“It seems reasonable to question whether TKA was the most appropriate intervention,” wrote authors Daniel Riddle, Dr. William Jiranek and Dr. Curtis Hayes of the departments of physical therapy, orthopedic surgery and radiology at Virginia Commonwealth University in Richmond. “Most of these subjects either had pain and functional loss profiles that were less than half that of typical patients undergoing TKA or they had no joint space narrowing.”
There was also extensive variation among patient characteristics, particularly when it came to knee pain, osteoarthritis severity and extent of functional loss, the study concluded. “It is likely this variation will continue until consensus is reached on the key criteria that drive decisions to recommend TKA to patients,” the authors said.
Data for the research was obtained from the Osteoarthritis Initiative, an NIH and privately funded multicenter, five-year longitudinal study of persons with, or at high risk for, knee osteoarthritis.
Concern about overuse of total knee replacement comes amid findings of another recent study, which estimated that the number of total knee replacement surgeries more than tripled in the U.S. between 1993 and 2009. The increase was linked closely to the overweight and obesity epidemic. An estimated 719,000 total knee replacements are done each year, according to the Centers for Disease Control and Prevention.
Because that number is expected to grow, Dr. Jeffrey Katz, of the Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women's Hospital in Boston, agrees it is reasonable to question whether knee surgeries are being done for appropriate indications. The new study “raises serious concerns about overutilization,” he said in an editorial accompanying the Arthritis & Rheumatology study.
At the same time, Katz cautions that any scale to determine “appropriateness” might be valued differently when considered from a patient's perspective. For example, even those who do not yet have severe knee damage might opt for surgery, even when considered inappropriate, if it means the patient would not have to experience pain or could see functional improvements.
“We must consider whether it is advisable and affordable to use costly technology such as TKR in the same fashion: to maintain and augment function rather than attempt (generally with muted success) to regain function once it's gone,” Katz wrote. But, in the absence of policy, he said, physicians should be sure to have conversations with their patients about the potential risks and benefits.
“This discussion is complex but seems the most appropriate course given the current state of play.”
Follow Sabriya Rice on Twitter: @MHSRice