How do you know when it's time to do this...

Jane Brody had a nice article about knee replacements and total joint replacements (TJR) in general  several months ago in the New York Times.  She even cited 2 good, albeit older, research studies about the topic.  The concept is something I discuss with physical therapy patients a lot and have been thinking about for years.  How do we better help people determine when or if it's time to pursue surgery?  ​ 

​The long time tenant of good healthcare practitioners is "to treat the patient and not the films".  Meaning that while a hip or knee (or spine or anything else) might appear to be at 'end stage' (the severest form of cartilage and bone deterioration using a scale like the Kellgren-Lawrence scale or similar type of radiologic staging) on X-ray, the patient may still have relatively high function, good joint motion and minimal pain complaints. We would not want to operate on that patient now, or perhaps ever.  The converse is also true.  Often the early joint changes are so different from previous, familiar soft tissue complaints that a patient with early, very minimal joint changes, may react much more poorly to these new symptoms.  That is, until they understand what they are and how to manage them.  We certainly would not want to operate on that person either as one of the articles studies points out. The risk, Ms. Brody highlights, is that not everyone is actually better with surgery.  Let's review that, how can putting a totally new joint to replace one that is wearing out, not be good?   How can new not be better?  Isn't Word version 14.3 sooo much better than 10.0?  Knee 2.0 - how is that not better?  

Some patients may do poorly post surgery because of the surrounding tissue they brought to the surgeons table, not the joint itself.  Not just an obese, out of shape body, what I mean is that some folks may wait too long for surgery and the destruction of the joint, or surrounding muscles or even their mental preparation or expectation may impede optimal recovery. For example some folks can martyr through stiff, painful joints better and longer than others and the resulting loss of joint range of motion (ROM) may actually lower the expectation of what "full recovery" of the limb after the new joint is placed, might be.   This sounds like perhaps what may have happened to Ms. Brody since she states she cannot kneel comfortably or bend her knees fully and she describes progressive bowing of her legs for many years prior to surgery.  While she reports she is very pleased with her results, others may not be.  There are some thresholds related to joint deformity and angular changes of the joint that reduce the likelihood of full ROM recovery.  

Still others, often patients with hip arthritis, may lose valuable muscle mass over the years while their joint deteriorates, but before it is meaningfully painful, making it very difficult to fully recover that strength and therefore resolve a limp, for example, after surgery.  Some patients equate still having a limp with a failed surgery.  Almost any patient I have ever treated has heard me say, 'in less than 90 minutes the surgeon put a brand new joint in your same old body...if your muscles were weak for years before surgery they're still weak now'.  The muscles move the joint, protect it, absorb force and are exactly the reason why some folks with very broken down joints still function very well, the muscles can and do absorb and adapt and protect the joint from detrimental forces or incidental strains.  
As with all surgeries, and relevant to the national opioid conversation, another reason surgery may not be for everyone, some folks are better adaptors than others when it comes to dealing with pre and post operative recovery, especially including pain.  I usually ask a patient how long they dealt with their joint pain before they conceded to surgery. My anecdotal experience was that the briefer the period prior to TJR the greater the struggle we both had recovering ROM and coping with pain.

If we go back to the original question, how do we help make a better decision...one tool I have been using for awhile now is the WOMAC pain and function scale.  This tool allows my patients to rate themselves related to pain, stiffness and function. In doing this specific self assessment we can get a gauge of subjective joint health to combine with my objective evaluation of joint health and general fitness.  Now we have a foundation from which to start making more informed choices. From there the 2 of us can make a plan to address the joint and revisit the WOMAC scale over 3 to 12 months to  evaluate how the joint is responding.  

I believe use of this tool combined with a precise and thorough physical therapy evaluation can help guide a better conversation and help patients make better decisions about when and if surgery is right for them.