If Dr. Nizar Mahomed and colleagues at the University Health Network (UHN) in Toronto succeed with fascinating new research, however, [knee replacement] surgery will eventually become a thing of the past.

The operations are, in fact, anything but panaceas, never really restoring people to their healthiest state, and often requiring replacement when the implant wears out, acknowledges Dr. Mahomed, head of orthopedics at the UHN’s Toronto Western Hospital.

With those limitations in mind, the UHN is pursuing research that aims to find a biological cure for joints decimated by osteo-arthritis, the most common form of the disease. Most dazzling among several experiments is a project that uses stem cells to create bone and cartilage, which researchers hope can be turned into a sort of organic joint implant that would fuse with existing tissue and regenerate diseased knees and hips.

Theoretically, the limits imposed on artificial joint-replacement patients would be forgotten.

“If we can find biological repair options, then basically we’re restoring the joint back to its native health state,” Dr. Mahomed said. “There would be no restrictions. You could go and run a marathon if you’d like. And there’s no concern that it is going to wear out, because we’ve basically restored it back to its [original] state of health.”

You can read the full National Post article here.

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The prices charged for surgery in California vary from one geographic region to another. We analyzed hospital charge information provided in the California Common Surgery Cost Comparison database—a record of the prices charged for common, elective, inpatient surgeries performed at hospitals across the state—and created a charge index that can be used to compare charges for the 12 most common surgeries, such as Cesarean births, knee replacements and angioplasty. Though the database includes information on how much hospitals charged, not on how much they were ultimately paid, the observed variation in prices suggests important differences in surgery pricing.

The report observes that knee replacement costs in California were among the most variable, with prices ranging as high as $164,000:

“The typical knee replacement surgery performed in a Fresno-area hospital in 2010 was charged at $46,800, versus $127,500 in an Alameda-region hospital,” the report says, while “in the Alameda County area, which has high surgery charges,” prices “ranged from $59,800 at Alameda County Medical Center—Highland Campus to $164,400 at Washington Hospital—Fremont.”

As prices continue to rise and the gulf between different healthcare centers continues to widen, the report concludes that there are a number of avenues to help curb this trend:

• California needs better information about the reasons for charge variation. Several of the possible explanations identified in this report are worth further study to reveal the extent to which they affect prices and might be addressed to help control costs.
• Building upon the best practices of regions with lower charges could help lower charges in high-cost regions. Learning more about the reasons for charge discrepancies would enable hospitals and networks of health care providers to improve their practices, providing quality care at reasonable cost.
• Patients need information on the quality of care provided by different hospitals to help ensure the best outcomes. Reliable information about hospital quality will avoid a situation where patients use price as a proxy for quality and gravitate toward hospitals that charge more.
• Better transparency of hospital discounts and accepted payments would improve patients’ ability to choose a facility based on price and would allow researchers and policymakers to better understand how California might control the cost of providing quality health care.

Lack of transparency in healthcare prices in the United States continues to plague the system, while other countries surge ahead in healthcare cost transparency. Knee replacement prices in many countries are publicly available for patients to consider prior to undergoing care.

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If you live long enough — that is, beyond 50 or 60 — chances are one or more of your joints, probably your knees or hips, will become arthritic. And if pain or stiffness begin to seriously limit your ability to enjoy life and perform routine tasks, chances are you’ll consider replacing the troublesome joint.

PERSONAL HEALTH

Jane Brody on health and aging.

“People with osteoarthritis are relying more and more heavily on surgery,” Dr. David T. Felson, a rheumatologist and epidemiologist at Boston University School of Medicine, told me. “The rate of knee replacement is just skyrocketing, out of proportion to increases in arthritic changes seen on X-rays, and replacement surgery is contributing greatly to the rising costs of Medicare.”

Between 1979 and 2002, knee replacement surgery rose 800 percent among people 65 and older. Although Dr. Felson described hip replacement as “dynamite” — highly effective in relieving pain and restoring function — knee replacement may be far less helpful.

“For 10 to 30 percent of patients, the improvement never comes,” Dr. Felson said.

How the Trouble Starts

Osteoarthritis results from wear and tear on the joints. (Rheumatoid arthritis, on the other hand, is an autoimmune disorder.) Some 27 million Americans have life-limiting osteoarthritis, and the numbers are rising as the population gets older and fatter.

“With every step, the force exerted on weight-bearing joints is one and a half times body weight,” said Dr. Glen Johnson, who reported on arthritis prevention and treatment at the annual meeting of the National Athletic Trainers’ Association in June. “With jogging, the force is increased seven or eight times. Thus, the most effective way to prevent arthritis in knees and hips is to lose weight if you’re overweight and to pursue non-impact activities for recreation.”

