Surgeon finds knee arthritis surgery lacking and criticizes TKA studies

OSLO — By focusing on a patient’s age, profile and expectations, orthopaedic surgeons can more effectively treat the growing numbers of young patients with knee osteoarthritis who seek pain relief and return to activity and sports, according to a knee surgeon from Brugge, Belgium.

Instead of automatically employing traditional approaches, Jan M. Victor, MD, PhD, said, “We need to be more critical, more precise and more innovative.”

During his presentation at the 2010 ESSKA Congress, Victor questioned total knee arthroplasty (TKA) as the gold standard for managing arthritis of the knee, providing evidence for why he believes this type of surgical intervention is not always warranted in these cases.

Among the key points Victor made during his lecture were the following:

• Be wary of data from orthopaedic trials and literature. Unlike pharmaceutical studies, they are frequently underpowered;
• Expect patient outcomes to improve as the orthopaedist’s precision with diagnosis and surgery increases;
• The literature does not elucidate specific patient factors associated with the best and worst outcomes in a study, so do not rely solely on it; and
• To avoid TKA revision, orthopaedists should understand the role that correct alignment in all three axes plays in patient and surgical variability.

Victor advocated using virtual preoperative planning of osteotomies for more precise plate fixation. Images: Victor JM

“Pick up any paper on the subject and you will have a 50% chance of finding this quote as a first sentence: ‘TKA is a highly effective operation for adult arthritis of the knee with proven excellent outcomes.’ Is that true?” Victor said.

Published TKA survivorship ranges from 94% to 99% at 15 years’ follow-up, yet by comparison some national registries report crude TKA revision rates between 4% and 9%. “Unfortunately, there is some discrepancy,” he said.

Furthermore, the orthopaedic literature is inherently biased and investigators may make erroneous or biased conclusions because their studies are not randomized or blinded, Victor added.

However, according to Victor, orthopaedic surgeons can readily overcome some of these obstacles by creating realistic expectations among today’s well-educated TKA candidates regarding pain relief and activity restoration postoperatively.

He mentioned several areas for improvement, including the need for more stratification in patient and treatment selection.

“In young patients, realignment procedures should be considered in time,” Victor told Orthopaedics Today Europe. “Three dimensional imaging technology allows for virtual planning of osteotomies. Reverse engineering of customized cutting guides allows the surgeon to execute and fix the osteotomy exactly as planned.”

Victor kept coming back to one point in particular: “We need to be more precise. By precision, I don’t mean just simply precision in surgery, but also precision in diagnosis and in proper indications for surgery.” – by Susan M. Rapp

Reference:

• Victor J. Surgical treatment of knee arthritis: always confident, sometimes right? Paper HL12-2186. Presented at the 2010 ESSKA Congress. June 9-12, 2010. Oslo.

• Jan M. Victor, MD, PhD, can be reached in the Department of Orthopedics, AZ St-Lucas, St-Lucaslaan, Brugge, Belgium; +32-369080; e-mail: j.victor@skynet.be.

I had the privilege of being in the audience when Dr. Victor gave this lecture. I will humbly report this was one of the most enjoyable and informative lectures to which I have had the privilege of listening. Dr. Victor used TJA as an example of the great success in orthopaedics, but how we can do better. His message was relevant for all orthopaedists: know your surgical product and don’t oversell it.

Joint arthroplasty has revolutionized our ability to keep our elder population active and functional in their daily life. However, as we extend the age limits to whom we are providing this operation, we may not be able to match patient expectations. For me, one take home message holds true for all of orthopaedic surgery: understand the patient’s expectations and try to provide them with a realistic picture of what to expect in terms of pain relief and activity restoration postoperatively. The more precise we are in reporting our surgical outcomes, the better we will be as orthopaedic surgeons in accomplishing this goal.

– Elizabeth A. Arendt, MD
Professor, Department of Orthopaedic Surgery
University of Minnesota
Minneapolis, Minn., USA

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