Knee osteoarthritis afflicts millions of Americans. Total knee replacement is but one treatment approach—one that yields often-remarkable results. Despite its good reputation though, there’s more to the operation than this article’s glancing overview suggests. For starters, knee replacement is a major surgery with potentially important complications, including blood clots in a leg or lung, infections, and (rarely) death. The costs include not only the price of the implant and the hospital and surgeon fees, but also time off of work, intensive rehabilitation, and sometimes an inpatient rehab facility or visiting nurse. While many people return to a relatively active lifestyle, others continue to have limitations (for example, in kneeling, squatting, climbing stairs, and getting into and out of cars). Other treatments often help people stave off worsening symptoms and mobility—and surgery. Reasonable alternatives to knee replacement include strengthening and exercise, weight loss, medications, injections, bracing, in-shoe orthotics, and others. For younger surgical candidates, this is important information, because knee implants have a limited life span, and young patients concerned about the need for a second operation later in life often prefer to wait as long as possible before having their first. Unfortunately, in the absence of a balanced view of surgery’s pros and cons and an independent voice (the sole source is an enthusiastic surgeon), the story finally feels more like a puff piece for a top-rated hospital than a balanced look at a medical problem.
The article does not mention cost. In knee replacement there is more to cost than the price of the implant and the hospital and surgeon’s fees. After surgery, patients must plan for time away from work, intensive rehabilitation, and perhaps the cost of an inpatient rehab facility or visiting nurse.
There is no attempt to quantify the benefit of total knee replacement, either for older patients or younger ones, except in the testimony of one knee surgeon. Although the scientific literature reports that most patients are satisfied after surgery, the results are neither as spectacular nor as risk-free as the article suggests.
The article fails to mention the small but real risks of total knee replacement, which include blood clots in the leg and lungs, joint infections, and (rarely) death. Because of the risks, costs, and inconvenience of knee replacement, many people prefer nonsurgical remedies. While the story entertains the idea of knee replacement in younger people, such procedures are likely to require another operation during a person’s lifetime – something not mentioned at all.
The article makes no attempt to characterize the nature of the evidence on total knee replacement. Its sole sentence about the typical outcome of surgery is the anecdotal testimony of one knee surgeon. (“Ninety-five percent of the people I treat feel much better after having surgery. How great is that?”) Together with the absence of evidence on costs and harms, the article reads more like a puff piece for knee surgery and New York’s (highly regarded) Hospital for Special Surgery than a balanced news brief on a major operation.
Painful osteoarthritis is a debilitating disease for some and a nuisance for others. As the article notes, younger patients with arthritis are increasingly interested in a surgical remedy. But the article would have been more complete if it explained that arthritis does not always worsen or cripple its victims. Though there is limited evidence about what happens over time if people choose not to have surgery, one study found that after 10 to 18 years, about 4 out of 10 people stayed the same or had improved pain and mobility, while symptoms worsened in about 6 out of 10 (Clin. Orthop. Relat. Res. 1977;123:130-7.) By omitting this message (and other key information on risks, outcomes, and nonsurgical options), the story could lead readers to an overly rosy view of knee replacement. As written, the story implies that surgery is such a simple, effective, low-risk option that it should be performed in younger patients with less severe disease.
The article cites one source—the chief of the knee service at a major New York hospital that performed 2500 knee replacements in 2006. It offers no independent sources who might have balanced his enthusiasm with information on harms, costs, and other treatment options.
The article fails to mention that the pain and functional limitations caused by knee osteoarthritis occasionally improve on their own or often respond to nonsurgical treatments (e.g. strengthening and exercise, weight loss, medications, injections, bracing, in-shoe orthotics) and smaller operations (e.g. osteotomy). (A sidebar on a motion analysis laboratory mentions braces and physical therapy). For younger surgical candidates, this is important information, because knee replacements have a limited life and young patients concerned about the need for a second operation later in life often prefer to wait as long as possible before having their first.
The article notes that American surgeons perform about half a million total knee replacements annually, suggesting that the operation is widely available.
The article notes that the popularity of knee replacement is expanding from older people to younger ones, suggesting that the operation is not new.
It is unclear whether the article relied solely or largely on a press release. It is clear that it presented only the rosy perspective of one surgeon at one hospital.