Knee replacement timing is all wrong for most

People delay surgery and lose function; others get it too soon with less benefit.

  • When surgery is delayed, people don’t get full benefit of new knee.
  • When surgery is premature, patients assume unnecessary risk and may need a second replacement.
  • Nearly 1 million knee replacement procedures are performed in the U.S. each year.

According to the American Academy of Orthopaedic Surgeons, only one in every 100 people who have a hip or knee replacement will develop an infection. Medical News Today

By Marla Paul, Northwestern University January 14, 2020

The timing of knee replacement surgery is critical to optimize its benefit. But 90% of patients with knee osteoarthritis who would potentially benefit from knee replacement are waiting too long to have it and getting less benefit. In addition, about 25% of patients who don’t need it are having it prematurely when the benefit is minimal, reports a new Northwestern Medicine study.

This is believed to be the first study to prospectively examine the timeliness of knee replacement among a large number of patients with knee osteoarthritis who could benefit from the surgery. Few prior studies have quantified timeliness of surgery but only among patients who already had knee replacement, and these studies generally were in smaller cohorts of patients.

“People are waiting and waiting to have the procedure and losing the most benefit,” said lead investigator Hassan Ghomrawi, associate professor of surgery at Northwestern University Feinberg School of Medicine.

African-Americans delayed knee replacement surgery more than Caucasians, the study found.

“When people wait too long, two things happen,” Ghomrawi said. “The osteoarthritis causes deterioration of their function. Some of them wouldn’t be able to straighten out their legs, affecting their walking and mobility. When you can’t get exercise, you can start to develop other health problems such as cardiovascular problems. You may also become depressed. The overall impact can be huge.”

The second problem with delaying surgery is less benefit. “You don’t get as much function back when you wait too long; your mobility is still reduced versus somebody who had it in a timely fashion,” Ghomrawi said.

The ideal timing of knee replacement surgery is based on an algorithm that factors in pain, joint function, radiographic assessment and age to determine if a person will benefit from surgery.

Getting knee replacement surgery too early based on the algorithm means patients are having major surgery with risk of complications and getting minimal benefit. They may also need a revision (second surgery) later in life, which is a much more difficult surgery with poorer outcomes than the original surgery.

The study was published Jan. 13 in the Journal of Bone and Joint Surgery.

Nearly 1 million knee replacement procedures are performed in the U.S. each year with projections of a rapid increase by 2030, the paper reports.

“As the number of surgeries rises, we need to make sure the timing is optimal for patients to obtain the most benefit and to keep health care costs down,” Ghomrawi said. “Because knee replacement is an elective procedure, the timing of surgery is susceptible to not just clinical factors but also demographic, socio-economic and socio-cultural ones. We need to develop a better understanding of these factors to improve timing of surgery.”

The Northwestern study was based on 8,002 participants who had or were at risk for knee osteoarthritis and were followed for up to eight years as part of two diverse multicenter trials, the Osteoarthritis Initiative and Multicenter Osteoarthritis Study, MOST.

Dr. Leena Sharma of Northwestern is a study coauthor. The study was funded by grants R21-AR069867 and P30-AR072579 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health.

Source Northwestern University via EurekAlert! AAAS


Examining Timeliness of Total Knee Replacement Among Patients with Knee Osteoarthritis in the U.S.: Results from the OAI and MOST Longitudinal Cohorts, Ghomrawi HMK, Mushlin AI, Kang R, Banerjee S, Singh JA, Sharma L, Flink C, Nevitt M, Neogi T, Riddle DL. J Bone Joint Surg Am. January 13, 2020. doi: 10.2106/JBJS.19.00432

  Further reading

Preoperative Expectations Associated With Postoperative Dissatisfaction After Total Knee Arthroplasty: A Cohort Study, Ghomrawi HMK, Lee LY, Nwachukwu BU, Jain D, Wright T, Padgett D, Bozic KJ, Lyman S. J Am Acad Orthop Surg. 2019 Jun 11. doi: 10.5435/JAAOS-D-18-00785. [Epub ahead of print]

Association of Race/Ethnicity With Hospital Discharge Disposition After Elective Total Knee Arthroplasty, Singh JA, Kallan MJ, Chen Y, Parks ML, Ibrahim SA. JAMA Netw Open. 2019 Oct 2;2(10):e1914259. doi: 10.1001/jamanetworkopen.2019.14259. Erratum in: JAMA Netw Open. 2019 Dec 2;2(12):e1918528. Full text

