What to ask about a sore joint

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Use these answers for basic help, not a diagnosis. Your joint still needs an exam when soreness lasts, walks shorten, or daily chores get harder. Bring your own questions to the visit. You're the one living with the result.

Sources

1. A systematic review and meta-analysis of 89,996 patients (60.6% female, mean age 67.4) awaiting primary elective total hip or knee replacement found a significant deterioration in joint function (mean difference 0.0575% per additional day of waiting, 95% CI 0.0064 to 0.1086, p=0.028) and in health-related quality of life per additional day of waiting. Meta-analysis could not detect a relationship with post-operative outcomes, and patient responses to delayed surgery were unanimously negative.

   Cooper GM, Bayram JM, Clement ND. — The functional and psychological impact of delayed hip and knee arthroplasty: a systematic review and meta-analysis of 89,996 patients.. Scientific Reports, 2024. DOI: 10.1038/s41598-024-58050-6.

2. In a prospective cohort of 134 patients on an Australian public orthopedic waiting list for hip or knee replacement, 69% waited at least 6 months (median 286 days, IQR 169-375). Health-related quality of life deteriorated overall during the wait (mean AQoL change -0.04, 95% CI -0.08 to -0.01), with 53% of participants experiencing a clinically important decline.

   Ackerman IN, Bennell KL, Osborne RH. — Decline in Health-Related Quality of Life reported by more than half of those waiting for joint replacement surgery: a prospective cohort study.. BMC Musculoskeletal Disorders, 2011. DOI: 10.1186/1471-2474-12-108.

3. Pooling the OAI and MOST cohorts (8,002 participants followed up to 8 years, 3,417 classifiable knees), validated appropriateness criteria classified only 290 knees (8%) as receiving a TIMELY total knee replacement, 2,833 knees (83%) as potentially appropriate but not replaced more than 2 years after replacement became appropriate, and 294 knees (9% of all knees, 26% of the 1,114 replacements actually performed) as PREMATURE. Of the potentially-appropriate-but-not-replaced knees, 1,204 (42.5%) had severe symptoms.

   Ghomrawi HMK, Mushlin AI, Kang R, et al. — Examining Timeliness of Total Knee Replacement Among Patients with Knee Osteoarthritis in the U.S.: Results from the OAI and MOST Longitudinal Cohorts.. Journal of Bone and Joint Surgery (American), 2020. DOI: 10.2106/JBJS.19.00432.

4. The 2023 ACR/AAHKS timing guideline conditionally recommends AGAINST delaying hip or knee arthroplasty to pursue additional non-operative treatment - physical therapy, NSAIDs, ambulatory aids or intra-articular injections - in patients with moderate-to-severe osteoarthritis for whom non-operative therapy has already been ineffective and who have chosen surgery. It conditionally recommends delay for nicotine cessation and for better glycemic control in diabetes, states that obesity by itself is not a reason for delay while weight loss should be strongly encouraged, and conditionally recommends against delay in patients with severe deformity or bone loss. Evidence for all recommendations was graded low or very low quality.

   Hannon CP, Goodman SM, Austin MS, et al. — 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.. Arthritis & Rheumatology, 2023. DOI: 10.1002/art.42630.

5. At 2 years across two parallel randomised trials (200 patients, mean age 66), total knee replacement plus non-surgical treatment beat non-surgical treatment alone by 18.3 KOOS points (95% CI 11.3 to 25.3), and non-surgical treatment in turn beat written advice by 7.0 points (95% CI 0.4 to 13.5). Among patients eligible for replacement, 16 of 50 (32%) in the non-surgical group had surgery within 2 years - meaning two out of three delayed it for at least two years.

   Skou ST, Roos EM, Laursen MB, et al. — Total knee replacement and non-surgical treatment of knee osteoarthritis: 2-year outcome from two parallel randomized controlled trials.. Osteoarthritis and Cartilage, 2018. DOI: 10.1016/j.joca.2018.04.014.

6. In 63,158 hip and 54,276 knee replacement patients in the Clinical Practice Research Datalink, the lifetime risk of requiring revision surgery was about 5% for patients operated on after age 70 with no sex difference, but rose to 35% (95% CI 30.9-39.1) for men having surgery in their early 50s, with women's risk about 15% lower at the same age. Median time to revision for patients operated on younger than 60 was 4.4 years. The authors state their evidence challenges the trend toward more replacements in younger patients.

   Bayliss LE, Culliford D, Monk AP, et al. — The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a population-based cohort study.. The Lancet, 2017. DOI: 10.1016/S0140-6736(17)30059-4.

7. Pooled national registry data covering 299,291 total knee replacements across 14 registries give a 25-year all-cause survival of 82.3% (95% CI 81.3-83.2); pooled 25-year survival of unicompartmental knee replacements across four registries was 69.8% (67.6-72.1).

   Evans JT, Walker RW, Evans JP, et al. — How long does a knee replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up.. The Lancet, 2019. DOI: 10.1016/S0140-6736(18)32531-5.

