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New Medical Research Targets Best Time for Joint Replacement Surgery

UMass Chan data shows fixed improvement score across typical patient population

Date Posted: Tuesday, June 10, 2014

UMass Chan Medical School Communications - umassmedNOW June 10, 2014

David Ayers, MD, seen here with a patient.
David Ayers, MD, seen here with a patient.

New data from a joint replacement monitoring program and database at UMass Chan Medical School shows there is an ideal time for typical patients to get the most out of a hip or knee replacement and that waiting too long will reduce the benefits of surgery.

“Don’t wait until you can’t walk or take the pain any longer,” said David Ayers, MD, the Arthur M. Pappas, MD, Chair in Orthopedics, chair and professor of orthopedics & physical rehabilitation and director of the Musculoskeletal Center of Excellence. “That’s what we hear a lot from patients and doctors—to wait until you can’t take it anymore. But the data is telling us that for typical patients, there’s only a fixed amount of improvement you can get from surgery. So if you wait too long, you don’t get the full value.”

“This isn’t about having surgery too early, either,” Dr. Ayers continued. “This is about the best time for surgery for the average patient. We now have objective, data-driven tools that can help patients decide together with their surgeons where they are with pain and function and when to have surgery.”

The nationally-recognized physical composite score for an individual with no joint pain or functional difficulty is 50. The new data, based on a study of 17,000 patients, reveals that typical patient scores improve an average of 12 points after total joint replacement (TJR) surgery. Because patients on average experience the same change in functional improvement after surgery, a typical patient who waits until their function is extremely impaired will not achieve the same degree of post-operative function as a typical patient who chooses surgery at the ideal time.

“What we’re seeing is that the average person who chooses total joint replacement has an average pre-TJR function score of 32,” said Patricia Franklin, MD, MBA, MPH professor of orthopedics & physical rehabilitations and family medicine & community health. “On average, TJR patients can achieve scores of 44 or greater and approach the function of non-arthritic patients after surgery. But, 20 percent of patients who wait until their score is 25 or lower generally don’t get the full 12 points of improvement. In fact, 40 percent of those who wait this long only achieve post-surgery function at the arthritis level of 32. If 50 is the goal, these are important measures for patients and surgeons to monitor when deciding on TJR surgery timing,” said Dr. Franklin.

There are exceptions to the rule of course. Both Ayers and Franklin, who are  said there are patients who break the evidence-based trends of the typical patient population.

“These are not absolutes, but it’s what we’re seeing in typical patients,” Ayers said.

The statistical analysis comes from patient data gathered by more than 136 orthopedic surgeons across 23 U.S. states through a joint replacement monitoring program and database called FORCE-TJR, led by Ayers and Franklin. FORCE-TJR uses a proprietary computerized system to collect standardized patient-reported information that allows joint pain and function to be scored independently. Together, the data produces a composite score for a patient’s level of pain and physical function.

“The uniformity of pain and function scores across such a wide population provides national benchmarks that patients and surgeons can compare against to assess where a patient falls on a spectrum and when they should undergo total joint replacement surgery to achieve the best outcomes,” said Regis O’Keefe, MD, chair of the department of orthopedics at The University of Rochester Medical Center and a member of FORCE-TJR.

FORCE-TJR is a national consortium of diverse orthopedic surgeons with varied hospital and surgical practices. Together, they are implementing a federally-funded effort tracking and reporting a wide range of quality measures to provide patients and their surgeons with in-depth, statistically-relevant information to guide decision-making around the timing, risks and benefits of joint replacement surgery.