CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 446, pp. 34–39
Agreement about Indications for Total Knee Arthroplasty
William W. Cross, III, MD*; Khaled J. Saleh, MD, MSc(Epid), FRCSC, FACS†;
Timothy J. Wilt, MD, MPH‡; and Robert L. Kane, MD§
Total knee arthroplasty is an effective and cost efficient pro-
cedure that improves the quality of life for patients with end
stage knee arthritis. With the prevalence of arthritis ex-
pected to increase with the aging of the population, the de-
mand for total knee arthroplasty will increase substantially.
We examined current indications for total knee arthroplasty
by reviewing articles extracted from a comprehensive Med-
line search. We studied the indications for proceeding with a
total knee arthroplasty, the indications for referring a pa-
tient for a total knee arthroplasty, and the contraindications
among orthopaedic surgeons, rheumatologists, and primary
care providers. We evaluated 27–42 different patient factors.
“Pain not responsive to drug therapy” was the only factor
with consensus for total knee arthroplasty. “Major psychi-
atric disorder, including dementia” was the only contraindi-
cation to total knee arthroplasty that had a consensus. The
lack of consensus within orthopaedics and across specialties
likely represents a limitation in empirical data associated
with total knee arthroplasty outcomes. Achieving better con-
sensus will require conducting and disseminating better re-
search on patient characteristics that predict the success of
total knee arthroplasty.
Level of Evidence: Economic and decision analyses, level IV
(analyses with no sensitivity analyses). See Guidelines for
Authors for a complete description of levels of evidence.
From the *Department of Orthopaedic Surgery, University of Minnesota
Medical School, Minneapolis, MN; the †Department of Orthopaedic Surgery
and Health, Evaluative Sciences, Adult Reconstruction, University of Vir-
ginia, Charlottesville, VA; the ‡Section of General Internal Medicine, Min-
neapolis VA Center for Chronic Disease Outcomes Research, Minneapolis,
MN; and the §University of Minnesota School of Public Health, Clinical
Outcomes Research Center, Minneapolis, MN.
All authors received funding from the Agency for Healthcare Research and
Quality, and the Office of Medical Applications of Research, National In-
stitutes of Health to conduct the review on which this paper is based. This
work is part of an evidence-based practice center contract (No. 290-02-0009,
Task Order #2).
One of the authors (KJS) received funding from the American Geriatric
Society and Smith Nephew and Stryker, and is a consultant with Smith
Nephew and Stryker.
Correspondence to: Robert L. Kane, MD, Professor & Minnesota Chair in
Long-term Care and Aging, University of Minnesota School of Public
Health, D351 Mayo (MMC 197), 420 Delaware Street SE, Minneapolis, MN
55455. Phone: 612-624-1185; Fax: 612-624-8448; E-mail: kanex001@
umn.edu.
DOI: 10.1097/01.blo.0000214436.49527.5e
34
© 2006 Lippincott Williams & Wilkins
Total knee arthroplasty (TKA) is an effective and cost
efficient procedure that improves the quality of life for
patients with end stage knee arthritis.2,5,14,21 The elective
nature of the procedure raises issues of access, equality,
and timeliness of waitlists.7,9,11–13,17,22,24,25 This is espe-
cially important as the prevalence of arthritis is expected to
rise from 12.9% to 20% in the next few decades as the baby
boom cohort ages, resulting in increased demand for TKA.3,18
Patients requiring TKA contact orthopaedic surgeons
through a variety of paths. The patients’ primary care phy-
sician may refer them to an orthopaedic surgeon. Alterna-
tively, the primary care provider may refer the patient to a
rheumatologist, who may then nonoperatively manage the
patient until the patient no longer responds to the regi-
mens. Some patients present directly to an orthopaedic
surgeon. Regardless of the referring physician, patients are
often at the end of exhaustive medical management for
arthritis, including NSAIDs (nonsteroidal antiinflamma-
tory drugs), physical and occupational therapies, and ste-
roid or viscosupplementation injections. Patients also may
present after failed joint preserving procedures such as
arthroscopic débridement, osteotomy, and cartilage trans-
plantation.19 Surgical decisions for TKA are often made
based on the opinions of various physician groups includ-
ing orthopaedic surgeons, rheumatologists, and primary
care providers.4,6,10,15,16,21,25,28,29 If the decision to per-
form knee surgery is the result of actions by primary care
physicians, rheumatologists and orthopaedic surgeons, and
if they do not agree on the indications for surgery, the
action taken may depend on which group is involved—a
capricious situation.