8. A systematic review of prospective studies in unselected osteoarthritis patients found that the proportion reporting an unfavourable long-term pain outcome ranged from about 7% to 23% after hip replacement and 10% to 34% after knee replacement; in the best-quality studies, 9% or more after hip and about 20% after knee replacement.

   Beswick AD, Wylde V, Gooberman-Hill R, et al. — What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients.. BMJ Open, 2012. DOI: 10.1136/bmjopen-2011-000435.

9. In the only randomised controlled trial to compare total knee replacement directly with non-surgical treatment in patients already eligible for surgery (n=100), the replacement group improved more at 12 months than the non-surgical group (KOOS4 32.5 vs 16.0; adjusted mean difference 15.8, 95% CI 10.0 to 21.5) but had four times the serious adverse events (24 vs 6, P=0.005). Only 13 of 50 patients (26%) assigned to non-surgical treatment alone had undergone knee replacement by 12 months.

   Skou ST, Roos EM, Laursen MB, et al. — A Randomized, Controlled Trial of Total Knee Replacement.. New England Journal of Medicine, 2015. DOI: 10.1056/NEJMoa1505467.

10. The Lancet's osteoarthritis Seminar states that the diagnosis of osteoarthritis is clinically based despite the widespread OVERUSE of imaging methods, that management should be tailored to the individual and focus on core treatments including self-management and education, exercise and weight loss as relevant, and that surgery should be reserved for those who have not responded appropriately to less invasive methods.

    Hunter DJ, Bierma-Zeinstra S. — Osteoarthritis.. The Lancet, 2019. DOI: 10.1016/S0140-6736(19)30417-9.

11. A lifetime cost-effectiveness analysis using the Osteoarthritis Policy Model found total knee replacement in patients with a BMI of 40 or greater increased quality-adjusted life-years by 0.71 and lifetime medical costs by USD 25,200 in those aged 50-65, giving an incremental cost-effectiveness ratio of USD 35,200 per QALY; in those older than 65 it added 0.39 QALYs and USD 21,100 in costs. Higher complication risk in this population does not by itself make the operation poor value.

    Chen AT, Bronsther CI, Stanley EE, et al. — The Value of Total Knee Replacement in Patients With Knee Osteoarthritis and a Body Mass Index of 40 kg/m(2) or Greater : A Cost-Effectiveness Analysis.. Annals of Internal Medicine, 2021. DOI: 10.7326/M20-4722.

12. The RESTORE trial randomised 288 community-based participants aged 50+ with symptomatic medial knee OA (Kellgren-Lawrence grade 2 or 3) to three weekly intra-articular injections of leukocyte-poor PRP or saline placebo, with participants, injectors and assessors all blinded. 93% completed the 12-month follow-up. PRP did not produce a clinically meaningful improvement in knee pain over placebo, and did not slow medial tibial cartilage volume loss on MRI.

    Bennell KL, Paterson KL, Metcalf BR, et al. — Effect of Intra-articular Platelet-Rich Plasma vs Placebo Injection on Pain and Medial Tibial Cartilage Volume in Patients With Knee Osteoarthritis: The RESTORE Randomized Clinical Trial.. JAMA, 2021. DOI: 10.1001/jama.2021.19415.

13. A meta-analysis of 16 randomised trials (807 participants) of intra-articular mesenchymal stem cells for chronic knee pain from osteoarthritis found that at 3-6 months MSC therapy probably produces little to no difference in pain (WMD -0.74cm on a 10cm VAS, 95% CI -1.16 to -0.33, against a minimally important difference of 1.5cm) or physical function, both moderate certainty; at 12 months, probably little to no difference in pain. MSC therapy may increase the risk of any adverse event (RR 2.67, 95% CI 1.19 to 5.99) and of knee pain and swelling (RR 1.58, 95% CI 1.04 to 2.38).

    Sadeghirad B, Rehman Y, Khosravirad A, et al. — Mesenchymal stem cells for chronic knee pain secondary to osteoarthritis: A systematic review and meta-analysis of randomized trials.. Osteoarthritis and Cartilage, 2024. DOI: 10.1016/j.joca.2024.04.021.

14. FDA states directly that regenerative medicine therapies - including stem cells, stromal vascular fraction, umbilical cord blood, amniotic fluid, Wharton's jelly, ortho-biologics and exosomes - have NOT been approved for the treatment of any orthopedic condition, naming osteoarthritis, tendonitis, disc disease, tennis elbow, back pain, hip pain, knee pain, neck pain and shoulder pain. FDA further states that being charged for these products, or being offered them outside an FDA-overseen clinical trial, means a patient is likely being deceived and offered a product illegally, and that a product's presence on clinicaltrials.gov or a firm's FDA registration does not mean the product is legally marketed. Reported harms include blindness, tumor formation, neurological events and life-threatening bacterial infections.

    US Food and Drug Administration, Center for Biologics Evaluation and Research — Important Patient and Consumer Information About Regenerative Medicine Therapies. FDA.gov, 2021.