One-Third of Total Knee Replacements Classified “Inappropriate”
Thirty-four percent of knee replacements performed over a 20-year period were classified as “inappropriate” in a study published online in the June 30, 2014, edition of Arthritis & Rheumatology.
More than 600,000 knee replacements are performed each year in the U.S., mostly to repair the damage caused by osteoarthritis (OA). The number reflects an average increase in total knee arthrosplasties (TKA) of 162 percent for each year of the study.
There is a disagreement on why the number of surgeries continues to increase. Some say it’s because TKAs are very effective; others argue that the procedure is overused and is “highly reliant” on subjective criteria, such as perception of pain.
COMPARING CRITERIA TO OUTCOMES. Daniel Riddle, PhD, Department of Physical Therapy, and his colleagues at Virginia Commonwealth University conducted what is believed to be the first study to compare a set of criteria to determine the appropriateness of TKA with actual surgical outcomes. A sample of 175 subjects with an average age 67 underwent total knee replacement surgery.
Based on existing criteria and results, their surgeries were classified as appropriate, inconclusive, or inappropriate. Forty-four percent of surgeries were deemed appropriate; 22 percent inconclusive, and 34 percent were classified as inappropriate.
“The classification system we used was developed based on standards of care in the late 1990s,” says Dr. Riddle, “so there are likely to be some important missing features. The effects of obesity and other conditions on OA pain and loss of function, for example, were not included in the standards. Some patients underwent surgery when they showed no joint space narrowing or when they had mild pain and mild loss of function. Others had end-stage knee OA, severe pain, and significant functional loss.”
SHIFTING STANDARDS. Dr. Riddle adds that the unofficial standards for who is a potential candidate for TKA are changing. People who are younger and have less pain and less functional loss are more likely to have the procedure than they would have been 10-15 years ago.
“This is why our findings need to be interpreted cautiously,” says Dr. Riddle.
Perhaps more important is the need to develop an improved, updated set of criteria for who qualifies for the surgery. Also, patients who are considering knee replacement should talk with their surgeons about what to expect following surgery.
“Preoperative status (of the knee) is the strongest indicator of postoperative outcomes,” explains Dr. Riddle. “We now have much stronger prognostic evidence to help us predict the kinds of outcomes patients should expect following surgery. The extent of knee OA is important because people with mild knee OA are at risk for poor outcomes (not meeting patients’ expectations), and these patients were classified as inappropriate in our study.”
FOR SOME, NONSURGICAL OPTIONS. The data in the VCU study suggest that for people with mild pain, relatively little functional loss, and mild knee OA (as evidenced by x-ray), nonsurgical approaches—physical therapy, exercise, weight loss, orthotics, medications—should be given strong consideration. In other words, view total knee replacement as a last resort, not a front-line strategy to treat knee pain.
The authors concluded that while patients should work more closely with their physicians in making the decision regarding total knee replacement, the medical community should develop an updated consensus on the criteria for patient selection.
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