While most people think of osteoarthritis as a breakdown of the cartilage that keeps bones from rubbing together, recent studies have shown it is a far more complicated disease that also involves tissues in and around joints, including bone and marrow. Inflammation can be a contributing factor, and genetics play a role. Three genes have been identified thus far that accelerate the development of arthritis in people who carry them.

Any kind of joint injury or surgery, even if performed arthroscopically, raises the risk that a joint will become arthritic. That is why so many professional and recreational athletes develop arthritis at younger ages.

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What is medical travel?

Medical travel – commonly referred to as medical tourism – is the practice of traveling overseas for healthcare. In recent years, medical travel has experienced tremendous growth, as costs in the United States have risen. As international travel has become more affordable, medical travel has become an increasingly sought-after option for a variety of procedures. Once viewed as the best option for healthcare, the United States has since been equaled – and even surpassed – by many countries around the world, especially Taiwan.

With medical teams that speak fluent English and are trained and educated in the United States, American patients can have confidence that the quality of healthcare they will receive in Taiwan will meet or exceed that of the United States – at a fraction of the cost.

Formosa Medical Travel

Formosa Medical Travel is a medical tourism agency, dedicated to helping Americans find high quality, low cost total hip and total knee replacement surgery overseas. There is no additional fee for using Formosa Medical Travel, and all of the hospitals in the network network have been accredited by Joint Commission International (JCI).

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After your operation, you will remain in the surgical ward for a short time. The bandages and dressings that protect your knee will be changed periodically, and you may be administered oxygen or painkillers as needed.

Following the operation, your rehabilitation will begin as soon as you are able. While most total knee replacement patients are unable to walk on the same day as the operation, you will begin a walking program within the first days after your surgery. In the early stages of this program, walking with a frame or crutches is usually necessary. Many patients are able to walk without assistance within one week, with the help of a cane or walking stick. This varies depending on the individual.

During your stay at the hospital, you will be under the care of a physical therapist who will instruct you in various knee-strengthening exercises, which usually begin the day after your surgery. These early stages hold a slight risk of complication or dislocation of the joint, so it is important that you follow your physical therapist’s instructions.

Going Home

Most patients will be able to leave the hospital after knee replacement surgery within a 7 to 10 days, depending on your rehabilitation progress.Partial knee replacement patients are usually able to return home sooner. In some cases, if you are physically fit, doctors may recommend an enhanced recovery program that will allow you to return home earlier.

After returning home, you will experience weakness and exhaustion. This is normal; you’ve just undergone major surgery! Your new knee will take some time to heal, and your muscles and tissues need the chance to recover. Some discomfort is normal, but if you have any worries or concerns you should contact your doctor. It may be wise to make some preparations to your home: toilet seat risers, handlebars, benches, and other devices may make your home life easier during your recovery.

Perhaps the most important thing following knee replacement surgery is to follow the rehabilitation plan laid out by your doctor. You will likely need several weeks of phyiscal therapy to regain full mobility in your knee, and you should follow this regimen very closely. Keeping a positive attitude and faithfully following directions are essential here; without dutiful attention to your recovery plan, you may take much longer to regain full mobility.

In the years following knee replacement surgery, you may find that you have more mobility and less pain than you have felt in years. Still, you need to maintain and monitor your knee replacement. If you feel anything abnormal, contact your doctor. Knee replacement devices may need to be replaced after 10 or 15 years, depending on your individual condition.

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You may decide that living with your arthritic knee is the best choice; not everyone elects to treat this condition with total knee replacement surgery. If you have limited mobility, you may choose to avoid strenuous and painful activity, and adopt a regimen of gentle exercise.

Weight loss can have very beneficial effects on patients with arthritic knees. By reducing the stress on your knee through weight loss, you may be able to regain some mobility and lessen your pain. In some cases, massage therapy, the application of heat, or other physical therapy may be helpful.

Additionally, you may be able to treat the symptoms of osteoarthritis of the knee through medication. Anti-inflammatory medications and painkillers may lessen the pain of osteoarthritis, and delay the need for a total knee replacement. Injections, such as cortisone or hyaluronic acid (HA) may increase your mobility and lessen your pain. Assisted mobility devices such as canes and crutches may be necessary in some cases.

Arthroscopy

Arthroscopy, a minimally-invasive surgical procedure, can help treat the symptoms of osteoarthritis and mitigate the need for a total knee replacement. This procedure requires a small incision near the knee, allowing a surgeon to use specialized instruments to trim and smooth the worn-down cartilage caused by osteoarthritis. This can reduce inflamation, and since the procedure is minimally-invasive patients can return home the same day. Unfortunately, knee arthroscopy is not capable of treating sever cases of osteoarthritis, and is sometimes only a temporary fix in patients who are advancing through the stages of osteoarthritis.