Ideally, the decision about who gets a knee replacement
should not depend on what type of physician sees the
patient. In an effort to see how the nature of physician
discipline affected beliefs about the indications for TKA,
we assessed the extent of agreement among orthopaedic
surgeons, rheumatologists, and primary care providers
about the indications for TKA.
MATERIALS AND METHODS
We performed a Medline literature search to identify all citations
concerning prosthetic knee procedures published from 1966–
2002. The literature search strategy for clinical predictors of
Number 446
May 2006
TKA was developed in consultation with the National Library of
Medicine, which conducted the search. The search was limited to
studies, reviews, consensus statements of guidelines related to TKA
published between 1995 and April 2003. Titles and abstracts of
3519 references were screened of which 611 were pulled for
further analysis. A review of these 611 references for articles
related to consensus panels or surveys of health care providers
yielded the 9 included articles regarding indications for TKA.
We obtained and systematically reviewed the abstracts for
each identified English language citation. We reviewed a subset
of these studies looking specifically for articles that described
efforts to obtain expert opinion on the need for surgery. Studies
that did not meet inclusion criteria (primary TKA studies with
indication data provided) were omitted. We also searched the
reference lists from each article and from articles recommended
by colleagues. Any articles pertaining to indications for TKA
were obtained, and the abstracts were reviewed for inclusion. All
articles meeting inclusion criteria were extracted and reviewed.
Data abstraction was carried out and entered into an abstrac-
tion form by a trained abstractor (WC) who was blinded to the
study hypothesis. Data from each article were compiled into two
formats: (1) a general synopsis of each study and pertinence to
TKA indications (Appendix 1), and a summary of patient factors
with clinical agreement or disagreement among providers (Table 1).
Five studies (Table 1) surveyed orthopaedic surgeons, rheu-
matologists, family practitioners, or a combination of the three
regarding their indications for referring patients for a TKA or if
orthopaedic surgeons proceeding with a TKA. The surveys con-
tained 27–42 different patient factors including subjective and
objective findings as well as psychosocial factors regarding rela-
tive indications and contraindications for TKA. Respondents
were asked to report on their level of agreement with the patient
factors as: (1) “more likely” or “for TKA” as indications for
surgery, (2) “less likely” or “against TKA” as contraindications
to surgery, or (3) “neutral.” Two studies4,26 based their surveys
on an original survey by Tierney et al.25 The total number of
physicians sampled across studies varied (98–933 physicians).
Of 1881 physicians sampled, 729 responded; a 39% response
rate across all studies reviewed. There were 550 family practi-
tioners polled with 169 responding (31%), 98 rheumatologists
polled with 66 responding (67%), 300 general internists polled
with 72 responding (24%), and 933 orthopaedic surgeons polled
with 422 responding (54%).
We used a reported level of clinical agreement among re-
spondents of > 90% to indicate significant consensus or clinical
agreement. In contrast, if the level of consensus was < 60%
among respondents it was categorized as a clinically significant
disagreement. No real consensus was chosen if the level of
agreement was > 60% but < 90%. These 90% and 60% levels
were similar to parameters previously suggested for clinical
practice decision making.8 Two studies reporting case scenarios
were analyzed using the same percentiles of consensus to assess
clinical agreement.21,28
RESULTS
Very few items showed strong clinical consensus as indi-
cations to proceed with TKA or to refer patients for TKA
TKA Indicators Agreement 35
(Table 1). There was more agreement in the contraindica-
tions, most notably within the orthopaedic community.
