Monday, July 14, 2014

One Third of Total Knee Replacements in US are ‘Inappropriate’

Figures from the Agency for Healthcare Research and Quality show that more than 600,000 knee replacements are performed each year in the US.

This surgery has become increasingly more common over the past 15 years, with studies showing a 162% annual volume increase in Medicare-covered knee replacement surgeries during 1991-2010.

Experts are divided on the reasons for this growth, with some maintaining it demonstrates that the procedure is effective, others argue the surgery is being overused. One concern of the critics is that the procedure “is highly reliant on subjective criteria.”

Researchers from Virginia Commonwealth University in Richmond examined the criteria that is used to determine appropriateness for total knee arthroplasties (TKA). They found that one third of TKA in the US are “inappropriate” when applied to a Spanish patient classification system, according to their study published in Arthritis & Rheumatology.

“To my knowledge, ours is the first US study to compare validated appropriateness criteria with actual cases of knee replacement surgery,” says lead author Dr. Daniel Riddle from the Department of Physical Therapy at Virginia Commonwealth University. In the study, Riddle and colleagues note that the Spanish criteria are considered by many experts in the field to be “among the most powerful tools for improving quality of care and controlling costs.”

The study looked a 175 people who underwent TKA surgery while participating in the Osteoarthritis Initiative – a 5-years study of 4,796 people partly funded by the National Institutes of Health. The mean age of knee replacement patients in the study was 67 years old, and 60% of them were female.

Dr. Riddle’s analysis found that 44% of the surgeries were classified as “appropriate,” 22% were “inconclusive,” and 34% were “inappropriate.” “Our finding that one third of knee replacements were inappropriate was higher than expected and linked to variation in knee pain severity and functional loss,” says Dr. Riddle. “These data highlight the need to develop patient selection criteria in the US.”

TKA is the most lucrative procedure in orthopedic surgery. Surgeons performing two replacements per week, along with the associated pre and post surgical evaluations, make upwards of $100K weekly. Hospitals absorb most of the overhead.

The mean age of 67 also appears to be way too young. I typically see patients in their mid-seventies having this procedure. However, the rapidly increasing percentage of US citizens with morbid obesity at a younger and younger age may be a driving factor here as well.

Another way to look at these statistics is that less than half of the surgeries were found to be “appropriate”. I am just as alarmed that even using the criteria that we fail to employ in the US, 22% of the patient’s surgeries were classified at “inconclusive.”

This is an area where stem cell therapy holds great promise. Imagine a series of injections that rebuilds the bone, ligaments, tendons, and cartilage of the knee with no surgery, no hospitalization, at a fraction of the cost of TKA.

If such a procedure were available today, most hospitals and many orthopedic surgeons would face extinction. I honestly believe that the people and institutions that benefit financially from TKA have blocked and delayed stem cell research at every turn.

TKA is an extensive surgical procedure that should be performed as a last resort for chronic, debilitating knee degeneration only. If TKA has been recommended for you, please get a second, and even a third opinion. I recently had a patient for whom the procedure was recommended. I referred her back to the orthopedic surgeon that had performed arthroscopic surgery on her knee several years ago. He examined her, reviewed the imaging studies, and told her there was nothing wrong with her knee structurally. She was 64 years old.

Source: Medical News Today -Monday, June 30, 2014