Knee OA; Total knee replacement or non-operative treatment?

What i’m trying
In clinical practice I trying to give an individual differentiated advice based upon best evidence of my knowledge.

My advice is based on clinical reasoning (Engebretsen et al 2015; “Unpacking the process of interpretation in evidence-based decision making“) taking the BPS model (Waddell et al 1987) into consideration and using the CLINICAL REASONING REFLECTION SHORT FORM fra Mark Jones bookClinical Reasoning for Manual Therapists to break down my reasoning into boxes before I make my decisions based on Ian Shier 3-STEP RETURN TO PLAY DECISION MAKING MODEL

How do you advice your knee OA patients? how we differentiate between whom we recommend surgery and to whom we recommend exercise?
In a clinical setting dealing with OA patients I take below facts into consideration, and first of all address them in order to make lifestyle changes before the choice of surgery. Obesity, smoking and information regarding prophylaxis of DVT and activity level hence before and after surgery should be addressed. I feel that a patient´s autonomy can best be addressed when him/her has the information at hand regarding proper measures and consequences.
From the literature, some distinct risk factors points out both in THR (Total Hip Replacement) and TKR
  • Obesity: Pasient with obesity has an increase risk of dislocation, revision and early stem loosening. (Lie 2004; Flugsrud et al., 2007; Munger et al., 2006; Sadr et al., 2008).
  • Age: Literature states that patients of young age < 60 years had increased risk of revision (Havelin et al., 2000; Espehaug et al., 2006; Santaguida et al., 2008) and suffering early stem loosening (Munger et al., 2006). In the latter research the risk for stem loosening increased linearly with decreasing age. Patients operated at the age of 50, had 50% increased risk compared to those operated by the age of 70. An increased activity level, as seen in young patients (Flugsrud et al., 2007; Munger et al., 2006) and those with unrestricted mobility, may be an important factor for the increased incidence of stem loosening. Age older than 80 years, is associated with deteriorating physical condition, and poorer wound healing (MacWilliam et al., 1996).The frequency of complication occurring after THR (HIP NOT Knee..) in patients over age of 80 years varies from 24% to 42.5% compared to 8% in the general population (De TE et al 2009). Early postoperative mortality is also higher in older patients (Lie et al 2004; Santaguida et al.,2008).
  • Sex: Males have in several studies been indicated as having increased risk for complications following THA/TKR. . As found in younger age, male sex is also associated with increased physical activity and thus revision due to aseptic loosening. There is a tendency that men get a THA/TKA earlier than women. Women are more likely to have pre-operative physical therapy intervention compared to men: 57% vs. 38% respectively the year before surgery. Thus the risk increases further when you have the combination: young age and male sex (Lie et al., 2004; Havelin et al.2000; Flugsrud et al., 2007; Munger et al., 2006).
  • Diabetes: DM predisposes for increased length of stay, higher hospital charge and more surgical and systemic complications (Marchant MH et al., 2009). Infection rates and overall complication rates are also increased for DM patients (Bolognesi et al., 2008)
  • Smoking: Smoking leads to increased risk for decreased wound healing cardiovascular complications, the need for intensive care and revision (Moller et al., 2001; Moller et al.,2003) Post operation days at hospital have been reduced among smoking patients who quit smoking 6-8 weeks prior to surgery. Former heavy smokers were found to have 2.6 times higher risk for early revision compared to people that has never smoked (Havelin et al.,2000).
  • DVT: DVT and PE are complication risks that are always present after surgery, a potential lethal complication as a result of immobilization. Mortality rate for patients undergoing THA/TKR is increased in the first 60 days, compared to the normal population and is due to thrombolytic disease and cardiovascular disease (CVD) (Lie et al., 2004)
  • The prevalence of thromboembolism during hospital stay is approximately 60% of patients undergoing THA (HIP!) . This is due to increased coagulant activity at the end of the first- postoperative week, and reduced blood flow in lower limbs for several weeks. Late venous thromboembolism is thus a risk factor for patients that are discharged from hospital after a week without continued thromboprophylaxis.

    Reference list:
    Lie et al. ”Nasjonalt register for leddproteser: Til beste for pasienter og det norske helsevesenet.” Norsk Epid. 2004;14(1):57-63.

    MacWilliam CH, Yood MU, Verner JJ, McCarthy BD, Ward RE. Patient-related risk factors
    that predict poor outcome after total hip replacement. Health Serv Res 1996 Dec;31(5):623-
    38.

    Havelin LI, Engesaeter LB, Espehaug B, Furnes O, Lie SA, Vollset SE. The Norwegian
    Arthroplasty Register: 11 years and 73,000 arthroplasties. Acta Orthop Scand 2000
    Aug;71(4):337-53.

    Espehaug B, Furnes O, Havelin LI, Engesaeter LB, Vollset SE, Kindseth O. Registration
    completeness in the Norwegian Arthroplasty Register. Acta Orthop 2006 Feb;77(1):49-56.

    Flugsrud GB, Nordsletten L, Espehaug B, Havelin LI, Meyer HE. The effect of middle-age
    body weight and physical activity on the risk of early revision hip arthroplasty: a cohort study
    of 1,535 individuals. Acta Orthop 2007 Feb;78(1):99-107.

    Munger P, Roder C, Ackermann-Liebrich U, Busato A. Patient-related risk factors leading to aseptic stem loosening in total hip arthroplasty: a case-control study of 5,035 patients. Acta Orthop 2006 Aug;77(4):567-74.

    Sadr AO, Adami J, Lindstrom D, Eriksson KO, Wladis A, Bellocco R. High body mass index is associated with increased risk of implant dislocation following primary total hip replacement: 2,106 patients followed for up to 8 years. Acta Orthop 2008 Feb;79(1):141-7.

    Dahl OE, Andreassen G, Aspelin T, Muller C, Mathiesen P, Nyhus S, et al. Prolonged thromboprophylaxis following hip replacement surgery–results of a double-blind, prospective, randomised, placebo-controlled study with dalteparin (Fragmin). Thromb Haemost 1997 Jan;77(1):26-31.

    Dowsey MM, Kilgour ML, Santamaria NM, Choong PF. Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study. Med J Aust 1999 Jan 18;170(2):59- 62.

    Santaguida PL, Hawker GA, Hudak PL, Glazier R, Mahomed NN, Kreder HJ, et al. Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review. Can J Surg 2008 Dec;51(6):428-36.

    Marchant MH, Jr., Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic
    control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone
    Joint Surg Am 2009 Jul;91(7):1621-9.

    Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking
    intervention on postoperative complications: a randomised clinical trial. Lancet 2002 Jan
    12;359(9301):114-7.

    Moller AM, Pedersen T, Villebro N, Munksgaard A. Effect of smoking on early
    complications after elective orthopaedic surgery. J Bone Joint Surg Br 2003 Mar;85(2):178- 81.

    Bolognesi MP, Marchant MH, Jr., Viens NA, Cook C, Pietrobon R, Vail TP. The impact of diabetes on perioperative patient outcomes after total hip and total knee arthroplasty in the United States. J Arthroplasty 2008 Sep;23(6 Suppl 1):92-8.

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