Introduction by Croakey: As the global climate crisis escalates, health systems around the world are under pressure to reduce low value care and to do more to support health promotion and the prevention of health conditions.
An upcoming #CroakeyLIVE webinar will put a timely focus on the need for better care pathways for people with knee osteoarthritis, which may help reduce low value interventions, such as inappropriate imaging and surgery referrals.
The #BetterCare webinar comes ahead of the release next Thursday, 15 August, of an updated clinical care standard for knee osteoarthritis, to be launched by the Australian Commission on Safety and Quality in Health Care.
Nigel Hartnett is a specialist knee surgeon in Melbourne who has a longstanding track record in trying to reduce the number of patients with knee osteoarthritis who undergo surgery, whether knee replacement or arthroscopy.
“If there is a viable and appropriate non-surgical solution/treatment, this should always be pursued before seeking a surgical solution, always,” he writes below.
Hartnett was to join the #CroakeyLIVE discussion, but has had to withdraw due to work commitments, and instead contributed below to a Q&A with Croakey. Please register here to join the webinar.
Q& A with Nigel Hartnett
Q: As a knee surgeon, why do you try so hard not to operate on everyone who is referred to you with osteoarthritis of the knee?
Nigel Hartnett: Knee arthritis is not a singular diagnosis. A myriad of symptoms can affect patients at different levels. Knee arthritis is a spectrum of conditions from early through to severe arthritis. Most patients understand that severe arthritis is “bone-on-bone” but that is only one level of arthritis.
I see many patients with severe arthritis but there are many evidence-based treatment pathways that are effective in treating knee arthritis dependent on the level of arthritis. I explain to patients about trying non-surgical treatments before considering knee replacement.
It is about symptom management. Knee replacement, although highly successful, is certainly not the be all and end all. In Australia, 10-20 percent of patients are not happy following knee replacement , and a variety of factors are involved. The most common reason for patients being unhappy is pain, followed by stiffness (a loss of movement). Infection is rare at 1 percent, and then there are technical factors such as instability, loosening, recurrent swelling etc.
Q: What proportion of patients referred to you are suitable for knee surgery?
Nigel Hartnett: For every 100 patients I see with knee arthritis, I will book 20 for surgery on the first consult.
Eighty patients can pursue non-surgical treatment options before considering surgery, either replacement (total – replacing the whole joint, partial – replacing only the arthritic part of the joint) or an osteotomy (surgically realigning the limb).
For those 80 patients where non-surgical treatments are appropriate before surgery, it does depend on a number of factors which treatment/s are to be undertaken.
Q: Why are so many people referred to you when they are not suitable for surgery?
Nigel Hartnett: A number of factors are involved: patient, health, and medically related.
Patients want to see a surgeon no matter what their level of arthritis is or how it affects them. Health professionals will read an imaging report and say you need to see a specialist for an opinion. Patients want answers and a treatment plan for their knee/s.
As a specialist I can give them a plan. This is through experience, training, and keeping abreast of best practice and evidence. GPs and allied health professionals have to keep abreast of so many other areas of medicine and health whereas my focus is just on the knee.
If there is a viable and appropriate non-surgical solution/treatment, this should always be pursued before seeking a surgical solution, always.
Q: How do patients respond when you advise them of non-surgical options?
Nigel Hartnett: It really does depend on the patient. Most patients are relieved that there is an option/s that does not involve surgery particularly coming for a second opinion, when the first surgeon has discussed replacement only.
Some patients want surgery, and it is difficult telling those patients they do not need an operation. Some patients do not believe in non-surgical treatment and it is difficult convincing those patients to undertake anything but replacement.
In my practice though, if a patient has not done appropriate non-surgical treatment/s I will not operate on them.
Q: What are the barriers to better care pathways for people with knee osteoarthritis?
Nigel Hartnett: These include:
- cost
- limitations of the GP management plan for chronic disease in those patients with knee or hip arthritis
- public hospital waiting lists/times
- access to appropriate non-surgical treatments such as the GLA:D program, Kieser Therapy, and physiotherapy/osteopathy/chiropractic services, which can have 3-4 month waiting lists
- patient understanding of their knee arthritis
- health professional communication to patients and colleagues
- scope of practice issues that limit access for patients.
Q: What are your key messages to patients?
Nigel Hartnett: Please know that there are always options for treating knee arthritis that do not involve knee replacement.
Knee replacement is an excellent surgical option when non-surgical options have been undertaken.
Key-hole surgery (arthroscopy – “a clean-up procedure”) is not considered an option for treatment of knee arthritis and should not be done.
Q: What are your key messages to GPs?
Nigel Hartnett: Consider appropriate non-surgical treatments for patients before referral to a specialist or public hospital. This will then lead to appropriate management in the public /private hospital system.
Patient education of appropriate non-surgical treatments.
Physiotherapy (allied health) programs, simple pain medication, joint supplementation, some intra-articular injections, weight loss/management, and genicular nerve blocks are appropriate treatments to consider that do not require specialist surgeon input.
Knee replacement is an excellent option when non-surgical options have been undertaken.
Q: What are your key messages to surgeons?
Nigel Hartnett: Knee replacement should be considered after non-surgical options have been undertaken.
There are treatment modalities that have best practice and evidence behind them that should be discussed with patients, not just consideration for knee replacement irrespective of the grade of knee arthritis.
The key take home message though for all groups is please treat the patient who is sitting in front of you. Treatment should never be based on imaging, so the adage of ‘treat the patient not the imaging’ is 100 percent correct for knee arthritis.
Q: What are your key messages to Health Ministers and policymakers?
Nigel Hartnett: Knee arthritis treatment needs to begin with improved funding at a primary care level, that is, funding of evidence based and best practice such as GLA:D/Kieser programs.
Better patient education through community access and social media platforms.
Multidisciplinary best practice guidelines with input from relevant stakeholders in developing guidelines for treating knee arthritis and continually refreshing these guidelines.
Knowing that not all patients fit easily into a one-size-fits-all approach and individualising treatment for the patient, not the condition.
Extending the five sessions of physiotherapy for GP management plans of chronic disease to 12 sessions or – even better – creating a separate GP management plan for arthritis to allow 12 sessions of allied health whilst allowing patients to use GP management plans for other conditions.
Prevention is better than cure. For knee arthritis there is no cure as such but the evidence shows that managing patients with knee arthritis is best achieved with non-surgical measures and this in my opinion is where the healthcare dollars should be directed into the primary care sphere.
Q: The Australian Commission on Safety and Quality in Health Care is about to release an updated clinical care standard for osteoarthritis of the knee. What difference did the 2017 standard make, and what do you hope to see different in this new updated version?
Nigel Hartnett: I personally did not see a difference as the guidelines that were published are what I utilise for my patients with additional non-surgical measures.
I hope to see a better distribution of the guidelines and more medical/allied health professionals utilising and referring to the guidelines.
Join us at #BetterCare
Croakey acknowledges and thanks the Australian Physiotherapy Association (APA) for sponsoring our webinar as part of our #Medicare40Years project marking the 40-year anniversary of Medicare.
Register here to attend the free webinar, and bookmark this link to follow coverage of the #CroakeyLIVE webinar series.
Further reading
By Dr Lesley Russell: How knee replacement surgery highlights issues of access, affordability and best practice in Australia’s two-tiered healthcare system (Pearls & Irritations, 2017) – Part 1 and Part 2
