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FOTO Rehab Outcomes Blog

Knee Osteoarthritis: Replacement Surgery or Conservative Care?

Knee replacement surgery has slowly been on the rise. Many payers incorporate required less invasive options prior to the surgical procedure.  When is it appropriate for a total knee replacement?

deciding-when-total-knee-replacement

I know from the upcoming report, Data Trends in U.S. Healthcare and Patient Rehabilitation - Focus Patient Characteristics, Patient Outcomes and Clinical Performance, that many patients present for services with a knee problem.

I realize that total knee replacements are costly. I also realize surgical risks are real. In all honesty, I really don't understand the spectrum of patients I have seen who have knee osteoarthritis. To feel a knee loaded in the weightbearing position that creaks and grinds with that deep bone sound causes me to internally cringe. As much as possible I focus on the patient's perception of their situation versus my internal cringing. There is no reason to get overly concerned when the patient only verbalizes annoyance of the sensation. On the opposite end of the spectrum are individuals who appear to have nicely aligned joints, no swelling, no crepitus. Some of these individuals report severe knee pain. 

The study I recently found might be somewhat helpful in providing advice. I am a tad confused with this study because half of the subjects were surgical candidates and the other half were not.  I suppose I need to read the full article to have a better idea in my head about the results of the study.

You'll find the abstract below.


Total knee replacement and non-surgical treatment of knee osteoarthritis: 2-year outcome from two parallel randomized controlled trials.

 

Abstract

OBJECTIVES:

To compare 2-year outcomes of total knee replacement (TKR) followed by non-surgical treatment to that of non-surgical treatment alone and outcomes of the same non-surgical treatment to that of written advice.

DESIGN:

In two randomized trials, 200 (mean age 66) adults with moderate to severe knee osteoarthritis (OA), 100 eligible for TKR and 100 not eligible for TKR, were randomized to TKR followed by non-surgical treatment, non-surgical treatment alone, or written advice. Non-surgical treatment consisted of 12 weeks of supervised exercise, education, dietary advice, use of insoles, and pain medication. The primary outcome was the mean score of the Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, activities of daily living, and quality of life.

RESULTS:

Patients randomized to TKR had greater improvements than patients randomized to non-surgical treatment alone (difference of 18.3 points (95% CI; 11.3 to 25.3)), who in turn improved more than patients randomized to written advice (difference of 7.0 points (95% CI; 0.4 to 13.5)). Among patients eligible for TKR, 16 (32%) from the non-surgical group underwent TKR during 2 years and among those initially ineligible, seven patients (14%) from the non-surgical group and ten (20%) from the written advice group underwent TKR.

CONCLUSIONS:

TKR followed by non-surgical treatment is more effective on pain and function than non-surgical treatment alone, which in turn is more effective than written advice. Two out of three patients with moderate to severe knee OA eligible for TKR delayed surgery for at least 2 years following non-surgical treatment.

 2018 Apr 30. pii: S1063-4584(18)31221-4. doi: 10.1016/j.joca.2018.04.014. [Epub ahead of print]

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