To Have Surgery, or Not to Have Surgery

Aug 7, 2018

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The first step of the joint replacement process is determining if joint replacement surgery is the right choice for you in the first place. As the number of individuals receiving joint replacements each year continues to grow, numerous studies have tried to determine the most important factors to consider when deciding whether or not to have surgery.

One study published just last week by Huynh et al. (2018) tried to determine what factors were associated with orthopedic surgeon’s decision to recommend total joint replacement (TJR) surgery of either the knee or hip.

The study used data from 1,905 patients from across 11 different countries. Each of these patients had osteoarthritis (OA) of either the hip or knee and were receiving consultation from an orthopedic surgeon. The study analyzed a wide variety of factors that could potentially play a role in the decision to recommend surgery. Different factors analyzed included:

  • Patient Age
  • Patient Gender
  • Body Mass Index (BMI)
  • Comorbidities
  • Symptom Severity
  • Joint-related Quality of Life
  • Radiographic imaging: OA severity
  • Patient social situation
  • Surgeon characteristics (gender, years of experience)

In all, TJR was recommended in 561/1127 of patients with knee OA and 542/778 of patients with hip OA. From the studies analysis, the factors most associated with the recommendation for TJR were:

  • Radiographic OA severity
  • Symptom Severity
  • Patient Age

For radiographic grade, the researchers used a scale called the OARSI (Osteoarthritis Research Society International) joint space narrowing grade. With this scale, joint space narrowing, a main sign of joint OA, is grade from 0-4 with a higher score indicating greater joint space narrowing and severity of OA.

For symptom severity, the researchers used a questionnaire called the Western Ontario and McMaster Universities Arthritis Index (WOMAC). This index includes 24 questions used to determine level of pain, stiffness, and physical function in individuals with hip or knee OA. Higher scores indicate worse pain, stiffness, and functional limitation. (See link below for full Questionnaire)

Older age was also associated with a greater indication for TJR, with the ages of 60-79 years old having the greatest indication for TJR.

Factors found to not be associated with indication for TJR included:

  • Gender
  • BMI
  • Comorbidities
  • Social situation
  • Surgeon characteristics

The authors state that patient BMI and comorbidities may have possibly affected decision making less due to improved surgical techniques, shorter surgical times, and less risk to patients.

Interestingly, the study also looked at the reasons surgeons did not indicate surgery for some of the patients. The most frequent reason was “symptoms were not severe enough” and the second most frequent reason was “another treatment should be tried first.”

Take Home Message:

This study helps better understand factors to consider when determining appropriateness for joint replacement surgery, but it is not conclusive. When determining if surgery is appropriate for you, it is important to consider all relevant information and take a big picture view. Imaging results can help with decision making, but are just one piece of the puzzle.

As supported by this study, it is important to assess your symptom severity and overall level of function, too. You should also consider all conservative treatment options, such as physical therapy, as these options are less invasive and have significantly less risk of complications. In the end, gather as much information as possible and speak with your physical therapist and orthopedic surgeon in order to make the best decision for you.


Huynh, C., et al. “Factors associated with the orthopaedic surgeon’s decision to recommend total joint replacement in hip and knee osteoarthritis: an international cross-sectional study of 1905 patients.” Osteoarthritis and cartilage (2018).


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