There is conflicting evidence about what factors influence outcomes after total knee replacement. The objective of this study is to identify baseline factors that differentiate patients who achieve both, minimal clinically important difference and a patient acceptable symptom state in pain and function, measured by WOMAC (Pain scoring system), after total knee replacement from those who do not attain scores above the cutoff for improvement.
What were the two most important factors the Spanish team looked at one year after surgery?
- Expectations -patients did not have a realistic expectation of what they could and could not do after the knee replacement.
- The mental anguish and health of the patient while they were waiting for the knee replacement.
The recommendation from this research?
- While they wait for surgery, doctors and caregivers should manage the patient’s expectations so they have a realistic opinion of what happens after the surgery. Manage their mental health before the surgery to help with a more positive outlook afterwards.
Patient expectations of greater independence immediately following the surgery not met
Important functions to the patients such as how fast they can walk are typically not measured in determining patient outcome scores, compromising true patient outcome surveys.
For many patients, simple expectations turned out to be unrealistic expectations as witnessed by research that suggested that people who receive knee replacements expect to have greater independence immediately following the surgery.
Overlooked but certainly one of the most important reasons many patients give for getting a knee replacement is that they need to be able to care for a family member.
From research from the University of Bristol in the United Kingdom: “Transformation from a person with osteoarthritis to someone recovering from a surgical intervention can lead to alterations in the source, type and level of support people receive from others, and can also change the assistance that they themselves are able to offer.
Findings highlight the value of the concept of interdependence to our understanding of participants’ experiences.”(5)
Conversely, the pressure to help the knee replacement patient recover fails mainly on the spouse and this may be a job that the spouse will need a lot of help doing. Here is the research from a team of leading Swedish and Finnish researchers in the International journal of orthopaedic and trauma nursing:
“(The spouse is) considered to be the primary caregivers. . . the spouses’ emotional state played an important role in the patients’ quality of recovery , with uncertainty and depressive state as the main predictors (of not meeting the patient’s or spouse’s expectations of a successful knee replacement).(6)
The problem is clearly the patients think they can do more after knee replacement and they are not forewarned to reduce their expectations.
Doctors at Australia’s leading medical universities combined to produce this opinion published in the Australian and New Zealand journal of surgery.
“Walking ability and speed are important to the total knee replacement patient and are representative of their pain and function.”(7) Important functions to the patients such as how fast they can walk are typically not measured in determining patient outcome scores, compromising true patient outcome surveys.
If you have joint pain in joints OTHER than the knee being replaced, you are at risk for less successful knee replacement
In their research study researchers were looking to determine whether symptomatic (painful/problematic) joints pre-total knee replacement surgery influenced the outcomes of knee replacements, and they did
- Pre- and post-surgery, worse outcome scores were observed with increasing joint count. (The more joints that hurt, the less successful the knee replacement). Why?
- Patients had worse pre-surgery fatigue and anxiety.
- Patients had worse fatigue, depression, pain and function in non-operated joints post-surgery
Conclusion? Findings suggest that a comprehensive approach to osteoarthritis management/care is warranted, and identify important associations between painful joints and mood that negatively impact post-total knee replacement pain and physical function.(8)
Why Were You Recommended for Knee Replacement Surgery?
There are several reasons why your doctor may recommend knee replacement surgery. Recently, the American Academy of Orthopaedic Surgeons published general criteria which included the following reasons:
- Patients with bowed knees.
- Patients in severe pain.
- Patients with knee stiffness that limits everyday activities.
- Patients with chronic knee inflammation and swelling that does not improve with rest or medications.
You will also be a candidate for knee replacement if these treatments failed to improve your condition:
- anti-inflammatory medications,
- cortisone injections,
- Hyaluronic Acid Injections and lubricating injections,
- physical therapy,
- or other arthroscopic knee surgeries.
Doctors say we are rushing too many patients to knee surgery
The rising number of unmet patient expectations is why some doctors believe we are rushing too many people to surgery.
In a recent study appearing in the Clinical journal of sport medicine, researchers assessed the screening process for surgical candidates with knee osteoarthritis.
They looked at 327 patients.
