With obtaining knowledge on the Dijk et al. study, it will enable a patient to be more proactive on how to work with their current knee conditions. By being proactive and well-prepared, a patient can slow the progression of destructing their knees and still have the chance to participate in knee replacement surgery to improve lifestyle. The primary demographic for this article would be elderly people who are struggling with a decline in lifestyle. Older people would find this study quite beneficial because it would provide instructions on how to buy extra time before having knee replacement surgery, and once the time is right for the surgery, it will provide ways to ensure preparedness.
The reason this study is very important to osteoarthritis sufferers is because it will enable them to gain a better understanding about knee replacement surgery Singapore cost. As the article clearly explains the costs, effects, and what should be done before the procedure, it will surely guide osteoarthritis sufferers into making informative decisions to if they should be considering knee replacement surgery. It also provides guidance on what can be done by individuals to prepare themselves for knee replacement surgery.
Dijk et al. created a study that is quite beneficial for individuals who suffer from osteoarthritis. With just a brief glance at the title of the article, it is quite evident the study is a good resource for instructions quitting the progression of knee osteoarthritis. By reading deeper into the study, the reader will find specific information on the knee replacement surgery, the costs of the surgery, the effects it has on people’s lives, and exactly what should be done before the procedure is executed.
On page 591, the month of publication of The Open Orthopaedics Journal, the work “Knee Replacement Surgery Cost and Best Treatment for Low Bone Density” created by authors Bart van Dijk, Mickael Hiligsmann, Rob G.H.H. Nelissen, and P.C. Poolman is a fantastic resource available for future orthopaedic patients. Knee replacement surgery, often called total knee arthroplasty, is a procedure used to relieve pain and mobility in patients who suffer from degenerative osteoarthritis in the knee. This often requires the implant of a prosthetic knee, and surgery is considered to be quite costly for the patient.
Overview of knee replacement surgery
Knee replacement surgery is a procedure that replaces the weight-bearing surfaces of the knee joint to relieve pain and disability. The first knee replacement was performed in 1968, and since then the procedure has become relatively common and very effective with more than 300,000 surgeries being performed each year by 700,000 Americans. According to the World Health Organization, knee osteoarthritis is becoming a major cause of disability in aging populations. Osteoarthritis is the most common reason for knee replacement surgery. Although this type of surgery has a very high success rate, there are still complications that can arise. These complications can be more severe for patients with low bone density. The last alternative for these patients is a total knee replacement (TKR). Low bone density can be caused by a variety of reasons such as aging, genetic factors, not attaining peak bone mass, and other illnesses. TKR is often postponed or avoided for patients with low bone density in fear that the bone may not be strong enough to hold the components. This can result in a progression of disability and increased pain for the patient due to putting off the surgery and the possible unsuccessful alternative procedures. This essay will look at the complications that can arise in knee replacement surgery for patients with low bone density, ways to diagnose and classification of low bone density, and what the best course of action is for patients deciding when to have knee replacement surgery.
Importance of addressing low bone density before surgery
Osteoarthritis is a universal knee joint disease that frequently requires surgical treatment. The approaching epidemic of osteoarthritis is largely due to the aging population since elderly people develop knee osteoarthritis from a lifetime of wear and tear on their joints. One of the recent reasons that knee osteoarthritis is becoming more of a burden is the obesity epidemic. The significant increase in the rate of obesity in the US has put more people at risk for developing knee osteoarthritis, because obesity is a well-recognized risk factor for knee osteoarthritis. A high body mass index is associated with a greater lifetime risk of developing knee osteoarthritis, and greater BMI at the time of knee osteoarthritis diagnosis is related to more rapid progression of the disease. Before 1997, the treatment of choice for end-stage knee osteoarthritis was non-surgical, which included medications and lifestyle modifications, and when non-surgical treatments proved to be ineffective, the patient would be advised to just cope with the pain until it becomes bad enough to justify total knee replacement. Partial meniscectomy in osteoarthritis of the elderly is controversial but is commonly performed and is often helpful when mechanical symptoms are present in conjunction with moderate to severe osteoarthritis. Bilateral or unilateral procedures are indicated in knees with disabling symptoms caused by meniscal tears and minimal to severe osteoarthritis. However, partial meniscectomy is only a temporary solution to relieve pain and disability because many patients have been known to develop osteoarthritis at an accelerated rate in the meniscectomized knee when compared with the slight to moderate osteoarthritis in the contralateral knee. Given that meniscectomy is only a temporary solution to a long-term degenerative disease process, total knee replacement may become a more frequent solution for patients with knee osteoarthritis. Total knee replacement is a surgical procedure that removes the damaged bone and cartilage of the knee joint and replaces it with smooth metal and plastic components.
