by Sandee LaMotte, CNN
(CNN)Living with knee pain?
A new study has found that 90% of Americans with osteoarthritis suffer too long
before having a knee replacement that could improve their quality of life.
"When people wait too long, they lose
more and more function and can't exercise or be active, thus leaving them open
to weight gain, depression and other health problems," said lead
investigator Hassan Ghomrawi, associate professor of surgery at Northwestern
University's Feinberg School of Medicine.
In addition, the surgery may not be as
successful, Ghomrawi said.
"There are multiple studies that have
shown that patients who do surgery when their function is very deteriorated may
improve quite a bit, but their improvement is still not to the average,"
Ghomrawi said. "They lag behind in optimal benefit."
On the flip side, the study also found that
25% of people who do choose knee surgery are getting it too early, running
significant risks, including potential complications, while incurring the cost
of major surgery potentially without getting much extra benefit in mobility.
"There are a million knee surgery
procedures occurring in the United States each year," Ghomrawi said,
"and 25% of those are premature. That's a lot of patients."
Because artificial knees wear out after 20
years or so, early adopters are also setting themselves up for yet another knee
replacement later in life, Ghomrawi said, which is typically a much more
difficult surgery with a poorer outcome than the original.
An objective algorithm
The study, published Monday in the Journal of
Bone and Joint Surgery, followed over 8,000 people with symptoms of knee
osteoarthritis for up to eight years.
While other studies have looked at people who
underwent the knife, this study is believed to be the first to examine the
timeliness of knee replacement among people who might benefit from the
procedure, Ghomrawi said.
The study applied an objective measure to
determine the "ideal timing" of knee replacement. It used an
algorithm first developed in Europe in 2003, then updated in 2014 by Virginia
Commonwealth researchers who analyzed data from a smaller study of 200 people and found a
third had surgery too early.
"There are 16 unique combinations that
can be assigned based on age, knee stability, and whether the patient has
slight, moderate, intense or severe pain," Ghomrawi said.
Knee stability is defined as the not only the
ability to bend, but also how "wiggly" the knee is due to loose
tendons, and also takes into account clicking and grinding sounds.
In addition, the measurement looks at the
severity of the osteoarthritis on X-rays -- "if it's bone on bone" --
as well as how many parts of the knee are affected: the femur (thigh bone),
tibia (shin bone), and patella (kneecap).
After factoring all of these elements,
Ghomrawi and his team assigned patients in the study to three categories:
timely -- they had the surgery within two years of the replacement becoming
potentially appropriate; delayed -- no surgery or surgery that waited until
after those two years; and premature.
The cost of premature
surgery
This isn't the first study to try and apply an
objective criteria to what has been a traditionally subjective conversation
between a patient and doctor. The UK's National Health Service commissioned a study last year to
see if they could apply objective measures to the decision.
The effort is partly driven by cost -- In the
UK the cost can range from 11,000 pounds ($14,300) to 15,000 pounds ($19,467)
and, according to a 2015 study,
if there are complications or the surgery must be redone, it can rise to 75,000
pounds ($97,313).
In the United States, according to a study by Blue Cross Blue Shield, a
typical knee replacement surgery can range between $12,000 to $70,000 depending
on what part of the country you live in.
And then there's the growing popularity of the
surgery: The American Academy of Orthopedic Surgeons projects knee replacements
in the US alone will grow by up to 189% in the next decade, for a projected
1.28 million procedures by 2030.
The US population of baby boomers is aging, as
are their knees, but those numbers may be partially driven by the rise in knee
replacements among those under the age of 65. A 2012 study found total knee replacement
more than tripled for people aged 45 to 64 between 1999 and 2008; for those
over 65, it only doubled. The cost for all those operations, the study found,
was more than $9 billion.
Can an objective
algorithm work?
Not everyone believes that such an objective
approach will succeed in the health care environment.
"I would say this paper looks at the
issue from the perspective of the experts and not necessarily from a patient
perspective," said Dr. Bart Ferket, an assistant professor of population
health science and policy at the Icahn School of Medicine at Mount Sinai
Hospital in New York City.
"It's an attempt to objectify things that
are subjective," said Mount Sinai orthopedic surgeon Dr. Edward Adler,
who, like Ferket, was not involved in the study.
Pain, for example, is subjective and could
interfere with the algorithm's ability to assess knee stability and a patient's
reported levels of pain.
"Some people will allow you to move their
knee even though their knee hurts a lot," Adler said. "They can have
a lot of pain, you wouldn't know it. They function well.
"There are other people who have a little
bit of pain and everybody around them has to know about it," he added.
"So it's fairly subjective as to how much you tolerate before you get your
knee replaced."
Ghomrawi agrees there could be excellent
subjective reasons why a person might decide to get an early knee transplant
instead of deciding to wait.
One scenario, he says, for a transplant at a
younger age, for example, could stem from financial considerations. A candidate
for the surgery may elect to go through with it, thinking, "I'm the only
financial support for my family; I'm maintaining my functional level so that I
can continue to be the breadwinner for my family."
Or perhaps an older person has a very painful
knee, "but they're bearing with it because they're taking care of their
spouse," Ghomrawi said.
Still, studies show many people aren't happy
with the outcome of their knee replacement; a 2010 study found almost 20% said they
were dissatisfied.
Objective or subjective, Adler said there
needs to be a realistic assessment by each person of what a new knee can really
accomplish. If a person has the surgery before the onset of severe or
significant pain, the patient may not see enough improvement.
"Knee replacements are not really made
for tennis and running," he said, "They are made for walking long
distances and performing activities of daily living.
"What God gave you is not necessarily the
same as what I can give you," Adler said."if your goal is to be
normal, that's a difficult thing to obtain when your knee is coming out of a box."
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