Knee Replacement Benefits Over Nonsurgical Treatment Questioned in Study

New research suggests that nonsurgical options may work just as well as knee replacement surgery, but without the risks of infections, implant failure and other complications. 

In a study published this week by the New England Journal of Medicine, researchers from the University of Southern Denmark found that while knee replacement surgery is often helpful, nonsurgical techniques alone were surprisingly successful at avoiding the need for surgery, decreasing pain and avoiding potential surgical complications.

Researchers indicate that about 1% of all knee replacement procedures result in death of the patient within 90 days, impacting about one out of every 100 patients. In addition, about 20% of knee surgery patients continue to have residual pain that can last for more than six months.

The study involved a randomized, controlled trial with 100 patients suffering moderate-to-severe knee osteoarthritis who were eligible for total knee replacement surgery. Some were given the surgery along with 12 weeks of physical rehabilitation, and some were given just the physical rehabilitation, which included exercise, education, use of insoles, pain medications and dietary advice.

Researchers found that while knee replacement surgery still scored a bit better, with 85% of patients who received a knee implant seeing a 15% or better reduction in pain, most of the nonsurgical knee replacement patients fared just as well; 68%.

“[I]t is noteworthy that more than two thirds of the patients in the nonsurgical-treatment group had clinically meaningful improvements in the pain score and that this group had a lower risk of complications,” Dr. Jeffrey Katz, of Harvard Medical School, said in an accompanying editorial. “For most patients, the dramatic pain relief associated with total knee replacement provides a compelling rationale to choose surgery. Other patients, particularly those who are more risk-averse, may prefer nonsurgical care.”

In the total-knee-replacement group, researchers reported several adverse events, including three cases of deep vein thrombosis, one infection, one supracondylar fracture, and three episodes of stiffness requiring manipulation of the knee while the patient was anesthetized. That compares to only one case of stiffness reported in the nonsurgical group.

Researchers and the editorial noted that nonsurgical treatment patients still had the option of going back and getting a knee implant if they were dissatisfied with the results of nonsurgical treatment.

The study comes a little more than a year after researchers from Virginia Commonwealth University published a study in Arthritis & Rheumatology which found that about one-third of all total knee replacement surgeries may be unnecessary.

The study found that 34% of the surgeries were inappropriate when they used standard accepted criteria, and another 22% were inconclusive. Only 44% of the surgeries were deemed appropriate. The researchers had anticipated that only about 20% of the surgeries would be considered inappropriate.

In addition to facing the risk of complications associated with knee replacement surgery, the study raises concerns about unnecessarily exposing patients to the risks associated with implants that may later develop problems or be found to contain design defects.