Uni-Compartmental Arthroplasty (Partial Knee Replacement)

In some cases, the entire knee does not require replacement. For these patients, a partial knee replacement, or uni-compartmental replacement, may be recommended. This occurs when there is uneven wear on the knee joint, and there healthy cartilage remains intact. Recovery time and physical therapy for partial knee replacement surgery is comparable to that of total knee replacement. This procedure is fairly uncommon, as most patients experience even wear in their knees.

Arthrodesis / Knee Fusion

For patients in whom the risk of failure in knee replacement is deemed to be very high, knee fusion may recommended. This surgery does not allow for the flexion of the joint, so mobility will be impeded following surgery. In this operation, the femur and tibia are fused together with pins or screws, allowing for the bones to fuse together. Patients who undergo this treatment will live with a nearly-straight leg for the rest of their lives, but the condition is not considered painful. This treatment is only recommended when total knee replacement is deemed risky or impossible.

Knee Braces

Some patients may find relief from specialized knee arthritis braces. These devices are designed to redistribute the load on your knee to an area that is more capable of handling stress. These knee braces are often used in less-advanced cases of knee osteoarthritis, when there is still some cartilage remaining.

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Knee replacement surgery, also known as knee arthroplasty, is a surgical procedure designed to restore function and eliminate pain in damaged knees. In this procedure, deteriorated knee cartilage and damaged bone is removed from the femur, tibia, and kneecap and is replaced with an artificial joint. With modern devices, patients can regain much of their former mobility and comfort and experience a full recovery after a knee replacement.

Your doctor may deem knee replacement surgery right for you if you suffer from osteoarthritis or rheumatoid arthritis, and you fit the profile of a knee replacement candidate. A knee replacement may be appropriate for you if you have disabling pain that causes mobility problems, such as when walking, climbing stairs, getting in and out of chairs, or an inability to exercise. If you have exhausted any of the knee replacement alternatives and still suffer from your damaged knee, your doctor may elect to perform the surgery.

Knee replacement surgery is typically performed on adults aged 55 or older, although it is considered for patients of all ages. People with knees worn-down by strenuous activity or exercise may need a knee replacement earlier in life. Generally, surgeons require that a person be in good health prior to undergoing knee surgery, as complications can affect those with high blood pressure, diabetes, or other conditions.

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They are also among the most popular surgeries. You might be surprised to learn that Canada’s yearly 75,000 joint replacements, at an estimated $15 000 each, cost the public health system about $1.125 billion annually – not an insignificant amount.

Auto industry does it better

The expenditures don’t end there: in the first year following elective hip or knee replacement surgery, hospitalization usage can increase by as much as 50 per cent. In the 15 years following surgery, about 10 per cent of hip and knee replacements have to be redone due to wear, dislocation, infection and other problems.

So you might also be surprised to learn that this billion dollar a year industry – with follow up expenditures – has few or poor mechanisms for implant monitoring and assessment. There is no systematized mechanism in place to follow the clinical track record of new implants that come on the market, there is still difficulty predicting who will do well (or poorly) with surgery, and there is little ability to quickly identify and recall poorly performing implants.

We know this can, and should, be done. After all, the automotive industry already does a pretty good job at this.

Exact specifications for a car manufacturer’s products are readily available, the dealer’s wholesale cost is readily accessible online, organizations such as Consumer Reports and JD Power provide independent prospective assessment of vehicle quality, car dealers relentlessly bombard recent customers with satisfaction surveys, manufacturers closely track warranty repairs to identify problematic design or manufacturing issues, and customers are readily contacted should their vehicle be subject to a recall.

A similar quality loop does not exist for hip and knee replacement implants. And it should.

At present, new implants are generally tested by manufacturers using “in-house” laboratory facilities, with the results being submitted to regulatory bodies as part of a process that largely depends on the new implant being similar enough to an old implant that clinical testing isn’t required for approval.

Implant costs, while generally low in Canada overall, can vary from hospital to hospital, and region to region, and purchasing agreements typically forbid the sharing of price information. Information on a surgeon’s or hospital’s joint replacement surgery outcomes typically do not exist, are not accessible, or do not exist in a format that is meaningful to a patient or a surgeon.

What little data that exists on the clinical outcome and survivalship of a particular hip or knee replacement device typically comes from small studies conducted in highly specialized centres where one would expect above average outcomes, or from large national registries (outside of Canada) that track only the longevity of the device.

If a problem is discovered with a particular hip or knee replacement implant, identifying and contacting patients is usually an error prone process of manually reviewing hospital charts one by one. This leaves patients and surgeons vulnerable.

These issues – which can cost the public health system untold amounts, and affect patient quality of life – can all be addressed.

Regulatory bodies such as Health Canada and the FDA can require independent wear testing of new implants, along with clinical data from properly constructed trials to ensure at least clinical equivalency to current implants.

