In many patients that come into our office, there is a complexity of symptoms. This means that someone comes in with pain in multiple joints. In one patient, for instance, it could be back, hip, and knee pain. In the patient history, we ask the patient if they have been recommended to any surgeries? Sometimes they will respond, yes, back surgery, or sometimes, hip surgery, or sometimes, knee surgery, depending on which is thought of by their doctor as being the worst of their problems. Sometimes the patient will say, “the doctor wants to do the back surgery first. If that does not help, then the hip. Of course for these patients this means years of recovery and rehab during the course and recovery from two major surgeries.
But what if the back surgery does not help at all? What if the surgeons wanted to do the knee surgery first? What if the back and the knee surgery were the “wrong operation”?
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 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, but who in fact had a hip problem, that participated in this study:
- Fifteen of the 21 patients were referred to knee pain treatment/surgery from musculoskeletal providers (12 from orthopaedic surgeons).
- Prior to the “correct” diagnosis of the hip etiology,
- 16 patients were reduced to major assistive devices including wheelchairs.
- Twelve of 21 patients had undergone surgical knee interventions, including total knee arthroplasty, 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.”
Let’s remember, this is surgeons talking about other surgeons.
Having the wrong joint replaced is not a new problem, it happens quite often, especially when the hip is involved.
In a study from the Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University in China, surgeons, published in the medical journal Modern Rheumatology, (2) 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, (3) 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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1. Dibra, F. F., Prieto, H. A., Gray, C. F., & Parvataneni, H. K. (2017). Don’t forget the hip! Hip arthritis masquerading as knee pain. Arthroplasty today, 4(1), 118-124. doi:10.1016/j.artd.2017.06.008
2. Nakamura J, Oinuma K, Ohtori S, et al. Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip. Mod Rheumatol. 2012 Apr 11
3. 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.
4. 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