Surgeons should not make knee replacement decision alone: expert

The decision to offer patients with osteoarthritis a knee replacement should not be made solely by the person who receives remuneration for the procedure, an expert says.

Leading rheumatologist and osteoarthritis expert Professor David Hunter from the University of Sydney was talking to the limbic following the release of a large US study that found knee replacement had minimal impact on quality of life and was only cost effective when performed in patients with severe disease.

The authors of the paper published in The BMJ argued that if the procedure were restricted to more severely affected patients, its effectiveness would rise and become more economically attractive.

Professor Hunter said the study confirmed that improvements in quality of life were not sufficient to meet a cost effectiveness threshold.

“Joint replacement in the right patient at the right time in their disease course is a wonderful procedure,” he said.

“However it is an expensive procedure and we need to be very thoughtful in our decisions about who gets this surgery.”

Knee replacement costs were increasing in Australia by about 10% per year, in part due to the volume of procedures.

However about 80% of patients on surgical wait lists had not tried other proven interventions such as weight loss, exercise or assistive devices. Not infrequently, they also had minimal pain and minimal radiographic disease, he added.

Professor Hunter, who chairs the Institute of Bone and Joint Research, said about one in four knee replacements have a poor outcome compared to about one in 20 hip replacements.

“It’s not yet common knowledge but it is concerning given the costs to the community.”

He said the decision-making had to be removed solely from the person who received remuneration for the procedure.

“By the time a patient is talking to a surgeon, the conversation is steered towards surgery. The threshold for surgical assessment and listing for elective arthroplasty has to be raised and decision-making should be shared with the patient and referring physician.”

“With knee arthroscopy, we waited for years for the industry to self regulate and it didn’t. The risk is the decision will be forced on us, by others such as insurers, he said.

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