Most patient factors were within the “no real consensus”
category, indicating < 90% but > 60% consensus. The
patient factors with the greatest consensus were “major
psychiatric disorder, including dementia” and “pain not
responsive to medication therapy.” “Major psychiatric dis-
order” was viewed by all orthopaedic surgeons surveyed
as a contraindication to TKA, whereas there was no real
consensus among referring providers. “Pain not responsive
to drug therapy” was viewed as an indication for TKA by
all referring providers, but two of the three orthopaedic
groups came to no consensus regarding this factor and the
third was not asked about it. Agreement concerning the
remaining factors was mixed. Four factors showed high
rates of poor agreement: septic arthritis > 1 year earlier;
obesity; severe hip osteoarthritis (OA); nursing home resi-
dency; and patient demand for TKA. All of these patient
factors had three or more of the groups demonstrating
< 60% consensus on what role the factor should play in the
clinical decision making process.
Among orthopaedic surgeons, there was unanimous
agreement with only one patient factor of 28 factors as-
sessed (Table 1). “Major psychiatric disorder, including
dementia” was the only universal contraindication to pro-
ceeding with TKA. There was little agreement on what
factors constitute indications for TKA. “No clear consen-
sus” was apparent with the vast majority of factors. With
50% of the patient factors (14 of 28), there was either “no
real consensus” or “clinical disagreement.”
Consensus among referring providers was likewise lim-
ited (Table 1). Only the patient factor “pain not responsive
to medication therapy” had unanimous clinical agreement
as an indication for referring for a TKA. There was unani-
mous disagreement with the patient factor “septic arthritis
> 1 year earlier.” There was no clear consensus with the
majority of factors, with unanimous no clear consensus
reached with 26% of patient factors.
DISCUSSION
Because different physicians may be involved in the rec-
ommendations for TKA, some level of agreement among
the different types may be seen as useful. Although indi-
cations for TKA are multifactorial, it is commonly ac-
cepted that TKA is an effective treatment for arthritis of
the knee that has not responded to other therapeutic op-
tions.1 Beyond that, however, agreement on indications
was limited, both within disciplines and across them. “Pain
not responsive to drug therapy” was the only consistent
indicator for TKA across all specialties, including ortho-
paedics.
Orthopaedic surgeons had more nonoperative treatment
 Clinical Orthopaedics
36 Cross, III, et al and Related Research

TABLE 1. Summary of Patient Factors with Clinical Agreement for Proceeding with or Referring
for TKA*
Less Likely to Refer Clinical Factors of
More Likely to Refer -OR- -OR- Disagreement
Study Population for TKA against TKA (< 60% consensus)
Coyte Rheumatologists Pain despite PVD—rheumatologists Family
et al5 (98) and famiy medications—family Isolated patellofemoral practitioners/rheumatologists:
(1996) practitioners practitioners/rheumatologists arthritis—rheumatologists Noncompliant, obese, septic
(250) (66 and 99 Limited walking < 1 block— Local active skin knee > 1 year ago, varus or
in final analysis, family practitioners infection—rheumatologist valgus deformity, high
respectively) physical demands at work
Family practitioners: < 55 years,
severe hip OA, quadriceps
lag, weak quads
Rheumatologists: Nursing home
resident, patient demands
TKA, limited active
flexion/extension, sensation
of instability
Mamlin Family practitioners Pain despite medications, Septic knee arthritis > 1 year
et al15 and general persistent weightbearing ago, no health insurance,
(1998) internists (300 knee pain isolated patellofemoral
each) (70 and 72 arthritis, patient demands
in final analysis, TKA, painful feet
respectively)
Mancuso Orthopaedists (328) Independent Poor soft tissue coverage Age > 80 years, weight
et al16 (80 in final Dementia > 200 lbs (91 kg), wants
(1996) analysis) Poor motivation psychiatric benefit
Hostile personality
Unreal expectations
Tierney All orthopaedists in Persistent weightbearing pain Alcohol or drug abuse Nursing home resident, painful
et al25 Indiana (280) Major psychiatric disorder feet, patient demands TKA,
(1994) (188 in final Local active skin infection unstable knee, severe hip OA
analysis)
Wright All orthopaedic Pain despite medications PVD, isolated patellofemoral Patient > 80 years, nursing home
et al28 surgeons in arthritis resident, severe hip OA, local
(1995) Ontario, Canada Alcohol or drug abuse, psoriasis, quadriceps lag,
(325) Local active skin infection, weak quadriceps, sensation of
major psyche disorder, instability
patient noncompliant, age
< 55 years, high physical
demands at work, septic
arthritis > 1 year ago

*Significance set at > 90% agreement for inclusion; OA = osteoarthritis; PVD = peripheral vascular disease; TKA = total knee arthroplasty

beliefs than the referring providers, which was likely
based on the larger number of contraindications. This dif-
ference seems appropriate to the extent that orthopaedists
are the last stop before surgery and they would like to ensure
that all treatments have been exhausted prior to that step.
