Timing of knee replacements can be tricky
Caitlin VanOverberghe Feb 03, 2020
Determining when a knee replacement surgery will be the most beneficial for a patient is one of the most difficult clinical decisions an orthopaedic surgeon can make, said Leonard Buller, MD, an assistant professor of orthopaedic surgery for Indiana University School of Medicine.
Too soon and there’s a risk the knee will wear out again. Too late and the patient’s quality of life might suffer.
A study, which gained national attention when it was published in the Journal of Bone and Joint Surgery in January, found that 90 percent of people with knee osteoarthritis wait too long to get a knee replacement surgery; while 25 percent of those who do undergo the procedure have it too early.
Those findings, while interesting, aren’t necessarily surprising. Buller said he’s met with patients who fall into both cohorts of participants noted in the study: some visit his office because they are unsatisfied with a knee replacement they received at a different hospital; others are so satisfied with the outcome of a surgery he performed they express regret for not having the procedure sooner.
It speaks to why it’s so important for doctors to listen to their patient, to converse with them and ask important questions that will lead to a true understanding of their symptoms, before arriving at a conclusion together, Buller said.
And it is why Buller stresses to the IU School of Medicine learners who pass through his clinic every day that open communication, empathy and compassion are some of the most important tools in medicine. Without them, a doctor’s job isn’t completely done.
“As a surgeon, it is important to remember that every patient is an individual,” he said. “Taking a holistic approach to patient care with respect to understanding their symptoms, setting preoperative expectations and fully informing a patient of the risks and benefits of total knee replacement is essential as we arrive at the shared decision of proceeding with surgery.”
When it comes to knee replacements, there isn’t a robust tool for determining when surgery is most appropriate, so research of any kind is important, Buller said. Debating and idea-sharing could help determine an objective means of measurement for this entirely subjective topic.
For now, Buller will continue to teach the students in his clinic that nothing beats benevolence–because it’s so important to approach conversations with osteoarthritis patients with kindness and understanding.
“The surgeon should sit down and maintain eye contact with the patient as they explain their symptoms. Patients come to my office hoping for a solution to their problem, are scared and oftentimes possess a limited knowledge of their underlying diagnosis,” Buller said.
“Prior to considering a knee replacement, it is critical that the patient has exhausted all conservative measures and their symptoms significantly interfere with their activities of daily living. I teach my students to take the time to synthesize the patient’s presenting complaint with the objective physical examination and radiographic findings to establish a diagnosis. If the diagnosis, like osteoarthritis, is one that can benefit from total knee replacement, and the patient has exhausted conservative management, that is when I have a long and honest discussion about the risks and benefits of surgery.”
More than 680,000 knee replacement surgeries are conducted in the United States each year, making them the most common procedure adults 45 years and older undergo, according to the Centers for Disease Control and Prevention.
Improving the procedure and recovery for patients is a common topic of research among faculty members in the IU School of Medicine Department of Orthopaedic Surgery, reflecting the school’s overall commitment to advancing musculoskeletal health.
Michael Meneghini, MD, found in a study that concluded last year that forgoing the use of a tourniquet during knee replacement surgery decreases a woman’s need for painkillers following an operation. And Jason Watters, MD, in partnership with an Indiana medical supply company, is currently testing the effectiveness of a mobile compression device in preventing deep vein thrombosis following a knee replacement.