Friday, October 23, 2015 Study: For Some, TKA With Nonsurgical Treatment Better Than Nonsurgical Treatment Alone According to a new study, patients with moderate-to-severe knee osteoarthritis (OA) who receive knee replacement surgery (TKA) and conservative treatment that includes physical therapy tend to fare better after 12 months than those who receive only the conservative treatment, though both groups see significant improvement. Researchers believe the findings—which also reported higher rates of serious adverse events for the surgery group—underscore the need for considering patients' "preferences and values" before deciding on a course of treatment. The study analyzed data from 95 patients who presented with moderate-to-severe knee OA and were determined to be eligible for TKA, with roughly half receiving TKA followed by 12 weeks of multidisciplinary rehabilitation, and the other half receiving only the rehabilitation treatment. Using the Knee Injury and Osteoarthritis Outcome Score (KOOS) as the primary outcome measure, researchers found that 1 year later, the surgery group recorded KOOS scores that were, on average, 16.5 points above the nonsurgical group on the 100-point KOOS scale (researchers used 10 points as the threshold for a minimal clinically important difference). Secondary outcome measures, including the Timed Up-and-Go test and averages of 20-meter walk tests, were also more favorable for the surgery group. The nonsurgical treatment administered to both groups comprised 5 interventions that included exercise, education, dietary advice, the use of special insoles, and pain medication when determined necessary for participation by an orthopedic surgeon (acetaminophen, ibuprofen, and pantoprazole). The exercise sessions were conducted in weekly 1-hour group sessions held over the course of 12 weeks and emphasized "neutral, dynamic alignment," according to authors of the study. Researchers assessed outcomes at 3, 6, and 12 months after the startup of the nonsurgical treatment. Results were published in the New England Journal of Medicine. Researchers pointed out that while the surgical group reported a bigger change, "both groups in our study had substantial improvement with respect to most outcomes," and they noted that among the nonsurgical group, only 13 of the nonsurgical patients (26%) wound up having TKA before the 12-month follow-up. Further tempering the results as a conclusive finding in favor of one approach over the other, researchers found that serious adverse events—deep venous thrombosis, stiffness requiring manipulation, musculoskeletal problems in areas other than the index knee, and other conditions—occurred at a higher rate in the surgery group. A story on the research published in The New York Times described TKA-plus-rehabilitation as relieving pain and improving function "much more effectively than nonsurgical therapy alone" but noted that the findings don't necessarily mean that TKA is the best course of treatment in every case of moderate-to-severe knee OA. "Most surgeons have assumed that total knee replacement provides superior results," the NYT reports. "But experts said this new trial suggested that patients with severe osteoarthritis and difficulty walking should not always go under the knife." A recent WebMD article on the research reached a similar conclusion, saying that physical therapy "is often effective and should be viewed as a viable option." Authors of the study conclude that for the population studied, TKA and nonsurgical treatment is "superior" to nonsurgical treatment alone, although they acknowledge the effect exercise can have on outcomes, and advocate for approaches to treatment that are patient-centered. "Even for patients progressing to surgery, participation in supervised exercise before surgery has been associated with a faster postoperative recovery," authors write. "The benefits and harms of the respective treatments underscore the importance of considering patients' preferences and values during shared decision-making about treatment for moderate-to-severe knee osteoarthritis." Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.