After 50 or 60 years of total knee arthroplasty (TKA) and with more than 670, 000 knee replacements being performed annually it kind of boggles the mind that no one thought to do this earlier.
Knee Replacement Surgery or Not?
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Secondary
But, here it is, finally.
The study was published online in the New England Journal of Medicine on October 22, 2015 and is available at http://www.nejm.org/doi/full/10.1056/NEJMoa1505467. The authors were Søren T. Skou, P.T., Ph.D., Ewa M. Roos, P.T., Ph.D., Mogens B. Laursen, M.D., Ph.D., Michael S. Rathleff, P.T., Ph.D., Lars Arendt-Nielsen, Ph.D., D.M.Sc., Ole Simonsen, M.D., D.M.Sc., and Sten Rasmussen, M.D., Ph.D.
The researchers designed a randomized, controlled trial with 100 patients with moderate-to-severe knee osteoarthritis who were eligible for unilateral total knee replacement.
The patients were randomly assigned to undergo total knee replacement followed by 12 weeks of nonsurgical treatment (total-knee-replacement group) or to receive only the 12 weeks of nonsurgical treatment (nonsurgical-treatment group), which was delivered by physiotherapists and dietitians and consisted of exercise, education, dietary advice, use of insoles, and pain medication.
The primary outcome was the change from baseline to 12 months in the mean score on four Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, activities of daily living, and quality of life (KOOS4); scores range from 0 (worst) to 100 (best).
After one year 95 patients had completed follow-up assessment. The nonsurgical-treatment group, 13 patients (26%) underwent total knee replacement before the 12-month follow-up. In the total-knee-replacement group, 1 patient (2%) received only nonsurgical treatment.
In the intention-to-treat analysis, the total-knee-replacement group had greater improvement in the KOOS4 score than did the nonsurgical-treatment group (32.5 vs. 16.0; adjusted mean difference, 15.8 [95% confidence interval, 10.0 to 21.5]).
The total-knee-replacement group had a higher number of serious adverse events than did the nonsurgical-treatment group (24 vs. 6, P=0.005).
Conclusions
In patients with knee osteoarthritis who were eligible for unilateral total knee replacement, treatment with total knee replacement followed by nonsurgical treatment resulted in greater pain relief and functional improvement after 12 months than did nonsurgical treatment alone.
However, total knee replacement was associated with a higher number of serious adverse events than was nonsurgical treatment, and most patients who were assigned to receive nonsurgical treatment alone did not undergo total knee replacement before the 12-month follow-up.
React:
Discussion
This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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