ORTHO NEWS

In the year before total knee arthroplasty (TKA), patients incur considerable costs for nonoperative treatments and other procedures for osteoarthritis (OA) – raising questions about the value of those procedures, reports a study in The Journal of Bone & Joint Surgery. The journal is published in the Lippincott portfolio in partnership with Wolters Kluwer.

The study shows “substantial variation in the type and cost of nonoperative procedures for patients with late-stage knee OA prior to TKA,” according to the report by Eric L. Smith, MD, of New England Baptist Hospital, Boston, and colleagues.

Estimated costs of $2.4 billion over 3 years for nonoperative procedures before TKA

Using nationwide commercial insurance databases, the researchers analyzed claims for nearly 24,500 patients who underwent primary TKA in 2018 and 2019. The study examined the types and costs of nonoperative procedures in the months leading up to TKA.

Average costs for nonoperative procedures in the year before TKA were $1,355 per patient. Knee imaging studies were the most common procedure overall, performed in about 96% of patients. Intra-articular steroid injections were the most frequent treatment procedure, performed in 54%. Bracing was the least common nonoperative treatment, performed in approximately 8% of patients.

Intra-articular injection of hyaluronic acid, excluding professional administration fees, was the most costly procedure: performed in about 13% of patients, it made up 10% of total costs. By comparison, steroid injections were performed in more than half of patients, but accounted to just over 1% of costs. Physical therapy was used in about 27% of patients and accounted for about 17% of costs.

Most patients underwent at least two nonoperative treatments, while more than one-third underwent three or more. Costs increased with time between diagnosis and surgery, exceeding $2,000 in patients with a 12-month duration before undergoing TKA.

Women had higher total costs for nonoperative treatment, with the greatest differences in physical therapy and prescription of nonsteroidal anti-inflammatory drugs. Men had higher costs for opioids. Procedures and costs also varied by region, with the Northeast region having the highest average cost ($1,740).

TKA is a highly effective and cost-efficient treatment for knee OA. The researchers note that decisions about TKA can be “extremely complicated,” involving factors related to patients, providers, and insurers. For example, insurers may require some period of nonoperative treatment before authorizing coverage for TKA. With the national focus on reducing costs while delivering high-value care, the requirement of nonoperative treatment in the months before TKA warrants evaluation.

Extrapolated to the 600,000 TKAs performed each year in the United States, the total costs of nonoperative treatment are estimated at $2.4 billion over a 3-year period and are likely to increase in the future. The authors point out some limitations of their study, mainly related to the use of insurance claims data.

“For patients who eventually undergo TKA, the cost-effectiveness of these nonoperative treatments right before TKA needs to be carefully considered as the health-care system transitions toward a value-based model,” Dr. Smith and coauthors conclude. They also note that some nonoperative treatments – for example, intra-articular steroid or hyaluronic acid injections or bracing – do not have strong evidence of effectiveness. The researchers call for further studies focusing on the benefits of nonoperative treatments at different stages of knee OA.

Is someone dear to you constantly complaining about nagging knee pain? Have you shown them to a doctor who may have advised a knee surgery? If the advice left you worried, you’re not alone. Every time a person, especially someone with arthritis, with excruciating knee pain is advised a surgery, a second or third opinion is sought. Many patients are still in two minds to consider knee replacement surgery for arthritic knee even though there may be enough medical evidence to suggest that Total Joint replacement is the only solution for arthritic joints.

There are about 350 million patients every year suffering with knee pain due to arthritis. It has become the second most dreaded condition after cardiovascular issues in the world. India stands at around over 15 million cases every year and this figure may touch 60 million by 2025 as per Arthritis society.

Knee replacement surgeries have evolved over the years.

“Today, a joint replacement surgeon with all his or her expertise can assure the patient of a favorable outcome and give functional ability of the implanted knee joint as good as natural knee,” says Dr Manish Samson, Senior Consultant Orthopedic and Joint Replacement Surgeon, Apollo Hospitals, Bengaluru.

According to him, knee replacement surgeries are recommended when all other treatment options – exercise, medication, dietary tweaks or use of essential oils for knee pain, are tried and exhausted. These surgeries are to make the patient functionally active without or with negligible pain. Knee replacement surgery not only takes away the pain and improves mobility of the patient, but also corrects any deformity of the patient around their knees for the rest of their life.

Here are some frequently asked questions about surgery for knee pain

Dr Samson explains the procedure and its important, for Health Shots.

1. When is surgery recommended?

There are various reason when a doctor may suggest knee replacement surgery.

* Wear and tear in the knee joint leading to stiffness and severe knee pain that restraints a person from day to day activities including walking, running, climbing stairs and other movements.
* Pain while resting, either day or night
* Chronic inflammation of the knee due to long standing Arthritis due to medical conditions like Rheumatoid, gout or Tuberculosis and that does not improve with medicines and rest.
* Knee deformity
* Failure of non-surgical methods like medications, infra-articular injections and physiotherapy.
* Arthritis due to old fractures which have healed in a non-acceptable position.