There was a similar lack of consensus among the refer-
ring providers. The only unanimous clinical agreement
was “pain not responsive to medication therapy.” This
finding seems fitting as the referring providers seek further
interventions for their patients once medical management
is no longer effective. The general lack of consensus for
indications and contraindications across all specialties is
likely the result of multiple factors, especially limitations
in the empirical data that indicate what patient factors are
associated with better or worse clinical outcomes.1 It is our
opinion that other causes may include the lack of a stan-
dardized tool used to gauge OA stages, a limited basis of
knowledge regarding the musculoskeletal system, and not
recognizing barriers that may cause patients to delay re-
ferral or initial assessment for knee pain.
There is not a great deal of strong evidence on which to
base recommendations.20 For example, there is no clear
Number 446
May 2006
evidence to support or refute knee replacement for persons
with dementia.
The greater enthusiasm among referring physicians ap-
pears to be tempered by orthopaedic restraint. Orthopae-
dists may have formed more negative judgments about the
value of the procedure because they see more of the com-
plications and failures. Given such orthopaedic restraint, it
may be appropriate to have a slight “over referral” rather
then an “under referral.” The overall findings suggest that
physicians within and across disciplines may act quite dif-
ferently when evaluating patients with similar levels of
knee disease severity and comorbidities. These differences
imply that recommendations for TKA may depend as
much on a clinicians training and medical specialty as on
a particular patient’s clinical condition. This may be be-
cause of different estimates of potential risk and benefits
of TKA within and between medical specialties. Recent
efforts to create a consensus statement reflect the weak
empirical base.21 More work is needed to conduct well
designed outcome studies that assess the effects of TKAs
on patients with various levels of severity and comorbid-
ity.
Several limitations to our study should be noted. This is
a review of the current literature and not a prospective
study on currently used indications. Only a few studies
have examined the indications for TKA. Furthermore,
most of the studies available for review have used varying
formats to study TKA indications including surveys to
various physician specialty groups, case scenarios, and
consensus panels. Many are not comparable. Ideally, a
large multi-center standardized survey would provide the
best data for assessment of current indications. Because
not all of the studies used our criteria for agreement or
disagreement, our conclusions may vary from the authors
of the cited articles.
Other countries seem to have been more successful in
promulgating standardized criteria for patient selection for
TKA. For example, the New Zealand Priority Criteria for
Major Joint Replacement project delineates who is the
appropriate candidate for a TKA and when the patient
should have the procedure scheduled.10,24 The United
States must reach greater consensus regarding the proper
indications for TKA to ensure that the procedure is avail-
able to patients who qualify regardless of the path they
take to seek help.
References
1. Evidence AHRQ. Report/Technology Assessment. Number 86. To-
tal Knee Replacement: Evid Rep Technol Assess (Summ). Publi-
cation No. 04-E006-1; December 2003. Available at:
http://www.ahrq.gov/clinic/epcsums/kneesum.htm. Accessed Feb-
ruary 20, 2004
2. Callahan CM, Drake BG, Heck DA, Dittus RS. Patient outcomes
following tricompartmental total knee replacement. JAMA. 1998;
271:1349–1357.
TKA Indicators Agreement 37
3. Center for Disease Control and Prevention. Public health and aging:
project prevalence of self-reported arthritis or chronic joint symp-
toms among persons aged > 65 years—United States 2005–2030.
MMWR Morb Mortal Wkly Rep. 2003;52:489–491.