More than half – 172 of them – were referred to a surgeon and 76% of them went on to have total knee replacement. Rush to judgment? These researchers thought so and concluded
“Few conservative management options were tried before referral,
indicating the need to enhance pre-surgical care for patients with knee osteoarthritis.”(9)
One Third of Knee Replacements Should Not Have Been Done
Over the years we have seen many patients who, following knee replacement surgery still had knee pain. After an examination we could clearly see that some of the patients did not need the surgery and that their doctors may have had an overzealousness to get them onto the operating table.
That has been our opinion for years and many times we would get the casual email saying that we were off base to offer such an opinion.
On June 30, 2014, a statement was issued by the medical journal Arthritis & Rheumatology, in it doctors said that their research suggested more than one third of total knee replacements in the United States were the “inappropriate” treatment.
This research strongly suggested to doctors the need for a consensus on patient selection criteria. In other words making sure those who needed a knee replacement got one, and those who did not were offered other treatments.
The Agency for Healthcare Research and Quality reports:
• more than 600,000 knee replacements are performed in the U.S. each year.
• In the past 15 years, the use of total knee arthroplasty has grown significantly
• Some experts believe the growth is due to use of an effective procedure, while others contend there is over-use of the surgery that relies on subjective criteria.
In other words a medical equation
“knee osteoarthritis = knee replacement”
In the related editorial, Dr. Jeffery Katz from the Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital in Boston, Mass., writes, “we should be concerned about offering total knee replacements to subjects who (have) “none” or “mild” on all items of the pain and function scales.”
Further as discussed below, patients are being made wait until they are old enough for knee replacement.
Ethically this should be a problem to many. People forced to live in pain until they are of appropriate age to get a knee replacement.
In October 2015, an editorial appeared in the New England Journal of Medicine. In that editorial Jeffrey N. Katz, M.D., the same mentioned above, cites the arguments that randomized trials (any further research) of total joint replacement are senseless if they all confirm a rationale to use them. After all, joint replacements are among the most significant advances of the 20th century; don’t we already know they are successful? Yes, but maybe not as successful as we think they are.
In this editorial, the readers of one of the most prestigious medical journals in the world learned that total knee replacement poses the following risks:
- About 0.5 to 1% of patients die during the 90-day postoperative period.
- The procedure is not universally successful; approximately 20% of patients who undergo total knee replacement have residual pain 6 or more months after the procedure.
- Third, there are alternatives. Clinical trials have shown that physical therapy (including exercises and manual therapies) can diminish pain and improve functional status in patients with advanced knee osteoarthritis.
- Finally, an ideal treatment for one patient may not be right for the next. Patients with knee osteoarthritis differ in the importance they attach to pain relief, functional improvement, and risk of complications. Therefore, treatment decisions should be shared between patients and their clinicians and anchored by the probabilities of pain relief and complications and the importance patients attach to these outcomes.
In a randomized, controlled trial, involving 100 patients with symptomatic knee osteoarthritis, patients were assigned to undergo total knee replacement followed by a rigorous 12-week nonsurgical-treatment regimen (total-knee-replacement group) or to receive only the nonsurgical treatment (nonsurgical-treatment group), which consisted of supervised:
- education, patient information
- dietary advice,
- use of insoles,
- and pain medication.
Total knee replacement proved markedly superior to nonsurgical treatment alone in terms of pain relief and functional improvement. However, it is noteworthy that more than two thirds of the patients in the nonsurgical-treatment group had clinically meaningful improvements in the pain score and that this group had a lower risk of complications.(10,11)
The video below will demonstrate on of the treatment options, Platelet Rich Plasma Therapy or PRP.
Delaying knee replacement with Hyaluronic Acid Injections
In regard to the use of these treatments as a means to delay inevitable knee replacement two recent major studies offer contradictory information – one study on the benefits of Hyaluronic Acid Injections says that these injections can delay total knee replacement for more than a year and in some patients up to 3.5 years.
Another study says patients should not delay total knee replacement and go right for it, Hyaluronic Acid Injections are not providing the patients with a quality choice.
In the first study on the benefits of delaying surgery with Hyaluronic Acid Injections doctors found:
- Patients who had one course of Hyaluronic Acid Injections, knee replacement was able to be delayed an average of 1.4 years.