Factors Affecting the Cost of Knee Replacement Surgery
Implants and the amount of time a specific procedure will take to perform all play into the cost of knee replacement surgery. Devices and/or components used in knee replacement are also a significant factor in cost. High-performance implants are often the best choice for younger, more active patients. These patients tend to put more demands on their replaced joints. As with anything, newer technology can often cost more. Patients should consult their physicians on what type of implant is being put into their body, its longevity and its performance. Patients should also inquire about the instrument trays used in their surgery. Many of the disposable instruments used in joint replacement can be costlier than their standard counterparts. Asking about such hidden costs can help a patient gauge what their surgery will truly cost. Duration of surgery and type of procedure can also affect the cost of the surgery. For instance, minimally invasive procedures may cost more than a traditional incision due to the specialized tools and techniques required. However, a shorter hospital stay and quicker recovery may offset some of this cost by ultimately costing the patient less.
Types of knee replacement procedures
All surgery carries with it the risks of anesthesia, but generally less invasive procedures have quicker recovery times and fewer complications. Some people might not be suitable for the less invasive procedures, due to the complexity of their specific condition. If you are considering some form of knee replacement surgery, it is best to consult your doctor.
Different people with different knee problems may be more suited to various specific procedures. Results for surgery vary, and your doctor will be able to explain the relative benefits and limitations of each various type of surgery.
Patellofemoral replacement is a procedure that resurfaces the patella (kneecap) and the worn groove on the femur (thigh bone) that it moves against.
Unicompartmental knee replacement is a procedure used to treat osteoarthritis of the knee, involving only one compartment (or area) of the knee. Often the procedure uses a minimally invasive surgical approach.
Total knee replacement is the most common type of knee replacement surgery. The surgery involves replacement of both the articulating surfaces of the knee joint.
There are three main types of knee replacement surgery. Your doctor will consider your individual needs and the severity of your hip or knee condition to determine the most appropriate type of surgery for you.
Hospital fees and additional expenses
Hospital charges are generally the largest component of the cost of a knee replacement surgery. Costs can vary significantly depending on whether the surgery is performed at an inpatient or outpatient surgical center. Charges for the use of the operating room, recovery room, and nursing care are fairly straightforward and usually are not negotiable with the patient. A study published in the Journal of Bone and Joint Surgery in 1998 cited that the average hospital charge for a total knee replacement ranged from $15,000 to $24,000. It is obvious that in the past decade with inflation and the rising costs of medical care these expenses will be higher now. Physical therapy is a crucial part of rehabilitation that can last for several weeks or months. With the establishment of new Medicare payment systems, it’s important for patients on Medicare to understand how this will affect their coverage and out-of-pocket costs. In 2000, the Centers for Medicare and Medicaid Services changed the way these procedures are paid for. They had been using a cost-based system to determine payment for the procedure. At this time, the average hospital charge for a total knee replacement was $17,000 and Medicare would reimburse based on the hospital’s cost rather than the specific service provided. Because of this change, the payment rate for the procedure was frozen and not changed according to inflation.
Insurance coverage and financial assistance options
Some surgeons will have an easier time convincing your insurance company to authorize the surgery. A surgeon who has a good track record of correctly documenting the medical necessity of knee replacement and who is willing to adhere to any specific procedures your insurance company may require prior to giving authorization can greatly help the chances of receiving an “ok” for surgery. Sometimes insurance companies require you to have a trial of physical therapy, medications, injections, and use of a brace before they will authorize surgery. This can be a long process. It is also common that your surgeon will have to submit a “letter of medical necessity.” This is an additional step that takes more time. When you are diagnosed with severe arthritis and are told you are a candidate for knee replacement, you should ask your surgeon to estimate where you fall in your insurance company’s medical necessity algorithm for knee replacement. This information, though usually only an estimate, can help you know how likely it is that you will receive an authorization for surgery, based on your insurance company’s knee replacement indications.
Rehabilitation and post-surgery care costs
Factors affecting the cost of knee replacement surgery There are a number of factors which affect the total cost of knee replacement surgery. Duration of hospital stay and type of surgery are main cost driving variables. A longer hospital stay increases cost as does a more complicated surgical procedure. Indirect cost in terms of time off work and type of occupational demands also play a part. More time off work in a physically demanding job will increase indirect costs as the patient is likely to take longer to return to work after surgery. Rehabilitation and post-surgery care are often overlooked when considering the total cost of surgery. This may include an extended stay in a rehabilitation unit, extra home help or even changes made to the home. All of these can be quite costly. There are also certain factors which decrease the overall cost of surgery. Staying within the public hospital system is usually the cheapest option. If the patient meets the requirements, they may be eligible for a government-funded knee replacement which is partially or fully subsidized. Private health insurance can also decrease cost as the patient will have the option of a wider choice of surgeon and shorter hospital waiting time.
