Doctors in Spain examined what factors influenced a patient having a successful knee replacement surgery, and what influences prevents patients from having successful knee replacement surgery.
There is conflicting evidence about what factors influence outcomes after total knee replacement. The objective of this study is to identify baseline factors that differentiate patients who achieve both, minimal clinically important difference and a patient acceptable symptom state in pain and function, measured by WOMAC (Pain scoring system), after total knee replacement from those who do not attain scores above the cutoff for improvement.
What were the two most important factors the Spanish team looked at one year after surgery?
- The mental health of the patient while they were waiting for the knee replacement.1
The recommendation from this research?
While they wait for surgery, manage the patient’s expectations so they have a realistic opinion of what happens after the surgery. Manage their mental health before the surgery to help with a more positive outlook afterwards.
Patient suffering waiting for knee replacement
Researchers have noted that patients on a waiting list for knee replacement surgery suffer from severe symptoms and the waiting list delay can be considered a major reason that patients seek alternative treatments.
- In one study, doctors from Laval University in Quebec wrote in the medical journal Rheumatology about 153 patients who had been given a date far in advance for their total knee replacement. What the doctors wanted to study was changes in pain, function and quality of life and the burden excessive wait times had on the these patients.
Here is what they published:
- “Overall, subjects suffered a significant deterioration of their condition while waiting, in terms of knee pain, contralateral knee pain, functional limitations and quality of life.”2
The problem is compounded because one of the factors that will give a patient pain after knee replacement, is the poor management of their pain before the surgery.
You are in pain, can you move yourself to the top of the knee replacement waiting list?
Researchers writing in the Medical Journal of Australia, wanted to know what influenced surgeons in determining the order in which patients are scheduled for surgery. In their study they asked a group of surgeons to assess patient profiles of 80 patients. They also asked a group of non-medical personal (lay people) to assess the patient profiles for their “lay” recommendation.
- Both groups determined that the patient’s pain was the number one concern.
- For the surgeons, the other determining factors were physical limitations and other medical factors.
- The lay people saw it a little differently. While agreeing on the physical limitation part, they were concerned with the patient’s socio-economic situation and the stress a prolonged wait would bring on the patient’s ability to make a living as well as the psychological distress that may bring.3
While the surgeons did not consider socio-economic factors in determining priority in patients wait time to surgery, it is clear that for the lay person, the delay to surgery, the surgery, and the recovery time from a total knee replacement are important factors.
One of the reasons the surgeons may not have prioritized this factor may be found in the literature. Researchers at the Case Western Reserve University School of Medicine. in their study published in the Journal of joint and bone surgery, wrote:
- “There is little in the literature to guide clinicians in advising patients regarding their return to work following a primary total knee (replacement). (This study) aimed to identify which factors are important in estimating a patient’s time to return to work. . .how long patients can anticipate being off from work, and the types of jobs to which patients are able to return following primary total knee arthroplasty.”4
Information for patients to assess from the study scores were:
- The average time to return to work after the surgery was nine weeks.
- Patients who reported a sense of urgency about returning to work were found to return in half the time taken by other employees
- Other preoperative factors associated with a faster return to work included being female, self-employment, higher mental health scores, higher physical function scores, higher functional comorbidity, and a handicap accessible workplace.
- A slower return to work was associated with having less pain preoperatively, having a more physically demanding job, and receiving Workers’ Compensation
- Insurance Coverage and Surgery Availability
- “Our objective was to compare the availability of hip and knee arthroplasty (replacement) to an adult insured by Medicaid and by private insurance.
- All orthopedic surgeons’ offices in a South Florida county were contacted by telephone and presented with a hypothetical patient that needed either a hip or a knee arthroplasty for end stage arthritis.”
Two scenarios were presented. The hypothetical patient was presented as either having private insurance or Medicaid.
- 14.3% of all offices contacted offered an appointment to patients with Medicaid coverage for hip and knee arthroplasty, respectively. All offices offered an appointment to patients with private insurance. “The mean time until appointment was longer for patients with Medicaid when compared with private insurance. Adults insured with Medicaid currently have limited access to total joint arthroplasty within the studied community.”5
In another study, in the Journal of Arthroplasty, researchers noted:
“A total of 1120 consecutive patients were asked what they believed a surgeon should be paid for performing hip and knee replacement surgeries….Most of the patients stated that Medicare reimbursement was “much lower” than what it should be. Many patients commented that given this discrepancy, surgeons may drop Medicare, which may decrease access to quality hip and knee arthroplasties.”6
Patient out-of-pocket costs
Total Knee Replacement procedures can cost an uninsured patient in the tens of thousands of dollars, for the Medicare patient out of pocket costs may reach into the hundreds of dollars, for the privately insured patient the out-of-pocket costs depends on your insurance coverage and can range from the thousands to tens of thousands. Patients are always recommended to check with their insurance carrier prior to surgery to get estimated out-of-pocket expense.
With all of these considerations, it is no wonder a patient may search for an alternative to knee replacement surgery. Not to mention the knee replacement failures and other complications associated with any type of surgery.
1 Escobar A, García Pérez L, Herrera‐Espiñeira C, Aizpuru F, Sarasqueta C, Gonzalez Sáenz de Tejada M, Quintana JM, Bilbao A. Total knee replacement: Are there any baseline factors that have influence in patient reported outcomes?. Journal of Evaluation in Clinical Practice. 2017 May 26.
2. Desmeules F. The burden of wait for knee replacement surgery: effects on pain, function and health-related quality of life at the time of surgery. Rheumatology (2010) 49 (5): 945-954.
3. Curtis AJ, Wolfe R, Russell CO, Elliott BG, Hart JA, McNeil JJ. Determining priority for joint replacement: comparing the views of orthopaedic surgeons and other professionals. MJA. 2011 Dec 5;195:699-702.
4. Styron JF, Barsoum WK, Smyth KA, Singer ME. Preoperative predictors of returning to work following primary total knee arthroplasty. J Bone Joint Surg Am. 2011 Jan 5;93(1):2-10.
5. Lavernia CJ, Contreras JS, Alcerro JC. Access to arthroplasty in South Florida. J Arthroplasty. 2012 Oct;27(9):1585-8. doi: 10.1016/j.arth.2012.03.014. Epub 2012 May 2.
6. Foran JR, Sheth NP, Ward SR, Della Valle CJ, Levine BR, Sporer SM, Paprosky WG. Patient perception of physician reimbursement in elective total hip and knee arthroplasty. J Arthroplasty. 2012 May;27(5):703-9. doi: 10.1016/j.arth.2011.10.007.
7. Perruccio A, Power J, Evans H, Mahomed S, Gandhi R, Mahomed N, Davis A. Multiple joint involvement in total knee replacement for osteoarthritis – effects on patient-reported outcomes.Arthritis Care Res (Hoboken). 2012 May 8. doi: 10.1002/acr.21629.