By Elaine Goodman
Knee replacement is an increasingly common surgery for treatment of osteoarthritis, but recent research is raising questions about the procedure’s effectiveness in relieving pain and improving function.
“Most patients have a very good clinical outcome after knee replacement, but multiple studies have reported that 20% or more of patients do not,” Professor Andrew Price with the Nuffield Orthopaedic Centre in Oxford, England, wrote in a November review article in medical journal The Lancet.
Researchers from the University of Bristol, England, analyzed past clinical studies of knee or hip replacements and found that the proportion of patients with an unfavorable long-term pain outcome ranged from 10% to 34% after surgery. An unfavorable pain outcome was considered moderate-to-severe pain or a lack of pain relief.
The 2012 research by Andrew David Beswick and colleagues was published in BMJ, formerly the British Medical Journal.
“After hip and knee replacement, a significant proportion of people have painful joints,” the authors wrote. “There is an urgent need to improve general awareness of this possibility and to address determinants of good and bad outcomes.”
Kaiser Health News spotlighted the knee-replacement research last month in an article titled, “Up to a Third of Knee Replacements Pack Pain and Regret.”
The article caught the attention of New Jersey claimants’ attorney Jon Gelman, who featured it in his blog.
The research makes it clear that the methods for deciding whether an injured worker is a good candidate for a knee replacement need to be overhauled, Gelman said on Monday. Candidate selection should include both medical and social criteria, he said.
“We are dealing with an aging workforce who may not be capable of handling such issues as rehabilitation or infection control,” Gelman said. “Workers’ compensation can not address these issues in a summary fashion any longer.”
The total number of knee replacements in the U.S. continues to grow and has reached 700,000 per year, according to Price’s report in The Lancet. Almost all knee replacements are performed to treat osteoarthritis, and patients typically have moderate to severe pain, and loss of function.
A study published in BMJ in 2017 looked for improvements in quality of life for patients with knee osteoarthritis who had replacement surgery. For those with less severe symptoms, the surgery seemed to bring little improvement in quality of life, and the authors deemed the procedure “economically unattractive” for this group.
But if the procedure were reserved for patients with more severe symptoms, its effectiveness would increase and there could be considerable savings in health care costs, the authors said.
“Our findings emphasize the need for more research comparing total knee replacement with less expensive, more conservative interventions, particularly in patients with less severe symptoms,” the authors concluded.
Knee replacement is just one option for patients with advanced knee osteoarthritis, Price and colleagues wrote in The Lancet.
“For example, physical therapy programs of strengthening and neuromuscular training can give symptomatic improvement in two-thirds of patients with advanced knee osteoarthritis,” they said.
In workers’ comp, early intervention with physical therapy is gaining ground as a strategy to potentially avoid the need for surgery.
“There has been a steady increase in claims with PT involvement due in large part to mounting evidence that a PT-first approach can improve outcomes, is an effective alternative to opioids or surgery and often results in fewer downstream costs,” MedRisk, a provider of managed physical medicine in workers’ comp, said in a 2018 industry trends report.
MedRisk managed 490,282 physical medicine cases involving injured workers in 2017, according to figures the company provided Monday.
Although numbers weren’t available specifically for knee replacement surgeries, “pain in the knee” was the No. 2 diagnosis in terms of MedRisk’s post-surgical case volume, with 1,490 cases in 2017.
The company’s top diagnosis for post-surgical PT was pain in shoulder, with 2,164 cases in 2017.