4. Coyte PC, Hawker G, Croxford R, Attard C, Wright J. Variation in
rheumatologists’ and family physicians’ perceptions of the indica-
tions for and outcomes of knee replacement surgery. J Rheumatol.
1996;23:730–738.
5. Coyte PC, Young W, Williams JI. Devolution of hip and knee
replacement surgery? Can J Surg. 1996;39:373–378.
6. Dieppe P, Basler HD, Chard J, Croft P, Dixon J, Hurley M, Lohm-
ander S, Raspe H. Knee replacement surgery for osteoarthritis: ef-
fectiveness, practice variations, indications and possible determi-
nants of utilization. Rheumatology (Oxford). 1999;38:73–83.
7. Dunlop DD, Song J, Manheim LM, Chang RW. Racial disparities in
the joint replacement use among older adults. Med Care. 2003;41:
288–298.
8. Eddy DM. Designing a practice policy: Standards, guidelines, and
options. JAMA. 1990;263:3077–3084.
9. Escarce JJ, Epstein KR, Colby DC, Schwartz JS. Racial differences
in the elderly’s use of medical procedures and diagnostic tests. Am
J Public Health. 1993;83:948–954.
10. Hadorn DC, Holmes AC. The New Zealand priority criteria project.
Part 1: Overview. BMJ. 1997;314:131–134.
11. Hawker GA, Wright JG, Coyte PC, Williams JI, Harvey B, Glazier
R, Badley EM. Differences between men and women in the rate of
use of hip and knee arthroplasty. N Engl J Med. 2000;342:1016–
1022.
12. Juni P, Dieppe P, Donovan J, Peters T, Eachus J, Pearson N, Green-
wood R, Frankel S. Population requirement for primary knee re-
placement surgery: a cross-sectional study. Rheumatology. 2003;42:
516–521.
13. Katz BP, Freund DA, Heck DA, Dittus RS, Paul JE, Wright J, Coyte
P, Holleman E, Hawker G. Demographic variation in the rate of
knee replacement: A multi-year analysis. Health Serv Res. 1996;
31:125–140.
14. Laupacis A, Bourne R, Rorabeck C, Feeny D, Wong C, Tugwell P,
Leslie K, Bullas R. The effect of elective total hip replacement on
health-related quality of life. J Bone Joint Surg Am. 1993;75:1619–
1626.
15. Mamlin LA, Melfi CA, Parchman ML, Gutierrez B, Allen DI, Katz
BP, Dittus RS, Heck DA, Freund DA. Management of osteoarthritis
of the knee by primary care physicians. Arch Fam Med. 1998;7:
563–567.
16. Mancuso CA, Ranawat CS, Esdaile JM, Johanson NA, Charlson
ME. Indications for total hip and total knee arthroplasties. J Arthro-
plasty. 1996;11:34–46.
17. McKenna TJ. The variation phenomenon in 1994. N Engl J Med.
1994;331:1017–1018.
18. Moran CG, Horton TC. Total knee replacement: the joint of the
decade. BMJ. 2000;320:820.
19. Hopman RM, de Bock GH, Bijlsma JW, Springer MP, Hofman A,
Kraaimaat FW. The pattern of health care utilization of elderly
people with arthritic pain in the hip or knee. Int J Qual Health Care.
1997;9:129–137.
20. Kane RL, Saleh KJ, Wilt TJ, Bershadsky B. The functional out-
comes of total knee arthroplasty. J Bone Joint Surg Am. 2005;87:
1719–1724.
21. National Institutes of Health Consensus Development Program.
NIH consensus development conference on total knee replacement,
National Institutes of Health consensus development statement
December 8–10, 2003. Available at http://consensus.nih
.gov/cons/117/117cdc_statementFINAL.html
22. Naylor CD, Williams JI. Primary hip and knee replacement surgery.
Ontario criteria for case selection and surgical priority. Qual Health
Care. 1996;5:20–30.
23. Rorabeck CH, Bourne RB, Laupacis A, Feeny D, Wong C, Tugwell
P, Leslie K, Bullas R. A double-blind study of 250 cases comparing
cemented with cementless total hip arthroplasty. Cost-effectiveness
 Clinical Orthopaedics
38 Cross, III, et al and Related Research

and its impact on health-related quality of life. Clin Orthop Relat
Res. 1994;298:156–164.