2. What is the ideal age for an arthritic patient to undergo knee replacement surgery?

There is no fixed age for knee replacement surgery. It can be at a very young age or at geriatric age. It all depends on how badly the knees are affected. Basically, there are various disease forms of arthritis where a patient can have advanced arthritis of knee joint at young age. In such cases, knee replacement surgery is an early option. There are age-related wear and tear – what is known as osteoarthritis – that comes at very late age after 60 years.

Based on severity and failure of all other non–operative methods, knee replacement surgery is executed.

Also read: 5 common age-related pains you must not ignore

3. Can both knees be operated simultaneously?

Yes, knees can be simultaneously operated after strict medical and cardiac evaluation. The final decision is taken based on medical reports on the day prior to surgery and preferably on patients without major medical issues.

4. How fast is the recovery after knee replacement? Can a patient squat after knee replacement?

The patient can be back to normal activity in 3 to 4 weeks. Yes, the patient can squat after surgery if the patient had the ability to do so before surgery. After a period of 6 months of good self-exercise, and use of the modern implants and good surgical techniques by experienced joint replacement surgeons, patients can squat and even sit cross-legged.

5. What happens if the surgery fails?

Unfortunately, if the patient has undergone a knee replacement surgery and has problems, or if the surgery has failed over a period of time – revision knee replacement surgeries can be offered. Practically all problems can be resolved to make the patient active and pain-free again by experienced joint replacement surgeons.

6. Is the knee replacement surgery very painful? Do all patients need physiotherapy after surgery?

Yes, knee replacement surgeries were very painful. However, now orthopedic surgeons take help of pain management experts who use various intervention blocks with sustained medications to mask or block the pain, making it easy for surgeons to operate on both knees simultaneously. This also gets them the same result as from operating one knee at a time.

Regarding the post-surgery physio therapy, it varies from surgeon to surgeon and the surgical technique used. It also depends on the patient’s pre-surgery activity level and motivation status.

7. How to protect your knee replacement?

Post-surgery, the patient should abide by the following rules to protect the new knee:

* Regular light exercise to maintain strength and mobility of the new knee
* Avoid falls and injuries.
* Routine follow ups and examination of the new knee
* Treat any infection elsewhere in the body with immediate attention and antibiotics as suggested by the physicians.

The MAKO® robot may benefit you

June 10, 2022

Author: Sarah Barber

According to the Center of Orthopedic and Neurosurgical Care and Research nearly one million hip and knee replacement surgeries are performed in the United States annually, making it one of the most common orthopedic procedures performed today.

With so many Americans needing or considering a knee or hip joint replacement it’s important to know how those surgeries are performed, and what options are available to you.

“The Mako® robotic arm is a surgeon operated and controlled tool, and is one of the latest technologies available for hip and knee replacement surgeries,” said Daniel Mesko, DO, fellowship trained, orthopedic surgeon who works with McLaren Greater Lansing. “This technology has been around since 2006, and has been used for more than half a million cases. The Mako® robotic arm isn’t required to have a great outcome for your joint replacement surgery, but it can be beneficial for many patients.”

What specifically does the MAKO® robot do? And should I find a surgeon who uses it for my joint replacement surgery?

This technology is unique in that it uses a Computed Tomography (CT) scan that provides the surgeon a 3D model of the joint they are replacing before they make a single cut. This road map allows the surgeon to make a clear plan in sizing and implant positioning before surgery begins.

“If the patient has had previous surgeries such as spinal fusions, previous hardware placement, or has experienced traumatic injuries to the area like fractures, the robot can really help us pre-plan and navigate for those specific cases taking into account the altered anatomy,” said Dr. Mesko.

The MAKO® robot can be used for full or partial knee replacements and hip replacements utilizing any approach including anterior, mini-posterior or lateral based approaches. The company is also looking at expanding this technology for shoulder, pelvis, and spinal surgeries in the future.

What are the benefits of MAKO® robotic-assisted surgery?

“The benefits of robotic joint replacement for my patients have been numerous. The largest difference I have noticed in my patients is they are walking with confidence right after surgery,” said Steven Drayer, MD, orthopedic surgeon and robotic specialist who works with McLaren Greater Lansing. “When they come in for their post-operative appointment, they aren’t using a cane or walker.”

Using the MAKO® robotic arm can also include additional benefits like CT based accuracy of component positioning and patient matched sizing, achieving accuracy in areas such as balancing a knee throughout the entire arc of motion as well as leg length accuracy in total hips.

The potential benefits of lower incidence of hip instability, less need for long term revisions and a diminished risk of something unplanned arising during surgery also may exist.  “Although patients experience some pain after surgery, my patients have less anxiety in their recovery and are quicker to ask when they might have their next replacement performed,” said Dr. Drayer.    

To learn more about robotic-assisted knee and hip replacement and the surgeons who perform robotic-assisted surgeries at McLaren Greater Lansing, click here.