Do Surgeon Expectations Predict Clinically Important Improvements in WOMAC Scores After THA and TKA? Ghomrawi HMK, Mancuso CA, Dunning A, Gonzalez Della Valle A, Alexiades M, Cornell C, Sculco T, Bostrom M, Mayman D, Marx RG, Westrich G, O’Dell M, Mushlin AI. Clin Orthop Relat Res. 2017 Sep;475(9):2150-2158. doi: 10.1007/s11999-017-5331-8. Epub 2017 Mar 28. Full text

Physician referral patterns and racial disparities in total hip replacement: A network analysis approach, Ghomrawi HMK, Funk RJ, Parks ML, Owen-Smith J, Hollingsworth JM. PLoS One. 2018 Feb 20;13(2):e0193014. doi: 10.1371/journal.pone.0193014. eCollection 2018. Full text

The influence of preoperative determinants on quality of life, functioning and pain after total knee and hip replacement: a pooled analysis of Dutch cohorts, Hofstede SN, Gademan MGJ, Stijnen T, Nelissen RGHH, Marang-van de Mheen PJ; ARGON-OPTIMA study group. BMC Musculoskelet Disord. 2018 Mar 2;19(1):68. doi: 10.1186/s12891-018-1991-0. Full text

Unfulfilled Expectations After Total Hip and Knee Arthroplasty Surgery: There Is a Need for Better Preoperative Patient Information and Education, Tilbury C, Haanstra TM, Leichtenberg CS, Verdegaal SH, Ostelo RW, de Vet HC, Nelissen RG, Vliet Vlieland TP. J Arthroplasty. 2016 Oct;31(10):2139-45. doi: 10.1016/j.arth.2016.02.061. Epub 2016 Mar 17.

A prospective study of the association of patient expectations with changes in health-related quality of life outcomes, following total joint replacement, Gonzalez Saenz de Tejada M, Escobar A, Bilbao A, Herrera-Espiñeira C, García-Perez L, Aizpuru F, Sarasqueta C. BMC Musculoskelet Disord. 2014 Jul 23;15:248. doi: 10.1186/1471-2474-15-248. Full text

Variation in hospital-level risk-standardized complication rates following elective primary total hip and knee arthroplasty, Bozic KJ, Grosso LM, Lin Z, Parzynski CS, Suter LG, Krumholz HM, Lieberman JR, Berry DJ, Bucholz R, Han L, Rapp MT, Bernheim S, Drye EE. J Bone Joint Surg Am. 2014 Apr 16;96(8):640-7. doi: 10.2106/JBJS.L.01639.

Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national Medicare data, Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P. Ann Rheum Dis. 2014 Dec;73(12):2107-15. doi: 10.1136/annrheumdis-2013-203494. Epub 2013 Sep 18.

Which patients are most likely to benefit from total joint arthroplasty? Hawker GA, Badley EM, Borkhoff CM, Croxford R, Davis AM, Dunn S, Gignac MA, Jaglal SB, Kreder HJ, Sale JE. Arthritis Rheum. 2013 May;65(5):1243-52. doi: 10.1002/art.37901. Full text

Joint replacement surgery in elderly patients with severe osteoarthritis of the hip or knee: decision making, postoperative recovery, and clinical outcomes, Hamel MB, Toth M, Legedza A, Rosen MP. Arch Intern Med. 2008 Jul 14;168(13):1430-40. doi: 10.1001/archinte.168.13.1430. Full text

Age and racial/ethnic disparities in arthritis-related hip and knee surgeries, Dunlop DD, Manheim LM, Song J, Sohn MW, Feinglass JM, Chang HJ, Chang RW. Med Care. 2008 Feb;46(2):200-8. doi: 10.1097/MLR.0b013e31815cecd8.

Also see
Guidance issued for optimal timing of knee, hip total joint arthroplasty Medeical Xpress
New guideline introduces recommendations for optimal timing of elective hip or knee arthroplasty Medeical Xpress
Total Knee Replacements in Knee OA Are Not Performed at Optimal Times Rheumatology Consultant
A Patient Perspective on Joint Replacement Surgery AAOS Registry Program Blog, American Academy of Orthopaedic Surgeons
When to Consider Knee Replacement Surgery WebMD
Knee replacement infection: What you need to know Medical News Today

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