Now a growing number of experts are asking if all these operations are really necessary, especially those done at younger ages. Are all prospective patients giving lesser remedies a fair trial? How many knee replacements result from unrealistic patient expectations or the subtle influence of monetary gain among surgeons who perform them?
One recent study conducted by Daniel L. Riddle, a physical therapist at Virginia Commonwealth University, and two medical colleagues, for example, examined information from 205 patients who underwent total knee replacements. Fewer than half — 44 percent — fulfilled the criteria for “appropriate,” and 34.3 percent were considered “inappropriate,” with the rest classified as “inconclusive.”
Although patients with less severe pain and loss of function may still benefit from replacement surgery, the researchers suggested that their gains are likely to be smaller. “What this study does show is that the cost associated with these small changes is very high,” Dr. Riddle said. “People who are on the very severe end of the spectrum of pain and functional loss have a lot more gain to make.”
In a multicenter study reported last year of 4,498 people with arthritic knees and a second study of 2,907 people with arthritis, improvements in the quality of patients’ lives following knee replacement surgery were less than had been previously reported. Dr. Bart Ferket of the Icahn School of Medicine at Mount Sinai in New York and co-authors stated that those with the worst functional status initially had the most to gain from surgery and made the operation economically more justifiable.
“The key issue is selecting those patients most likely to benefit from surgery,” Dr. Ferket said in an interview. “At the moment, this is not optimal. Up to 20 percent of patients are not satisfied with the outcome of surgery.”
Dr. Steven Teutsch of the U.C.L.A. Center for Health Advancement said it’s important for “patients to have a clear understanding of the benefits and harms of knee replacement surgery because recovery from it is no picnic. A significant number of these procedures can be avoided or delayed.” Still, he added in an interview, “this is an elective procedure that can be extremely valuable in the right person at the right time.”
A detailed discussion with the doctor should precede a decision about surgery, “and the decision should be a shared one,” Dr. Teutsch said.
So what should be tried before deciding to go under the knife? Most important are weight loss (if needed) to reduce stress on arthritic knees and exercises or physical therapy to strengthen the muscles that support these vulnerable joints and improve range of motion. One or more injections of a gel of hyaluronic acid directly into the knee joint to lubricate it can relieve pain in some patients for up to six months. Or injections of corticosteroids, which reduce inflammation, can provide more immediate relief, although these injections cannot be repeated too often lest they further damage the joint.