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A Randomized, Controlled Trial of Total Knee Replacement

PainSci » bibliography » Skou et al 2015
updated

One article on PainSci cites Skou 2015: Knee Replacement Surgery Doubts

PainSci notes on Skou 2015:

(See also Skou 2018, a follow-up study that basically extended the trial, adding more data: “Combined reporting of the two trials allowed more in-depth comparison of available treatment options.”)

Skou et al found a lots of people who weren’t eligible for surgery for various reasons. Some of those were virtually ignored (just given educational pamphlets, the “basically nothing” group), and the rest were given the best possible care, basically everything medicine could throw at them that wasn’t surgery: exercise, education, dietary advice, use of insoles, and pain medication, and all with regular guidance from physicians and physical therapists. And then those groups were compared to patients who did get TKR. The results of high quality non-surgical care were definitely better than nothing, literally, but nowhere near as good as the TKR results.

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

BACKGROUND: More than 670,000 total knee replacements are performed annually in the United States; however, high-quality evidence to support the effectiveness of the procedure, as compared with nonsurgical interventions, is lacking.

METHODS: In this randomized, controlled trial, we enrolled 100 patients with moderate-to-severe knee osteoarthritis who were eligible for unilateral total knee replacement. Patients were randomly assigned to undergo total knee replacement followed by 12 weeks of nonsurgical treatment (total-knee-replacement group) or to receive only the 12 weeks of nonsurgical treatment (nonsurgical-treatment group), which was delivered by physiotherapists and dietitians and consisted of exercise, education, dietary advice, use of insoles, and pain medication. The primary outcome was the change from baseline to 12 months in the mean score on four Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, activities of daily living, and quality of life (KOOS4); scores range from 0 (worst) to 100 (best).

RESULTS: A total of 95 patients completed the 12-month follow-up assessment. In the nonsurgical-treatment group, 13 patients (26%) underwent total knee replacement before the 12-month follow-up; in the total-knee-replacement group, 1 patient (2%) received only nonsurgical treatment. In the intention-to-treat analysis, the total-knee-replacement group had greater improvement in the KOOS4 score than did the nonsurgical-treatment group (32.5 vs. 16.0; adjusted mean difference, 15.8 [95% confidence interval, 10.0 to 21.5]). The total-knee-replacement group had a higher number of serious adverse events than did the nonsurgical-treatment group (24 vs. 6, P=0.005).

CONCLUSIONS: In patients with knee osteoarthritis who were eligible for unilateral total knee replacement, treatment with total knee replacement followed by nonsurgical treatment resulted in greater pain relief and functional improvement after 12 months than did nonsurgical treatment alone. However, total knee replacement was associated with a higher number of serious adverse events than was nonsurgical treatment, and most patients who were assigned to receive nonsurgical treatment alone did not undergo total knee replacement before the 12-month follow-up.

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