termed Bone Marrow Aspirate Concentrate (BMAC). At the same time, platelet rich plasma is obtained from the patient’s whole blood. Platelets are cells in the blood that contain multiple growth and healing factors.
A medium gauge needle is then inserted into the hip or knee and used to “irritate” the cartilage and adjacent tendons to stimulate an inflammatory response. Inflammation is the body’s response to injury and is the first stage of healing. The stem cells and platelet rich plasma are then injected into the joint and the patient is placed at limited weight-bearing for one week.
Follow-up imaging studies including magnetic resonance imaging and diagnostic ultrasound have confirmed the re-growth of cartilage in small uncontrolled studies. These observations are consistent with the larger scale controlled studies seen in the veterinary literature.
Patient selection is important in that patients over the age of 60 tend to have “senescent chondrocytes.” This means their cartilage cells are older and less responsive to stem cell stimulation. That is not meant to entirely exclude patients in their 660’s. A patient who is physically active, at ideal weight, and is interested in remaining so, might be a much better candidate than a 50 year-old couch potato.
The added attraction is that this procedure can be done in an outpatient facility at a fraction of the cost of a joint replacement!