Best Treatment Options for Low Bone Density
Surgical procedures such as Periarticular osteotomies and resurfacing of isolated OA lesions aim to achieve these goals and have some early promise, but have yet to be shown to be superior to joint replacement in large scale RCTs. Low bone density may be a relative contraindication for knee replacement because implant micromotion is increased and peri-implant fracture risk is raised, particularly with uncemented fixation. If patients with severe bone loss do require joint replacement, consideration should be given to use of an implant specifically designed for low bone density. These are typically revision prosthesis and some have shown good long term results, although revision arthroplasty carries higher risk of medical complications and patient reported outcomes are consistently worse than primary knee replacement. In summary, although a lot is known about how to improve bone density in knee OA patients and it is a very attractive strategy to prevent joint replacement, there is currently no treatment proven to be effective and knee replacement remains the end stage option for those with severe disease.
Improving or maintaining a patient’s bone density is the best option to prevent the need for future knee replacement surgeries. Knee replacement is not indicated for severe bone loss at present, probably involving the lateral or patellofemoral compartments, because conventional implant designs depend on good bone stock and are not suitable in knees with severe deformity. So it is important to identify a patient with increased risk of knee OA and prescribe more effective treatment. The Osteoarthritis Initiative is identifying patients as potential candidates for joint replacement purely on x-ray evidence of severe disease, but no specific guidance has been provided. Oral Bisphosphonates inhibit resorption and have proved efficacy in preventing systemic bone loss, but there is very limited evidence of their effectiveness in preventing loss of periarticular bone or joint space narrowing in knee OA. The only RCT investigating an anti-resorptive medication in knee OA found no benefit of Ibandronic acid over placebo on knee pain and function or structural endpoints over 2 years. So there is no medication proven to be effective in preventing loss of periarticular bone or cartilage in OA. Anabolic agents such as Teriparitide could theoretically improve subchondral bone quality and strength, but they are not licensed for use in OA and there is no evidence that they slow OA disease progression. Osseointegration of uncemented implants depends on good bone quality, so it has been suggested that patients at risk of arthroplasty could benefit from joint preserving measures to improve bone stock. For example, a recent RCT found that Vitamin D and Calcium supplementation and a regimen of supervised weight-bearing exercise improved periarticular bone density in the knee, although this was not associated with improvement in pain or function.
Medications to improve bone density
The most proven way to prevent or treat osteoporosis is taking a class of drugs called bisphosphonates. Bisphosphonates act on the bone to decrease resorption by the bone cells. It slows the rate at which the bone cells break down the bone matrix. This allows the mineral content of the bone to increase, and over time increases the bone density. There is a wide availability of oral bisphosphonates, most well known being alendronate (Fosamax) and risedronate (Actonel). Both have been shown to be beneficial in preventing further bone loss and increasing bone density, and also decreasing the risk for fractures in people with osteoporosis. Ibandronate (Boniva) is also another oral bisphosphonate option which is taken once a month, which has also shown to increase bone density at the hip. If someone is not well compliant with the oral medications, or if it is not tolerated by the gastrointestinal system, IV options are also available. These include pamidronate (Aredia) and zoledronic acid (Reclast). Administering these medications by the intravenous route has the same benefits as the oral form, and in some cases may even increase bone mineral density to a greater degree than the oral. However, it is much less convenient than taking a pill, as it needs to be done in a healthcare setting and is much more expensive.
