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News & Trends - MedTech & Diagnostics

Knee surgery no quick fix: New guidelines shift focus away from knee replacement

Health Industry Hub | August 15, 2024 |

MedTech & Diagnostics News: Knee osteoarthritis affects 1.2 million Australians and has a high burden on people living with this chronic condition, and on the healthcare system. The Australian Commission on Safety and Quality in Health Care has teamed up with experts to introduce the 2024 Osteoarthritis of the Knee Clinical Care Standard.

Knee osteoarthritis is a growing concern in Australia, with over 53,500 knee replacements performed annually, a figure that continues to rise. By 2030, knee replacements are expected to surge by 276%. While surgery can offer significant relief when performed on the right candidates at the right time, ~10% – 20% of patients remain dissatisfied due to unmet expectations following joint replacement.

Since the initial release of the Standard in 2017, research has increasingly supported non-surgical treatments as the preferred approach for most individuals with knee osteoarthritis. Studies have shown that knee arthroscopy does not significantly improve pain or function in osteoarthritis, leading to a 47% decrease in its use among those over 45 between 2015 and 2022.

Gold Coast orthopaedic surgeon Adjunct Professor Christopher Vertullo, who is the Deputy Clinical Director of the Australian Orthopaedic Association (AOA) National Joint Replacement Registry and a key contributor to the updated Standard, stressed that knee surgery should not be viewed as a ‘quick fix.’

“The most important aspect of the revised clinical care standard is the focus on reducing unnecessary imaging and ultimately avoiding surgery that isn’t needed,” said Professor Vertullo.

“For most middle-aged and older patients with atraumatic onset – where knee pain has developed without injury – the pain is likely to subside on its own, and immediate imaging is often unnecessary. Patients and healthcare practitioners need to rethink investigations and referrals for knee pain unless they are clinically appropriate.”

He further explained, “In my practice, about a third of referred patients don’t need to see me, and about 60% of all my patients have undergone inappropriate imaging or scans without any initial management for osteoarthritis. I regularly discuss the need to maximise non-surgical management.

“In Australia, while we’ve seen a gradual decline in knee arthroscopy rates, there’s been an increase in investigations like X-rays, MRIs, ultrasounds, and CT scans, accompanied by a reduction in proper clinical assessments and appropriate management before patients are referred for surgery.”

The revised Standard outlines best practice care for knee osteoarthritis throughout a patient’s journey, from community-based care provided by GPs, physiotherapists, exercise physiologists, and dietitians, to specialist care from rheumatologists, orthopaedic surgeons, and other experts.

Dr Phoebe Holdenson Kimura, Medical Advisor for the Commission and a general practitioner, highlighted the importance of the Standard as a tool to integrate the latest research into everyday medical practice.

“Our understanding of osteoarthritis and the pathology of the knee joint and soft tissues has evolved,” she noted. “There must be a corresponding mindset change in how we both think and talk about osteoarthritis of the knee as a disease, to have a more holistic view of the person.”

The updated Standard also offers practical communication tips for clinicians, encouraging them to avoid language that catastrophises osteoarthritis.

“Let’s avoid phrases like ‘bone on bone’ and ‘wear and tear,’ which suggest we will damage our joints by moving them—this is simply not true,” Dr Holdenson Kimura said. “Non-operative approaches such as physical activity, exercise, and weight management have been proven to significantly improve the quality of life for most people with knee osteoarthritis. This is great news for patients who can better manage their condition and may avoid or delay knee replacement surgery.”

She added that the Standard empowers patients to take control of their condition and encourages clinicians to prioritise non-surgical treatments over immediate surgery or reliance on pain relief medications.

“There is an opportunity to shift the conversation to focus on active management and to reduce unhelpful beliefs – such as fear and avoidance of physical activity,” Dr Holdenson Kimura emphasised.

Osteoarthritis is most common in people over the age of 45, and with Australia’s aging population, the number of people with knee osteoarthritis increased by 126% between 1990 and 2019.

Professor Vertullo highlighted that improved weight management and increased physical activity could mean that many patients with knee osteoarthritis may never need to see a surgeon or undergo surgery.

“A patient should only be considered for joint replacement once they have maximised non-operative management as much as possible and reached a point where their pain is untenable or unmanageable. No one should enter surgery lightly. It is fantastic for end-stage osteoarthritis of the knee when someone has severe pain, but for an occasional ache, you are likely to be dissatisfied with the outcome,” he said.

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