24. Rothwell AG. Development of the New Zealand Joint Register. Bull
Hosp Jt Dis. 1999;58:148–160.
25. Tierney WM, Fitzgerald JF, Heck D, Kennedy JM, Katz BP, Melfi
CA, Dittus RS, Allen DI, Freund DA. Tricompartmental knee re-
placement: A comparison of orthopaedic surgeons’ self reported
performance rates with surgical indications, contraindications, and
expected outcomes. Knee Replacement Patient Outcomes Research
Team. Clin Orthop Relat Res. 1994;305:209–217.
26. Wells VM, Hearn TC, McCaul KA, Anderton SM, Wigg AER,
Graves SE. Changing incidence of primary total hip arthroplasty
and total knee arthroplasty for primary osteoarthritis. J Arthro-
plasty. 2002;17:267–273.
27. Wilson MG, May DS, Kelly JJ. Racial differences in the use of total
knee arthroplasty for osteoarthritis among older Americans. Ethn
Dis. 1994;4:57–67.
28. Wright JG, Coyte P, Hawker G, Bombardier C, Cooke D, Heck D,
Dittus R, Freund D. Variation in orthopedic surgeons’ perceptions
for and outcomes of knee replacement. CMAJ. 1995;152:687–697.
29. Wright JG, Hawker G, Bombardier C, Croxford R, Dittus RS, Fre-
und DA, Coyte PC. Physician enthusiasm as an explanation for area
variation in the utilization of knee replacement surgery. Med Care.
1999;37:946–956.

APPENDIX 1. Selected Study Findings on Indications for TKA

Study Population Focus (n)
28
Wright et al All orthopaedic surgeons
(1995) in Ontario, Canada (325)
Coyte et al5 Rheumatologists (98) and
(1996) family practitioners (250)
(66 and 99 in final
analysis, respectively)
Wright et al29 Orthopaedists and primary
(1999) care providers (provider
data from Wright et al26
and Coyte et al5)
Hadorn and Holmes10 New health policy
(1997) description
Mancuso et al16 Orthopaedists (328) (80 in
(1996) final analysis)
Results
—Clinical agreement (> 90%) in 14 of 34 patient characteristics (38%) in determining
need for TKA
—Clinical disagreement (< 60%) with 7 of 34 (21%) patient characteristics
—No agreement in treatment with 3 hypothetical case scenarios with varying degrees
of OA (n = 205) (highest agreement was 86.8%)
—High volume orthopedists disagreed with low volume orthopaedists in 7 of 34
patient characteristics as indication for TKA (21%)
—Speculated causes for disagreement:
a. May reflect limitation of available knowledge
b. May reflect controversy within orthopaedic literature
c. Information may not be adequately disseminated to, or adopted by, practicing
orthopedists despite the fact that the factor’s effect on outcome of TKA has been
clearly demonstrated in the medical literature
d. Surgeons may choose to treat patients based on personal experience or training
—Clinical agreement (> 90%) for rheumatologists and family practitioners with 2 of 32
patients’ factors.
—Rheumatologists’ clinical agreement (> 90%) with 6 of 32 (13%) patients factors
—Family practitioners’ clinical agreement (> 90%) with 4 of 32 (19%) factors
—Clinical disagreement (< 60%) with 10 of 32 factors for family practitioners
—Clinical disagreement (< 60%) with 10 of 32 factors for rheumatologists
—Disagreement among specialties: Family practitioners > rheumatologists >
orthopaedists (family practitioners and orthopaedists, p < 0.0001; rheumatologists
and orthopaedists, p < 0.04).
