With a graying nation projected to see millions of patients undergoing knee replacements each year at an annual cost to taxpayers running in the billions of dollars, it may be past time to ask if surgeons and hospitals promote and perform these popular procedures to excess.
Liz Szabo, in a story written for the nonprofit, nonpartisan Kaiser Health News Service (KHN) and published in the Washington Post, reported that knee surgeries have their “risks and limitations,” and “doctors are increasingly concerned that the procedure is overused and that its benefits have been oversold.”
As she wrote:
Research suggests that up to one-third of those who have knees replaced continue to experience chronic pain, while 1 in 5 are dissatisfied with the results. A study published last year in the BMJ found that knee replacement had ‘minimal effects on quality of life,’ especially for patients with less severe arthritis. One-third of patients who undergo knee replacement may not even be appropriate candidates for the procedure, because their arthritis symptoms are not severe enough to merit aggressive intervention, according to a 2014 study in Arthritis & Rheumatology. ‘We do too many knee replacements,’ said James Rickert, president of the Society for Patient Centered Orthopedics, which advocates for affordable health care, in an interview. ‘People will argue about the exact amount. But hardly anyone would argue that we don’t do too many.’
As Szabo reported, surgeons performed 723,000 knee replacements in 2014 alone, costing patients, insurers and taxpayers more than $40 billion. Rates of the surgery doubled from 1999 to 2008, and forecasts see 3.5 million patients annually undergoing the procedure by 2030.
Demographics alone aren’t driving all these operations. Yes, they’ve become a boom and a boon among baby boomers. The rise in knee surgeries has been driven by patients’ wear on joints because they carry too much weight currently and in past years had engaged in exertion — notably sports and recreation — that were less common and done with far less vigor in previous generations.
Surgeons and hospitals, abetted by technology advances, also have expanded the group of patients who might benefit from knee surgeries: Americans in their middle and pre-retirement ages — those 45- to 64-years-old — now get knees replaced earlier than before. The procedures previously were not performed until patients were older, 65 and more. Doctors operate now with the belief that new surgical techniques and materials used in knee and hip prosthetics will be more durable, allowing operations earlier in the belief that these will not fail and require repairs or overhauls for decades.
That hasn’t exactly proved true, Szabo reported, as “ 35 percent of men and 20 percent of women” 60 and younger, “need a revision surgery, according to a November article in the Lancet.”
In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, effective, and excellent medical care. All medical procedures carry risks, and surgeries — even operations that doctors and hospitals insist have become almost routine — should never be undertaken without extensive discussion, preparation, investigation, and care.
As Szabo reported, patients have options and they many can benefit from physical therapy and doses of over-the-counter anti-inflammatory and pain-killing medication, rather than knee replacements. Just compare the outcomes for patients who take two different treatment paths:
Surgical patients developed four times as many complications, including infections, blood clots or knee stiffness severe enough to require another medical procedure under anesthesia. In general, 1 in every 100 to 200 patients who undergo a knee replacement die within 90 days of surgery.
The KHN report describes well how doctors must provide patients with a better, fuller explanation of knee replacement risks and benefits, giving them their fundamental and needed right of informed consent, so they can make intelligent choices about who will do what to them, when, and how.
Still, it’s self-evident that patients, inundated by advertising and marketing hype from hospitals and doctors, see knee and hip procedures in an almost magical light. They look at the photos of models playing with grandkids, zooming around on bikes, and swatting away at sunny afternoons of vigorous tennis or golf. It makes a procedure costing $31,000 or so per patient sound like a breeze.
But what they may want to take in, instead, is the testimony of Eric Topol, a nationally known medical commentator, cardiologist, and professor of genomics at the Scripps Research Institute. He was a self-described “perfect” patient for knee replacement, designed to ease the discomfort he experienced for a lifetime from an inherited condition affecting his joints. He didn’t get the fast and easy, “one size fits all” time after his surgery and in his rehabilitation. Instead, he reported:
From the first day of physical therapy, I experienced pain beyond the reach of the prescription painkiller oxycodone. … The pain, purple discoloration, swelling and severe ‘Tin Man’ stiffness worsened. I couldn’t sit or stand without considerable discomfort. Unable to sleep more than an hour at a time because of pain, I became desperate. Crying spells were frequent. Searching the Web, my exceptionally supportive wife found a book titled Arthrofibrosis, which describes a complication occurring in 2 to 3 percent of patients after knee replacement. I’m a doctor, but I’d never heard of the term.
He followed conventional wisdom, throwing himself with abandon into excruciating and extensive physical therapy (PT), as well as experimenting in ways that were unacceptable to him as a medical scientist with “acupuncture, electro-acupuncture, cold laser, topical ointments, curcumin and many other supplements.”
His misery lasted for a year, before a colleague insisted that he see a physical therapist with decades of experience and diagnostic acumen. She halted his existing treatment and told him that he was an outlier: He needed a different, gentle, easy, and slow regimen of PT that also emphasized reducing the inflammation that had riddled his knee.
Topol acknowledges he was lucky. He sees that too many patients may be getting too many surgeries with too little individual and personalized care, as opposed to factory paced procedures and cookie-cutter recommendations on care. That’s unacceptable.