Treatment Plans for Knee Osteoarthritis Patients

FEBRUARY 23, 2018
MD Magazine Staff

Paul Lachiewicz, MD: Peter, I think it’s important that the orthopedic surgeon have a good conversation with the patient on the type of treatment plan. A key factor is that the patient should be shown their x-rays. And, they have to be realistic in regard to what we can provide for them.

Peter Salgo, MD: “Oh, no, I want a cure.” “I want a cure today.” “I saw it on TV.”

Paul Lachiewicz, MD: But, most importantly, the patients come and they say, “I want to be like I was when I was 20 years old. I want to be able to do this.” The first thing I say to them is, “You know, no matter what I do, whether it’s surgical or nonsurgical, you have to be realistic. We can’t make you like you were when you were 18 years old. But, we can help you with your symptoms.” If they have terrible end-stage arthritis, and we’ve exhausted all of the nonsurgical things, I say, “We can help you with knee surgery. But, again, it’s not going to be a normal knee.” I think that’s where a lot of dissatisfaction comes up. People have unrealistic expectations.

Richard Iorio, MD: Peter, we did a lot of work on this, and we came up with the term “modifiable risk factor,” which looks at a patient’s risk profile as it pertains to their operation. And clearly, as Andrew said, if you’re a diabetic, you’re morbidly obese, or you smoke, your risk of infection and complication after knee replacement goes up astronomically. These factors are multiplicative. They’re not additive.

Peter Salgo, MD: Don’t you hear this all the time: “I don’t want to do anything. I just want you to fix the knee?”

Richard Iorio, MD: So, let me get back to this. We then applied those characteristics to patients, preoperatively, with the thought that, “If we can help you understand what your risk is for operation, and how these risk factors increase your risk of needing a joint replacement, perhaps we can modify them before the operation.” That’s what part of this arthritis education website is about. The important thing is to join the patient in a shared decision-making discussion, and to identify the risks for them on what their health status does to them as it pertains to arthritis, and the risk of operation. Then, the key part, as Paul said, is expectations. “Well, what do you want to do? Do you just want to walk to the refrigerator and get more Twinkies out? Or, do you want to actually participate in exercise and improve your health status?”

Then, the key is to engage them, right? We’ve shown that they engage, if they do anything­—it doesn’t even matter if they completely stop smoking, or if they just lose 10 pounds, or if they do some exercise—it improves their ultimate outcome.

Peter Salgo, MD: But, buy-in is what you’re talking about?

Richard Iorio, MD: The patient has to have skin in the game. We can’t just be technicians and provide them with replacements. If their expectations aren’t defined ahead of time, we’ll never be successful.

Andrew Spitzer, MD: One of the things that we’ve learned, as well, is that the expectations have a lot to do with, ultimately, patient satisfaction. If we don’t understand those expectations, and they don’t understand them, and they don’t understand the limitations of what we, as surgeons, can offer them (in terms of satisfying those expectations), their outcomes and their satisfaction is not going to be as good.

Paul Lachiewicz, MD: That’s what I want to get back to. Even the perfect artificial knee, total knee, is not a normal knee. I think patients have trouble with that.

Peter Salgo, MD: They don’t want to hear that.

Paul Lachiewicz, MD: They don’t want to hear that. They just want to be normal.

Peter Salgo, MD: They want to reset the clock, right?

Paul Lachiewicz, MD: Right.

Peter Salgo, MD: “Oh, good. I’ve got a new knee. Now I can gain weight, because my knee is better. I can start from ground zero. I can also run in the next 10 marathons.”

Andrew Spitzer, MD: There’s ample data in the literature, and we’ve reproduced that, as well, that suggests that patients say to their doctors, “Well, fix my knee and then I’ll go lose weight.” Because they can’t exercise, they don’t. You look at them, a year later, their BMI [body mass index] is unchanged.

Paul Lachiewicz, MD: I actually did a study on that, too. Patients actually gain weight after successful total knee…

Peter Salgo, MD: Really? Why?

Paul Lachiewicz, MD: That’s been reproduced.

Richard Iorio, MD: Well, as people age, they gain weight.

Paul Lachiewicz, MD: They age and they gain weight.

Richard Iorio, MD: Ten pounds a decade.

Peter Salgo, MD: Really? I mean, if you give them a knee, they can go out there and move better. You would think...

Richard Iorio, MD: In their mind, they think that they’re still 38 years old. They’re now 65. They’re 70. They are not 38 years old. The rest of their body aged too. I liken it to a good used car. With a knee replacement, we didn’t replace the knee. We resurfaced the knee. “The rest of you is still 65 years old.”

Peter Salgo, MD: Seriously, people have unrealistic expectations.

Transcript edited for clarity.

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