Study: Surgeons Show Little Bias in Recommending Knee Replacement

Knee arthritis and knee pain are extraordinarily common. Nowadays there are a tremendous number of treatment options to help alleviate the pain that might otherwise slow you down. There are many injection options: steroid (cortisone), PRP (platelet rich plasma), and HA (hyaluronic acid viscosupplementation). There are many oral medications. And even more kinds of braces. The final stop is a knee replacement. And even this option comes in different flavors (partial, total, and other nuances).

Most patients who undergo TKA (knee replacement) experience reduced knee pain and regain function. The procedure entails a surgeon removing damaged bone and cartilage from the thigh bone, shin bone and kneecap; and implanting an artificial joint made of metal, plastic or polymers. The prosthetics are available in a range of designs for patients with differing ages, weights, activity levels and general health.

The surgery is an effective method of repairing joint damage caused by osteoarthritis or rheumatoid arthritis. Many patients are able to relieve their symptoms by taking anti-inflammatory medications, receiving physical therapy and altering their activities. However, some continue to have trouble walking, climbing stairs and getting up from chairs. They experience knee pain even while inactive. TKA (knee arthroplasty) is frequently advised for such patients.

Although arthritis does seem to demonstrate some degree of genetic predisposition, research has failed to reveal significant differences in how often orthopedic surgeons recommend total knee arthroplasty (knee replacement) for patients of varying races and genders.

More than 100 surgeons conducted a study in 2012 while attending meetings of the New York State Society of Orthopaedic Surgeons, and the American Association of Hip and Knee Surgeons. They sought to challenge previous research that seemed to insinuate that orthopedists are sometimes biased in recommending TKA (total knee arthroplasty) for men over women, and whites over blacks.

The doctors wrote that they “developed four computerized scenarios for all combinations of race (white or black) and sex (male or female) for otherwise similar patients with end-stage knee osteoarthritis.” All the patients had experienced increasing knee pain, and a gradual loss of function in the joint, for at least two years. Anti-inflammatory drugs and corticosteroid intra-articular injections had failed to relieve their symptoms.

All the surgeons reviewed the medical history of a white man, and some were also asked to look at the cases of a white woman, a black woman and a black man. The doctors then decided which patients warranted TKA.

The result was “a 15 percent difference in the likelihood of recommending surgery for white versus nonwhite patients,” the research team concluded. Thirty-nine surgeons reviewed the white male and black female cases. Thirty-three (85 percent) of them said both patients needed the surgery. Six of the orthopedists recommended TKA for just one of the people, though “no effect of patient race and sex” reportedly was involved; ie, they recommended surgery for the black female and not for the white male or vice versa.

“Of the 37 surgeons who viewed the white male plus black male scenario, there were 33 (89 percent) concordant responses and four discordant responses, with no effect of patient race,” the researchers wrote. “Of the 37 surgeons who viewed the white male plus white female scenario, there were 30 (77 percent) concordant responses and seven discordant responses, with no effect of patient sex.”

Following the trials, the surgeons declared that “patient race and sex were not associated with a different likelihood of a surgical recommendation.”

They added: “Our findings support the notion that patient race and sex may be less influential on decision making when there are strong clinical data to support a decision. Physician bias may have a greater effect on decision making in situations where the indications for surgery are less clear.”

Often times studies done that make treatment recommendations that differ based on a patient’s gender or race have results that are shrouded in doubt secondary to associated socioeconomic differences and obesity differences that are inextricably tied with body mass index (obesity) and other confounders.

If you have been told you have knee arthritis or suffer from knee pain, contact our renowned sports medicine providers at Orthopedic Surgery San Diego.