Knee Replacement Surgery for Osteoarthritis of the Knee

Peter Salgo, MD: I don’t want to leave this topic without briefly touching on knee replacement surgery. This is sort of the final common pathway for people who get really sick. You’ve already talked about when you shouldn’t do it. When should you do it? What is the indication for it?

Richard Iorio, MD: Again, lifestyle has become the major driver in joint replacement. The age of intervention continues to get lower. The operation continues to get better. There are fewer complications. Expectations are higher. Patients want to do more. They want this to last longer. We can pretty much guarantee people that these things will last for 20 years, or perhaps longer, if they behave themselves appropriately, and they don’t get sick or have a fracture or an infection. What we can’t ensure is that we’re completely reduplicating original knee function. It’s a really good substitute. It’s not the same as the one God gave you. You’re not going to automatically become age 29 again. So, I go back to what I said earlier. If you’re having symptoms that are unresponsive to conservative treatment, if you can’t do the things that make you the person you want to be—if you can’t go to work in the morning, you can’t get pain relief at night to sleep, or you’re having instability or episodes—you may very well be a candidate for knee replacement.

Peter Salgo, MD: Those are the benefits you talked about. What are the risks of this operation?

Andrew Spitzer, MD: One of the things that is the motivation for the remainder of this conversation that we’ve had is that there are large registry data that suggest that roughly 20% of patients are not satisfied with their pain and function after total knee replacement. We look at their x-rays. We look at their clinical function. We say, “He looks good but feels bad.” That’s a challenge for us. That’s really the motivation to sort of delay that joint replacement until patients are really ready for it—with all of the symptoms that Rich described and with realistic expectations. Up to a third of those patients have residual symptoms of some sort after knee replacement. Those are certainly some of the risks of outcome. We talk about all of the other risks of infection, and cardiovascular issues around the time of surgery. But, overall, I think our risk profile is really quite low, in terms of giving patients a really successful, game-changing outcome, in the patients who are successful with it.

Paul Lachiewicz, MD: I think we know that there are groups of patients who don’t do as well as we’d like with knee replacement—those patients who are depressed and on medication or those patients with very high anxiety or catastrophizing behaviors, those patients with fibromyalgia, or those with other comorbidities. They just don’t seem to do as well. You try to give them realistic expectations. I think it is a valuable tool. Certainly, as Rich mentioned, we’re doing a lot of knee arthroplasties. But, again, I think the take-home message for patients is that this is not a normal knee. It’s pretty good, but it’s not a normal knee.

Transcript edited for clarity.