Improving the criteria for appropriateness of total joint replacement surgery: comment on the article by Riddle et al

摘要

To the Editor: We read with interest the recent article by Riddle et al and the editorial by Katz (1,2). Our data from a national cohort study of >21,000 patients undergoing total joint replacement (TJR) differ greatly from the findings by Riddle and colleagues. In fact, our data show that <5% of patients do not report symptoms consistent with advanced knee arthritis. In contrast, Riddle et al reported that in 60 (34.4%) of 175 patients, total knee replacement (TKR) was classified as inappropriate. The Agency for Healthcare Research and Quality-funded Function and Outcomes Research for Comparative Effectiveness in TJR (FORCE-TJR) registry is a nationwide, comprehensive database of TJR surgical and patient-reported outcomes. This registry contains a national sample of patients who elected to undergo TJR surgery between 2011 and 2014, performed by 136 surgeons practicing in 22 states (3). All patients in the FORCE-TJR registry complete standardized assessment surveys of pain and physical function both before and after surgery and contribute comprehensive data regarding risk factors for medical and musculoskeletal disorders. Although patients in the FORCE-TJR registry completed the surveys before surgery, the scores were not available to the surgeons at the time of the surgical decision-making process; therefore, their decisions whether to proceed with elective TJR were based on standard clinical practice. Thus, we evaluated the pre-TKR pain and function profiles of thousands of patients who underwent primary TKR in the US. In total, 76% of patients reported both advanced pain and significant functional limitation before TKR, at levels comparable to those historically associated with TKR use (4). Interestingly, the patients with significant pain and disability were younger, more obese, and reported more medical comor-bidities compared with the other patients. Younger patients are the fastest-growing group utilizing TKR, and significant levels of pre-TKR pain and functional limitations are consistent with TKR utilization. An additional 19% of patients report either advanced pain or significant functional limitation at the time of TKR, both of which are consistent with TKR utilization. Finally, as mentioned above, <5% of patients report minimal pain or minimal disability.