“I’d play golf and literally could not walk, but I wasn’t going to give that up,” Herber recalled from his Phoenix-area home.

He was equally adamant that he didn’t want one of the most common elective orthopedic surgeries in the country: total knee replacement.

Although safe for healthy individuals and the gold standard for patients with knees as damaged as Herber’s, the procedure can be an arduous undertaking that requires up to a year for full recovery. Herber also knew that 20 percent of knee replacement patients are unhappy with their outcome. Even more ominous: A close friend died two weeks after the procedure of complications from an infection he developed because of the surgery.

“I kept putting knee replacement off,” Herber said. “I just didn’t want to go through all of that.”

An estimated 30 million Americans — or more than 11 percent of the adult population — suffer from knee osteoarthritis, the degenerative disease that prompts most knee replacements.

In addition to people like Herber who don’t want to undergo the surgery, many Americans aren’t eligible for it because of health issues, including obesity. For those people, several medical specialties — including reconstructive plastic surgery, interventional radiology, and physical medicine and rehabilitation — have developed clinically recognized treatments designed to bring at least temporary relief.

Physicians said patients suffering from debilitating knee pain should consider the following when weighing which treatment is best for them:

• How quickly do I want to recover?
• How much time do I want to invest in my treatment options?
• How healthy am I overall?
• What is the rate of success of the treatment I’m considering? What’s the likelihood it won’t help?

The medical community remains essentially united that, at least at this juncture, knee replacement is the only permanent cure.

“Knee replacement is the best treatment we have available, but it unfortunately comes at the cost of a long, challenging recovery,” said Osman Ahmed, a vascular and interventional radiologist and professor at UChicago Medicine.

Alternatives, however, may enable a patient “to kick the can down the road until they can reach a time when it’s more advantageous,” noted Anthony Giuffrida, director of interventional spine and pain management at the Cantor Spine Center at the Paley Orthopedic & Spine Institute in Fort Lauderdale, Florida.

The alternatives include procedures that target and at least temporarily silence the nerves that transmit pain signals emanating from the knee.

Physicians who perform the nerve operations note that they don’t permanently solve the problems of an arthritis-riddled knee joint. The three procedures described below are regarded as invasive, with requisite risks, although the risks are lower than with knee replacement.

Pain exists for a reason — to alert the person experiencing it that something is wrong — so concerns abound about whether an individual could do more damage to a knee after a nerve-related treatment.

“Patients ask me all the time: ‘If I don’t feel it, am I going to hurt myself more?’” said Michelle Poliak-Tunis, a double-board-certified physician in pain management and physical medicine and rehabilitation, and associate professor at the University of Wisconsin. “If you’re going to go jump out of airplanes, maybe. But if you’re going to live day-to-day life, the answer is ‘no.’”

There are indications that the procedures could help slow the mechanical decline in the knee.

“The knee doesn’t degenerate any faster,” Giuffrida said. “If anything, it degenerates more slowly because you’ve regained some range of motion and you’re more active,” which helps to maintain the health and function of supporting muscles, ligaments and tendons.

Many insurance policies cover the procedures, but the physicians interviewed for this article said that coverage is market- and insurer-specific. None of these treatments preclude a patient from having a knee replacement later.

“Neuromodulation [interrupting nerve pain signals] is the future of pain management,” said Joshua Hustedt, a Phoenix-area double-board-certified reconstructive plastic surgeon and assistant professor of orthopedics at the University of Arizona College of Medicine-Phoenix. “We’ll go after the pain signal, not replacing the worn-out parts.”

Hustedt has spent the past five years refining a procedure known as surgical knee denervation that was pioneered 30 years ago by A. Lee Dellon, a Johns Hopkins University School of Medicine professor emeritus and globally recognized expert in neuropathy.

During the 45-minute outpatient procedure, performed under either anesthesia or a local nerve block, Hustedt makes two roughly one-inch incisions on either side of the knee and uses a tiny, endoscopic camera to identify and isolate the four nerves that send pain signals to the knee. He then severs and reattaches them to surrounding leg muscles.

Research conducted by Hustedt and his colleagues found that the process of attaching the sensory nerves to motor nerves triggers a reaction in the brain that tricks the sensory nerves into thinking they are motor nerves, leading them to no longer transmit pain signals.

Sixteen days after Hustedt performed the procedure on Herber, the retiree traveled and played three consecutive days of golf without pain, something he said he could have only dreamed of before the surgery. “My knee is not a perfect knee,” Herber said. “But for what I want, at this stage of the game, it’s perfect for me.”

Hustedt has performed the procedure on about 200 knees, starting in 2020. It’s currently available only at his practice in Arizona, although he has launched a campaign to train surgeons worldwide on how to perform it. Patients may still pursue the original procedure championed by Dellon at most U.S. medical teaching hospitals, Hustedt said.

Nerve denervation is permanent, so it doesn’t need to be repeated, Hustedt said, although more studies like one he co-wrote last summer must be conducted to establish its long-term outcomes.

A procedure known as radiofrequency (RFA) ablation was introduced in the 1970s to treat back pain and expanded to knees in 2008. RFA uses radio waves guided by X-rays to find and ablate — or destroy — the nerves that transmit pain signals from the knee.

Patients undergoing the 30-minute procedure are lightly sedated. Unlike nerve denervation, the results aren’t permanent because the nerves eventually regrow and reconnect. Patients report relief for six months to one year, and the procedure may be repeated.

Doctors have deployed embolization — the blocking of blood vessels — for decades to interrupt the blood supply to tumors and to stop internal bleeding. It has been used only in recent years for knee pain.

As knee cartilage breaks down, it results in the release of inflammatory markers that promote abnormal blood vessel growth in the lining of the knee joint, Ahmed said. These abnormal arteries carry nerves with them, causing more pain and inflammation. Genicular artery embolization (GAE) targets and blocks blood flow to these abnormal arteries.

During the 35-minute-to-45-minute procedure, patients are lightly sedated and an interventional radiologist uses an X-ray to identify the abnormal arteries and then injects them with an agent that blocks those specific vessels.

Research shows the results last for at least one year and as long as four years. Ahmed said he is embarking on a study funded by the National Institutes of Health to further investigate GAE. Earlier indications that the procedure may increase infection risks for patients who later have knee replacement have largely been debunked, Ahmed said.