Important shared decision-making questions on knee replacement surgery

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MedPage Today (and a few others) report on an important article in The Lancet on knee replacement and how “Because replacement is increasingly considered for patients younger than 55 years, improved decision making about whether a patient should undergo the procedure is needed.”

MedPage Today reports that long-term data on knee replacement is inadequate in the eyes of the authors,  “leaving clinicians and patients in the dark about outcomes such as residual pain and disability.” Excerpt from the story:

“More than 600,000 knee replacement procedures are performed in the U.S. annually, according to the Agency for Healthcare Research and Quality.

Writing online in The Lancet, (Andrew J.) Carr (of the University of Oxford in England) and colleagues outlined four directions for the future of knee replacement surgery:

  • More consistent patient selection for knee replacement
  • Long-term monitoring with patient-oriented outcomes, as well as revision, as endpoints
  • Approval of new designs only after large randomized trials that demonstrate cost-effectiveness as well as clinical efficacy
  • Better management of young people with early arthritis to avoid need for replacement surgery

(A side note, perhaps only of interest to journalists and news hounds:  MedPageToday has a partnership with  It looks like ABC grabbed the MedPage story and just slapped a past video interview on knee replacement atop their version of the online story because the video clip never addresses the issues raised in the MedPageToday story.  Odd.  Looks like shovelware.)

On the Scientific American blog, Katherine Harmon also did a nice job with the story. Excerpt:

Unlike new medications, knee replacements and other implants often get far less scrutiny from regulatory agencies, such as the U.S. Food and Drug Administration. A 2011 report from the Institute of Medicine found that medical devices have long lacked adequate safety and efficacy testing. Information on the safety or success of knee replacement implants, in particular, comes primarily from small studies done by individual surgeons who might be the inventor or co-owner of the technology. That connection can lead to bias and conflict of interest in reporting results. “Without high-quality, unbiased and reliable information, surgeons can not make informed decisions,” Carr said in a prepared statement.

As of this writing, the story received surprisingly little mainstream news coverage.  Sigh.


(Photo credit:  LesKZN via stock.xchng)

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Gregory D. Pawelski

March 7, 2012 at 1:00 pm

All implants undergo physiological changes after implantation. The earliest and probably clinically most important step is the “race for the surface,” a contest between tissue cell integration and bacterial adhesion to that same surface.

On contact, body fluids immediately coat all surfaces with a layer of host material, primarily serum proteins and platelets. Adherence progresses to aggregation of microorganisms on the surface of the foreign body, forming a Biofilm.

Supposedly, sophisticated prevention strategies have been developed during the past two decades to lower the risk of infectious complications in implant surgery. However, the treatment of such an infection is poorly standardized, resulting in a number of patients with orthopedic device-related infections.