All hospitals in Canada should submit their hip and knee replacement data to the Canadian Joint Replacement Registry (CJRR) so that the longevity of the various types of implants used in Canada can be monitored. This will assist greatly in identifying both superior and inferior implants in a timely fashion, facilitate the identification of patients who may have received a recalled implant, and provide information on how provider and patient characteristics affect outcome.

Ontario has made CJRR participation mandatory, BC and Manitoba are looking to follow suit – the rest of the provinces need to get on board.

Coordination key

Implant cost information also needs to be more transparent; prices should not vary by hospital nor by manufacturer for similar designs. Finally, hospitals and surgeons need to ensure that good quality data on the care they provide is routinely collected, and that this data is incorporated into ongoing quality improvement. This has started in various locations across Canada, but needs to be expanded. The CJRR has started producing region and hospital specific reports, but these need to be strengthened through routine, mandatory data collection across Canada.

Hip and knee replacements are amongst the most successful modern medical interventions developed. With a bit of coordinated effort, we can continue to improve the quality and accessibility for all Canadians.

Eric Bohm is an expert advisor with EvidenceNetwork.ca and an Orthopaedic Surgeon with the Concordia Joint Replacement Group in Winnipeg Manitoba. He is also an associate professor at the University of Manitoba.

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Total knee replacement surgery—also known as knee arthroplasty—is a procedure performed when a patient’s knee has degraded to the point where it no longer functions or causes severe pain. Usually, knee replacement surgery is necessary for patients who suffer from severe osteoarthritis and have impeded mobility.
When determined to be necessary by a doctor, knee replacement surgery is usually covered by a patient’s health insurance. Most health plans cover any necessary surgery, including orthopedic surgery, as long as it is not specifically excluded (as is common in the case of weight loss procedures).
For patients on Medicare, knee replacement cost is usually covered. However, this may depend on your individual condition, and you may be subject to additional fees. Patients should always contact their provider for coverage information.
For patients with health insurance, there will usually be some additional out-of-pocket expenses. These costs can range from a few hundred to several thousand dollars, depending on your deductible, co-pay, and other factors. According to CostHelper.com, “a Medicare patient undergoing a knee replacement at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, could expect to pay $4,257 out of pocket, including deductibles and coinsurance. A patient with a $1,000 inpatient surgical deductible and 20 percent coinsurance, but an out-of-pocket maximum of $3,000 would pay $3,000.”

What should be included in the cost?

Prior to surgery, your orthopedic surgeon should carry out an evaluation of your knee’s present strength and range of motion, and make the determination of whether total knee replacement surgery is the best course of action.

If your surgeon decides to proceed with the operation, there are a number of services that should be included in the cost. Anesthesia, perhaps the most important part of any surgical procedure, is included in the cost at almost every hospital. For total knee replacement, general or epidural anesthesia is usually required.

While you are under anesthesia, the orthopedic surgeon will remove your damaged bone and cartilage, and insert artificial joint surfaces made of plastic and metal. The cost of the knee replacement device itself will also be included in the total cost of your surgery. There are a number of different knee replacement device manufacturers, with different products used depending on the hospital and your particular condition. Two of the more common device manufacturers are Zimmer and Stryker.

After surgery, you will be required to stay in the hospital for several days for initial recovery from your knee replacement. Your hospital bill may or may not include the cost of preliminary physical therapy and rehabilitation sessions.

Additional knee replacement costs

After knee replacement surgery, patients start on the road to rehabilitation. Following the procedure, you will be required to undergo physical therapy to regain the strength in your newly-repaired leg. Some preparations can be made to speed this process along.

First of all, some additions to your living space can be made to ensure your comfort during recovery. These include toilet seat risers, safety bars, a shower bench, and even a modified first-floor living area to eliminate the need for stairs.

For patients with insurance, physical therapy costs are often covered. Usually patients will have to complete several weeks of physical therapy sessions following a knee replacement. It’s always advisable to enter this stage of your recovery with an open mind and a positive attitude: after all, your recovery depends on you, and the mobility that you regain is directly related to the effort you put into your rehab.

Finally, depending on your lifestyle, your knee replacement device may need to be replaced later in life. The lifespan of current knee replacements can range from 10 to 15 years, to even longer. Remember to always notify your doctor if you experience uncharacteristic discomfort or limited mobility, as it these may be indicators of a complication with your knee replacement.

Knee replacement complications can include infection (which occurs in less than two percent of surgeries), complications from anesthesia (rarely including heart attack or stroke), and other issues.

All material on this page is for informational purposes only and should not be construed as medical advice. Always consult your physician or pharmacist regarding medications or medical procedures.

For American patients without health insurance, it is worth considering medical tourism – leaving the country for knee replacement surgery. Many countries in the world offer this procedure for costs dramatically lower than those in the United States. We have listed knee replacement cost estimates from various medical tourism destinations in the chart below. The cost of total knee replacement surgery will also vary from patient to patient, depending on factors such as age and medical history.

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