Knee Replacement Timing Needs Improvement

By Cari Wade Gervin
Monday, July 20, 2020

Many people are receiving total knee replacements too early or too late, study shows.

Far too many people with osteoarthritis are waiting too long to have total knee replacement surgery, according to a recent study in the Journal of Bone and Joint Surgery — and many others are likely having it too soon.

“Evidence shows that if you do it too early in the disease state, you’re not going to get as much benefit from the surgery,” says Hassan Ghomrawi, PhD, an Associate Professor of Surgery at Northwestern University Feinberg School of Medicine and the study’s lead investigator. “People who have surgery later in the stage of the disease don’t do as well after surgery, and also until they actually do the surgery, they are in a state of debilitation that could prompt other comorbidities to occur — primarily cardiovascular problems and maybe diabetes.”

Ghomrawi and his research team examined a database of 8,002 osteoarthritis or at-risk-for osteoarthritis patients that had been followed for up to eight years during two trials by the Osteoarthritis Initiative and Multicenter Osteoarthritis. They found that 25% of patients who had knee replacement surgery had done so too soon, and 91% of people who likely needed the surgery had not done it within two to four years after it had become appropriate, and half had debilitating symptoms.

The most concerning finding, Ghomrawi says, is that the majority of people postponing the surgery were Black people, who were three times more likely than white people to put it off. The study did not assess whether a lack of insurance or high insurance deductible costs might have contributed to this delay; as of 2018, 10% of Black people were uninsured, almost double that of white people. Although that number has increased since the ACA, Ghomrawi says the study shows the limits of the legislation.

“That is a misconception, that by providing insurance, we solve all sorts of access problems and we improve outcomes, but it’s not the only variable driving access, ” Ghomrawi says. “We speculate that there are other factors that could be driving this lack of access or timeliness, because there is [research] out there about Black people being less trusting of physicians. Their expectations of [surgical] outcomes are not as good as the expectations of non-Hispanic white people, and so addressing these issues is important.”

Ghomrawi says more study is needed, but he hopes that physicians will take the new findings into account when discussing the timing of knee replacement surgeries with patients.

“I would like for the appropriateness criteria to be used more often to help inform the decision that’s being made beyond what’s actually being done today in clinical practice,” Ghomrawi says.