Marc Darrow MD, JD 

In many patients that come into our office, there is a complexity of symptoms and pain in multiple joints. In one patient, for instance, it could be back pain, hip pain, and knee pain. In the patient history, we ask that patient if they have been recommended to any surgeries? Sometimes they will respond, “yes, I have been recommended to back surgery,” or sometimes they will say, “my spinal surgeon is suggesting back surgery, my orthopedist is recommending hip surgery. The two of them agree that I should have the hip surgery first then the spinal surgery.” Sometimes a patient will say that their doctors are recommending a spinal surgery, hip surgery, and bi-lateral knee replacement, which surgeries first are dependant on which is thought to be the worst of their problems.

In this article I will discuss research that suggests that in some of these situations, where a patient has hip, back and knee pain, the rush to surgery may be sending many patients to an inappropriate or unnecessary surgery knee replacement.

Fixing a problem that is not there, 21 patients who were referred to knee treatments, but who in fact had a hip problem,

If you have an MRI of your knee and it shows degenerative arthritis and you tell your doctor that your knee hurts, there is a strong possibility that you will be recommended to knee replacement.

In a 2018 study, surgeons at the University of Florida publishing in the journal Arthroplasty today (1) suggested that patients could be getting unnecessary and unneeded knee surgery because their main problem was not what the knee MRI was revealing, but an unrecognized and misdiagnosed hip problem that was referring pain to the knee. Let’s read what happened to the 21 patients who were referred to knee pain treatment.

  • Twelve of the 21 patients had undergone surgical knee interventions, including a total of 8 knee replacements with minimal to no relief of their pain.
    • After unsuccessful knee pain relief, seventeen of 21 referred patients underwent total hip replacement.
    • Fourteen patients had complete resolution of knee pain after total hip arthroplasty.

Conclusions of the study: “Although knee pain referred from hip disease may be considered a basic and common knowledge, it continues to be an overlooked phenomenon. Most of the cases were misdiagnosed by musculoskeletal providers including orthopaedic surgeons and this highlights the need for continued education and awareness of this clinical scenario.”

Knee pain complaints in women over 50. Is it really knee osteoarthritis or is it hip pain? Back pain? Weight?

Here is an interesting 2018 study (2) centered on women over the age of 50.

The researchers of this study investigated the factors associated with the level of knee pain in community-dwelling women aged 50 years or older. The radiographic grade of knee osteoarthritis, presence of low back pain, level of hip pain, Body Mass Index and presence of depressive symptoms were significant factors associated with the level of knee pain in the study group. For women without knee osteoarthritis, knee pain was found to increase according to increasing age, BMI, level of hip pain, and presence of low back pain. For women with knee osteoarthritis, knee pain was significantly associated with radiographic grade of knee osteoarthritis, BMI, level of hip pain, presence of low back pain, and presence of depressive symptoms.

Previous studies have indicated that patients with hip disease can go to the doctor with with knee pain. The sensory nerves of both the hip and knee joints originate from the femoral, sciatic, and obturator nerves (nerves at the L2-L4 lumbar region that impacts the mid-thigh). Hip joint pathology is known to be an important cause of pain referred to the knee joint. In addition, spinal problems can cause anterior knee pain through radiating pain or through the weakness of the quadriceps muscle. A previous study showed a high percentage of spinal symptoms in patients with knee pain, compared with controls. Although hip or back pain does not necessarily represent hip pathology or radiculopathy, our study results suggest that associated hip and spine disorders need to be evaluated in women with knee pain.

The question is. Women with knee pain without MRI evidence of osteoarthritis and women with knee pain with clear evidence of osteoarthritis. In this study the doctors warned to check the back, the hip, depressive episodes, and weight to determine the true cause of pain. This could prevent a recommendation to surgery that was not needed, worse, the wrong joint gets operated on.

Having the wrong joint replaced is not a new problem, it happens quite often, especially when the hip is involved.

In a study published in the medical journal Modern Rheumatology,(3) surgeons discussed the complexity of hip disease and how it impacts other joints and areas of the body.

Here the surgeons found that:

  • Hip disease was the cause of knee pain in 29% of patients. 
  • Hip disease was the cause of low back pain in 17% of patients. 

Their warning to their fellow surgeons?

  • “be aware of hip disease masquerading as knee pain or low back pain” That is how wrong surgeries may be performed.

“Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis.”

Here is study from surgeons in the United Kingdom. Published in the medical journal International Orthopaedics, (4) the surgical team of this study wanted to answer the question as to why up to 20% of total knee replacement patients complain of persisting pain after the knee replacement. Here was there answer:

  • The investigators examined 45 consecutive patients with pain after total knee replacement. Of the 45 patients, one-third, 15 patients had degenerative hip and lumbar spine disease. Nine patients had unexplained pain.
  • The study concluded: “Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis. We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.”

The patients still had knee pain after knee replacement because it was not their knee generating the knee pain, it was the hip and spine.

A 2017 study published in the journal Clinical Orthopedic Surgery, (4) doctors found that in the patients they examined with pain after knee replacement

  • 25.6% of the patients in the study were found to have nerve entrapment in the spine,
  • 15.4% were found to have hip osteoarthritis or femoral head avascular necrosis.

Knee pain persisted after knee replacement because the problem was not the knee but the hip and spine.

Physical examination can help rule out “wrong joint surgery”

I have written extensively on this website about the problems of MRIs sending people to surgery that they do not need. W\hat an MRI cannot do is gently press on the hip joint. If we can press  on the hip joint and you get a shooting pain in your knee, we can have a realistic expectation that knee replacement may not be the answer. If we can gently press on your spine, and this creates a knee pain, we may come to the same conclusion. Knee replacement may not be the answer.

Do you have questions? Ask Dr. Darrow



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REFERENCES:
1. Dibra FF, Prieto HA, Gray CF, Parvataneni HK. Don’t forget the hip! Hip arthritis masquerading as knee pain. Arthroplasty today. 2018 Mar 1;4(1):118-24.
2 Lee KM, Kang SB, Chung CY, Park MS, Kang DW, Chang CB. Factors associated with knee pain in 5148 women aged 50 years and older: A population-based study. PLoS One. 2018 Mar 8;13(3):e0192478. doi: 10.1371/journal.pone.0192478. PMID: 29518078; PMCID: PMC5843201.
3  Nakamura J, Oinuma K, Ohtori S, Watanabe A, Shigemura T, Sasho T, Saito M, Suzuki M, Takahashi K, Kishida S. Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip. Modern rheumatology. 2013 Jan 1;23(1):119-24.
4. Al-Hadithy N, Rozati H, Sewell MD, Dodds AL, Brooks P, Chatoo M. Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies? Int Orthop. 2012 Jan 11.
5. Lim, H.-A., Song, E.-K., Seon, J.-K., Park, K.-S., Shin, Y.-J., & Yang, H.-Y. (2017). Causes of Aseptic Persistent Pain after Total Knee Arthroplasty. Clinics in Orthopedic Surgery, 9(1), 50–56. http://doi.org/10.4055/cios.2017.9.1.50