TKR trial in OA highlights viability of non-surgical alternatives

The results of a randomised trial of knee replacement in people with OA illustrates the importance of informing patients about alternative non-surgical options, experts have said.

The trial published in this week’s NEJM showed that a combination of total knee replacement and nonsurgical treatment — involving supervised exercise, education, dietary advice, use of insoles and pain medication — was markedly superior to nonsurgical treatment alone in terms of pain relief, functional improvement and quality of life 12 months after treatment.

The percentage of patients who had an improvement of at least 15% (a clinically important difference) in the score for pain after 1 year was 85% in the total-knee-replacement group and 68% in the nonsurgical-treatment group.

However only 1 in 4 patients in the non-surgical group elected to undergo total knee replacement before the 12-month follow-up.

Surgery involved a higher number of serious adverse events (24 vs. 6; p=0.005), including three episodes of deep venous thrombosis, one deep infection, one supracondylar fracture, and three episodes of stiffness requiring manipulation of the knee while the patient was anesthetized.

Commenting on the study rheumatologist Professor David Hunter from the University of Sydney said total knee replacements had become such a common procedure for the treatment of osteoarthritis that patients often do not realise there is a viable treatment alternative.

“If the option was presented to them, many would appreciate a nonsurgical option,” he told the limbic.

“In Australia 80% of patients on a waiting list for surgery have never been offered access to nonsurgical treatment despite the availability of numerous programs such as the ‘Healthy Weight for Life’ program or the osteoarthritis chronic care program (available in NSW with similar programs available in the other states)”.

“Many patients, GPs and surgeons do not know they exist… there is room for education,” he said.

In an editorial accompanying the trial, Professor Jeffrey Katz from the Department of Medicine and Orthopedic Surgery, Brigham and Women’s Hospital, Boston said although total knee replacement was clearly superior in terms of pain relief, the findings suggested that the decision for treatment with total knee replacement is no parachute at all.

“Patients face choices that are associated with different levels of symptomatic improvement and risk… Each patient must weigh these considerations and make the decision that best suits his or her values… Since patients vary considerably in their preferences, physicians should present the relevant data to their patients and then listen carefully,” he wrote.

It was important that patients were routinely involved in the decision making process, said Professor Hunter.

“But in order to participate fully they must be fully informed and educated about the risks and benefits and out-of-pocket expenses that are involved in any proposed treatment,” he added.

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