Analyzes data from previous studies:
—Surgeon opinion or “enthusiasm” was “the dominant modifiable determinant of area
variation” in the utilization of TKA
—Surgeons’ propensity to operate (based on responses to the survey in the article
cited above) and opinions on patient outcome were both correlated with the total
number of procedures performed in the study period (p < 0.0001)
—Checklist utilizes 4 major components incorporating clinical and social factors in
determining order for receiving TKA: Pain (40% of scale), functional activity (20%),
movement and deformity (20%), and other factors (20%)
—Checklist created to assess where patients would be placed on list for elective
surgeries prior to New Zealand moving away from waiting list format to booking
appointments
—Criteria to be used in outcome studies that are being planned in New Zealand
—Clinical agreement (> 90%) with 6 of 24 (25%) factors related to determining need
for TKA
—Clinical disagreement (< 60%) with 3 of 24 (13%) factors related to determining
need for TKA
—They found no correlation with number of years in practice and agreement
Number 446
May 2006
APPENDIX 1. Selected Study Findings on Indications for TKA (Continued)
Study Population Focus (n)
6
Deippe et al Review article: Consensus
(1999) panel of professionals to
examine problems (use
of TKA in management
of OA)
Mamlin et al15 Family practitioners and
(1998) general internists (300
each) (70 and 72 in final
analysis, respectively)
Tierney et al25 All orthopaedists in
(1994) Indiana (280) (188 in
final analysis)
Naylor and Williams22 Consensus panel (11):
(1996) 4 orthopaedists
2 rheumatologists
2 general practitioners
1 general physician
1 epidemiologist
1 physiotherapist
THA = total hip arthroplasty, TKA = total knee arthroplasty
TKA Indicators Agreement 39
Results
—Primary care physicians likely lack confidence in examining the knee joint, leading
to delays in diagnosis and inability to assess severity of joint damage due to little
exposure in training.
—Four potential problems:
1.) Persistent negative attitudes towards OA and towards value of TKA, particularly
amongst the public and primary care physicians
2.) The lack of simple tools to help assess severity and impact of knee
osteoarthritis that can be used in the community.
3.) The absence of any clear guidelines or agreed evidence based indications for
TKA
4.) The absence of any studies that compare the efficacy of TKA with nonoperative
intervention strategies
—Three useful variables for surgical decision making in TKA:
1.) Severity of joint damage (pain at night, severity of pain, and function)
2.) Other patient related variables (psychosocial and patient motivation)
3.) The environment (socioeconomic status, surgeon availability, and patient’s
economic status)
Consensus Panel Recommendations:
1. No clear evidence based indications for TKA
2. No comparisons with other forms of treatment
3. No understanding of which patients are particularly likely to benefit from the
procedure
4. The absence of any studies that compare the efficacy of TKA with nonoperative
intervention strategies
—Combining family practitioners and general internists, clinical agreement (> 90%)
with 6 of 26 patient factors (23%) determining need for TKA
—Clinical disagreement (< 60%) with 5 of 26 patient factors determining need for
TKA (this paper advocated agreement with > 60% consensus and states
agreement with 19 of 24 factors)
—Clinical agreement (> 95%) in 7 of 34 patient factors (21%).
—Agreement (ⱕ 95% and > 60%) with 21 of 33 factors
—No agreement (< 60%) with 5 of 34 (15%) patient factors
—When correlated with number of TKAs in prior year, significant factors were:
Patient characteristics: female gender (r = −0.17, p = 0.02), noncompliant patient
(r = −0.20, p = 0.008), and unstable knee (r = −0.20, p = 0.008)
Continuous parameters: Old age (r = 0.16, p = 0.03), varus deformity (r = 0.16,
p = 0.03), and valgus deformity (r = 0.17, p = 0.02)
—Independent variables associated with reported number of TKAs in prior year:
Independent Variable p Value
Pain relief at 2 years 0.0001
Female gender 0.0009
Unstable knee 0.488
Patient can be too old 0.076
—The key determinants to prioritize surgery were: pain at rest, severity of functional
impairment, problems with care giving, and perceived likely improvement in
function
—Panel agreement statistics:
Convergence of ⱖ 9/11 (82%) panelists occurred 60.8% of appropriateness
scenarios (n = 120) with 1 of 3 appropriateness bands for referral for TKA
categories (not appropriate, uncertain, and appropriate) and in 16.7% or urgency
categories
Convergence of ⱖ 10/11 (91%) panelists within 2 adjacent appropriateness bands
occurred in 92.5% of appropriateness scenarios and 73.8% or urgency scenarios