- Patients who received more than 5 courses of Hyaluronic Acid Injections delayed Knee Replacement by 3.6 years.(12)
HOWEVER, the second in the journal American Health and Drug Benefits suggest that patients over the age of 70 should proceed to total knee replacement as opposed to delaying the knee replacement with steroids or hyaluronic acid to save on national health care costs.
This is from the study:
- “findings indicate that members without significant comorbid (other health problems) conditions who underwent knee or hip replacement procedure had a greater decrease in osteoarthritis-related healthcare resource utilization and costs after they recovered from surgery, compared with pre-surgery, and compared with the members who received intraarticular injections of (steroid and hyaluronic acid ).”(13)
Why Were You NOT Recommended for Knee Replacement Surgery?
Knee Replacement – How old is too young? Is it 55?
Here is research from researchers at the University of Tampere, Finland suggesting that in patients age 55 or younger, knee replacement should not be recommended unless the case presents special situations:
- “In the short-term follow-up the relatively young age of 55 years or less was associated with a higher risk of revision, especially for aseptic failure (infection). The underlying mechanisms require further investigation, but current knowledge indicates that in patients who are less than 55 years old, total knee replacement should only be used in selected cases when there are no other satisfactory means of giving relief from pain and dysfunction.”(14)
Researchers writing in the journal Clinical orthopaedics and related research say you may be at high risk for these 22 different risks associated with total knee replacement
The 22 complications and adverse events include:
• wound complication,
• thromboembolic disease, (surgery caused blood clots)
• neural deficit, (nerve damage)
• vascular injury,
• medial collateral ligament injury, (surgery caused knee instability by damaging ligaments)
• deep joint infection, (see below)
• extensor mechanism disruption, (damage to ligaments and tendons in the knee cap region and disruption of quadriceps)
• patellofemoral dislocation, (knee cap is not sitting properly)
• tibiofemoral dislocation,
• bearing surface wear,
• implant loosening,
• implant fracture/tibial insert dissociation,
• need for revision surgery,
• need for readmission to hospital,
• and death. (15)
You may also be at high risk for post-surgical heart attack. Doctors at Harvard Medical School released their study in October 2015 that showed risk of heart attack was significantly higher during the first postoperative month in those who had knee replacement surgery and that venous thromboembolism was a significant risk during the first month and over time for those having total knee or total hip arthroplasty as well.(16)
Exploring the options for Knee Replacement Surgery
Doctors from Australia published these observations about their patients suffering from knee osteoarthritis in the medical journal BioMed Central musculoskeletal disorders.
They had concerns about knee replacement being the right choice for every patient.
- The Australian team noted that current accepted medical treatment strategies for osteoarthritis are aimed at symptom control rather than curing or reversing the disease. Once symptom control can no longer control pain in knee osteoarthritis patients, surgical options including knee replacement are given.
- However the recommendation to knee replacement are sometimes not carefully examined as the best option. Before knee replacement is agreed to the possibility of significant complications after the knee replacement should be discussed with patients. For more of a discussion on this topic please see our article: When knee replacement is the wrong operation
The answer patients want explored – non-surgical stem cell treatments:
- There is a growing patient interest in the area of regenerative medicine, led by an improved understanding of the role of mesenchymal stem cells (stem cells from soft tissue) in tissue repair.
Encouragingly, results of pre-clinical and clinical trials have provided initial evidence of efficacy and indicated safety in the therapeutic use of mesenchymal stem cell therapies for the treatment of knee osteoarthritis.17
Destructive treatments and destructive forces
While covering studies above in this article which clearly shows the detrimental effects of some “conservative care,” treatments on a knee deep in degenerative disease, it can not be emphasized enough how damaging nonsteroidal anti-inflammatory medications and corticosteroid injections are to the joint, especially the articular cartilage.
These treatments make it more difficult in the long run for the patient to walk. Besides independence and mobility, your knee needs to walks because that is how nutrients reach the articular cartilage to help it heal.
Our goal of treatment is to help the person with knee pain and osteoarthritis who has been told that knee replacement is their only option, stop destructive treatments and to stabilize their knee to prevent the destructive stress forces from further damaging their knee.