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Danette Lake thought that an operation would relieve her knee pain.
The pain of arthritis started as a dull ache in the early forties, mainly because of the pressure exerted by an unwanted weight. Lake managed to lose 200 pounds by dieting and exercising, but her knee pain persisted.
A badual badault two years ago left Lake with physical and psychological trauma. She injured her knees while fighting her attacker, who had entered her home. Although she managed to escape, her knees never recovered. Sometimes the sharp pain took her to the emergency room. Lake's task of loading luggage into planes often left her in misery.
When a doctor said that knee replacement would reduce his pain related to arthritis by 75%, Lake was ecstatic.
"I thought the knee replacement was going to be a cure," said Lake, who is now 52 years old and lives in the Iowa countryside. "I'm all excited, thinking," Finally, the pain will end and I'm going to have some quality of life. "
But one year after her right knee surgery, Lake said she was still in pain.
"I suffer constantly, 24 hours a day, 7 days a week," said Lake, who is too disabled to work. "Sometimes I can not even sleep."
Most knee replacements are considered successful and the procedure is considered safe and cost-effective. Surgical rates doubled from 1999 to 2008, with 3.5 million interventions per year expected by 2030.
But Lake's test illustrates the risks and limitations of surgery. Doctors worry more and more about the overuse of the procedure and its benefits.
Research suggests that up to one-third of people whose knees have been replaced continue to suffer from chronic pain, while one in five is not satisfied with the results. A study published last year in the BMJ found that knee replacement had "minimal effects on quality of life", especially in patients with less severe arthritis.
According to a 2014 Arthritis & Rheumatology study, one third of knee replacement patients may not be suitable candidates for this procedure because their arthritis symptoms are not serious enough to warrant aggressive intervention. .
"We are doing too many knee replacements," said in an interview Dr. James Rickert, president of the Patient Centered Orthopedic Society, which advocates for affordable health care. "People will discuss the exact amount. But hardly anyone will say that we do not do too much. "
Although Americans are getting older and getting heavier, these factors alone do not explain the explosive growth of knee replacement. The increase could be fueled by a higher rate of injury among younger patients and by the increased willingness of doctors to operate younger patients, such as those aged 50 to 60, said Rickert, an orthopedic surgeon at Bedford, Indiana. This change has occurred because new implants can last longer – perhaps 20 years – before they wear out.
Yet even the most recent models do not last forever. Over time, implants can come off and come off the bone, causing pain. The plastic components of the artificial knee slowly wear out, creating debris that can cause inflammation. Wear can cause knee rupture. Patients who remain obese after surgery can put extra pressure on the implants, reducing their life.
The younger the patients, the more likely they are to "survive" their knee implants and require a second surgery. These "revision" procedures are more difficult to perform for many reasons, including the presence of scar tissue from the initial surgery. The bone cement used during the first surgical procedure can also be difficult to extract, and the bones can fracture when the older artificial knee is removed, said Rickert.
Revisions are also more likely to cause complications. According to an article published in November in the Lancet, about 35% of men under age 60 need a revision surgery, with 20% of women.
Yet, hospitals and surgery centers heavily market knee replacements, with advertisements showing patients running, cycling and even playing basketball after the intervention, said Dr. Nicholas DiNubile, orthopedic surgeon specializing in sports medicine in Havertown, Pennsylvania. Although many people with artificial knees can resume moderate physical activity, such as doubles tennis, it is unrealistic to imagine them playing basketball on the court again, he said.
"Hospitals compete with each other," DiNubile said. Marketing can mislead younger patients by saying, "I'll get a new seal and start doing everything I did before," he said. For Rickert, "medical advertising is an important part of the problem. His goal is to sell patients on procedures. "
Rickert said some patients are offered surgery they do not need and money can be a factor.
Knee replacements, which cost an average of $ 31,000, are "really essential to the financial health of hospitals and doctors' offices," he said. "The doctor wins a lot more when he operates."
Ignore the alternatives
However, surgery is not the only way to treat arthritis.
Patients with early illness often benefit from over-the-counter pain relievers, diet advice, physical therapy and education about their disease, said Daniel Riddle, a physiotherapy researcher and professor. at Virginia Commonwealth University in Richmond.
Studies show that these approaches can even help people with more serious arthritis.
In a study published in Osteoarthritis and Cartilage in April, researchers compared the surgical and nonsurgical treatments of 100 elderly patients eligible for knee replacement surgery.
In two years, all patients have improved, whether they are offered surgery or a combination of non-surgical treatments. Patients randomly badigned to immediate knee arthroplasty performed better, with an improvement of more than twice that in patients receiving combination therapy as measured by standard medical tests of pain. and operation.
But the surgery also entailed risks. Operated patients had four times more complications, including infections, blood clots or knee stiffness severe enough to require further medical intervention under anesthesia. In general, 1 in 100 patients who undergo knee replacement surgery die within 90 days of the operation.
Significantly, most people treated with non-surgical therapies were satisfied with their progress. Although all were eligible for knee replacement later, two-thirds chose not to do so.
Make informed decisions
Doctors and economists are increasingly concerned about inappropriate joint surgeries of all types, not just by the knees.
Inappropriate treatment not only hurts patients; it hurts the health system by increasing costs for everyone, said Dr. John Mafi, an badistant professor of medicine at UCLA's David Geffen School of Medicine.
The 723,000 knee replacements performed in 2014 cost patients, insurers and taxpayers more than $ 40 billion. These costs are expected to increase as the country gets older and is struggling with the effects of the obesity epidemic and the aging of the population.
To avoid inappropriate joint replacements, some health systems are developing "decision aids", written documents and videos that are easy to understand about the risks, benefits and limitations of surgery to help patients make more choices. enlightened.
In 2009, Group Health developed decision aids for patients considering joint replacement of the hips and knees.
Blue Shield of California has implemented a similar "shared decision-making" initiative.
Health care planners have been particularly concerned about the sharp increase in the number of younger patients undergoing knee replacement surgery, said Henry Garlich, director of health care solutions and improved clinical programs.
According to the Agency for Health Research and Quality, the percentage of knee replacements performed on people aged 45 to 64 years increased from 30% in 2000 to 40% in 2015.
As devices can be used in just a few years, a younger person could survive on his knees and require replacement, Garlich said. But "revision" surgeries are much more complicated procedures, with a higher risk of complications and failures.
"Patients think that after undergoing a knee replacement, they will participate in the Olympics," Garlich said.
Danette Lake had previously considered knee replacement surgery on the other knee. Today, she does not know what to do. She is afraid of being disappointed by a second operation.
Sometimes she said, "I think," I might as well stay in pain. "
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