Nutritional and lifestyle changes
Some of the best treatment options for low bone density have been seen to revolve around nutritional and lifestyle changes. Health Canada released a report in 2002 which included guidelines for the treatment and prevention of osteoporosis. It was stated in the report that a nutritious diet is key in attaining and maintaining peak bone mass. It also mentioned that while supplementation can be beneficial in increasing the nutrient density of a diet, it is not a substitute for the real thing. This means that it is better to get your nutrients from actual food sources than from taking vitamin pills. Protein is also important in the development of bone, it makes up half of the bone volume and one third of its mass. Low protein intake is associated with decreased calcium absorption and may also affect hormone levels which are needed to maintain calcium homeostasis. The report also mentioned specific nutrients which have proven to be important in bone health. These were: calcium, vitamin D, phosphorus, magnesium, fluoride, iron, zinc, copper and vitamins A, C and K. It was recommended that an overall balanced diet which included increased consumption of foods rich in these nutrients was the most beneficial. It also stated that while no specific foods needed to be avoided, certain indulgences such as alcohol, caffeine or sodium could affect the way that certain nutrients were metabolized or absorbed and thus might need to be limited. Finally, it provided a food guide which was composed of how many servings daily were needed from different food groups in order to meet the nutrient requirements for healthy bones. This can be found at: [Link]
Physical therapy and exercise programs
Most patients with low bone density can safely participate in physical therapy and regular exercise programs aimed at preventing falls and fractures. In fact, some degree of regular weight-bearing exercise is probably helpful in the treatment of low bone density. The weight-bearing form of the exercise is not only more effective in increasing bone mass, it also creates better balance during activity, reducing the probability of fall and related fractures. However, the patients with the osteoporosis-related fractures or who have spinal or other non-spinal fractures associated with low bone mass should avoid high-impact exercise for fear of further injury. They are better and safer to begin with progressive strength training or resistance exercises. These exercises are proved to be effective in reducing the risk of fractures by improving the muscle strength and coordination, and maintaining and improving the bone density especially in the hip and spine area. Other than directly relating to the treatment of the low bone density, regular exercises are beneficial for the general health condition of the patient, proving greater independence in the activities of daily living and improving their psychological well-being. All exercises preventive for osteoporosis-related fractures can recruit both the patient and the therapist with similar ambitions, and should be discussed thoroughly and practiced regularly for a better treatment outcome.
Surgical interventions for severe cases
Surgical interventions are necessary for those who have gone beyond the threshold of low bone density and have developed weakened bones. The purpose of surgery is to provide a stronger structure for the affected bone. An example of a surgical procedure that is performed in vertebral or hip fractures is a kyphoplasty. Kyphoplasty is a procedure used to treat spinal compression fractures caused by osteoporosis. It aims to relieve the pain associated with the fracture, stabilize the bone, and in some cases restore some or all of the lost vertebral body height. The procedure is done in a special operating room using either local or general anesthesia and x-ray guidance. First, a narrow hole is made in the bone and then a balloon is inserted through the hole and inflated to try and return the vertebral body to the correct height. After the balloon is removed, the space that was created is filled with a special type of bone cement. This procedure is beneficial to the patient in that it increases mobility, decreases pain. The procedure is low risk and provides almost instant improvement to the fracture. Another option is to get metal screws and rods inserted in the affected area to increase stability of the bone. This procedure is effective in providing stability to a fracture; however, the metal work is usually an annoyance to the patient and may cause complications in the future. All surgical procedures are discussed with the patient about the risks, benefits, and possible complications.
Importance of considering both cost and bone density in knee replacement surgery
The importance of considering both cost effectiveness and outcome in knee replacement surgery in the current climate of budget restrictions within the health sector cannot be ignored. This is particularly pertinent when operating on the elderly with low bone density. Cost effectiveness is a comparison of the resources consumed relative to the benefits produced. This is an ideal way to approach the situation of operating on the elderly person who has an average life expectancy of 18.7 years in comparison to people of the same age 25 years ago. Choosing a knee replacement would intend to benefit these people in the earlier years providing an increase in quality of life and mobility. In recent times there has been a substantial amount of research in this area, which provides information valuable to the older generation with low bone density but equally important if not more so than their younger counterparts. The improvements in surgical techniques, prosthetic designs, and cementation have yielded excellent results in total joint arthroplasty. Despite 10-year implant survivorship now exceeding 90%, the annual number of revision procedures continues to rise. According to the Australian Orthopaedic Association National Joint Replacement Registry, there was an estimated 45% increase in the number of knee replacement revision procedures from 2005-2010. This trend is expected to continue and by 2050, it is projected that the total number of knee replacement revision procedures will have increased by up to 601%. An individual’s choice of primary TKR presents an option to wait until the projected increase in revision procedures will be able to provide a more favorable outcome from their surgery. An increased revision rate will also mean that having chosen the surgery, people with low bone density will be more at risk of needing a revision procedure which is not an ideal situation.
Recommendations for individuals with low bone density seeking knee replacement
It is recommended that individuals with low bone density in need of knee replacement seek alternatives when possible. This is due to the fact that all artificial knees have a limited lifespan and are prone to wear. For someone with low bone density, one of the most important things is to keep the knee replacement surgery as a last alternative. Alternative treatments such as pain management, weight loss, exercise, bracing, and use of ambulatory aids may prolong the time to knee replacement and are worth considering, keeping in mind that for some individuals, pain and limited function will be a compelling indication to proceed to surgery. Patient age and overall health should also be taken into consideration. For someone who is not a viable candidate for the surgery, the risks far outweigh the benefits. In the case where use of an artificial knee is essential, it may be worth putting the surgery off for a period of time. This option should be discussed with the surgeon and weighed up with the probability of a less successful outcome due to the change in severity of the knee problem and/or age of the patient.
