The desire to undergo surgery is the strongest driving factor for surgery, despite first-line treatment helping 9 out of 10 patients

July 11, 2022

Osteoarthritis is one of the world’s fastest growing diseases. Increased longevity together with a more sedentary lifestyle and a rise in obesity has led to an increase in the amount of people living with joint pain. By 2032, 30% of all adults over the age of 40 are expected to have been diagnosed with osteoarthritis. 

What’s positive is that there is help available. The so-called osteoarthritis treatment pyramid is well established and backed by a substantial amount of science. First-line treatment, at the bottom of the pyramid, consists of patient education and physical exercise (especially individualized, supervised exercises). People living with osteoarthritis should always start treatment at the bottom of the pyramid and not where most patients unfortunately begin today, with painkillers in the middle of the pyramid. According to leading scientists and the Centers for Disease Control and Prevention (CDC), surgery, at the top of the treatment pyramid, should only be considered if other treatment methods have not been effective. Today we know that only about 10% of those living with osteoarthritis require surgery to reduce their pain to a level that substantially improves their quality of life. For the remaining 90%, first-line treatment (sometimes in combination with painkillers), is enough to improve quality of life among osteoarthritis patients. 

A new study from Linköping University based on 72,069 osteoarthritis patients in Sweden, showed that after completing first-line treatment, the majority of patients did not require surgery within 5 years. However, at the same time, the study showed that the strongest driving factor for joint replacement surgery was the patient’s desire to have surgery. Neither walking difficulties nor level of pain due to osteoarthritis were strong driving forces for joint replacement surgery.  This may not come as a surprise due to the fact that all healthcare is voluntary and no one is operated on without wanting to be operated on. 

What is worrying is that studies have shown that patient cohorts who begin first-line treatment do not differ significantly in terms of age, BMI or pain estimation from the patient cohorts who undergo surgery. This most likely means that a large number of patients today undergo joint replacement surgery when they instead could have been helped by first-line treatment, which is cost-effective and, unlike surgery, does not involve any risks.

So why is this a problem? The US healthcare system already has record-long wait times, including wait times for joint replacement surgery. The myths surrounding osteoarthritis are many and there is a general misconception among patients that surgery is the only way out. Despite the fact that both the CDC and large orthopedic organizations like OARSI and ACR recommend first-line intervention before considering joint replacement surgery, figures from the Swedish study show that most patients who undergo knee or hip joint replacement surgery have not attended self-management programs for osteoarthritis. 

In Sweden, hundreds of thousands of patients with osteoarthritis have been treated digitally via the Joint Academy app and/or physically via a Supported Osteoarthritis Self-Management Program (SOASP). Both the recently published study by Linköping University and other studies show that thousands of these patients have changed their attitude toward surgery. This is greatly beneficial for both osteoarthritis patients and the healthcare system, and an indication of how wait times for joint replacement surgery could look if more patients are offered first-line treatment.

For the healthcare system, for taxpayers and last but not least for patients, the current situation is unsustainable. If more osteoarthritis patients have access to self-management programs as early on as possible, the 10% who actually require surgery can be prioritized more easily and get to the operating table faster. It’s not more difficult than that.

/ Leif Dahlberg

Chief Medical Officer at Joint Academy

Professor emeritus, Lund University