Surgeons and academics call for delay in knee replacement surgery

A new study reveals that structured education and exercise therapy could be a cost-effective alternative to knee replacement surgery for patients with lower pain levels, while contributing to healthcare sustainability.

Knee osteoarthritis affects 1.2 million Australians and has a high burden on people living with this chronic condition, and on the healthcare system. The Australian Commission on Safety and Quality in Health Care teamed up with experts to introduce the recent Osteoarthritis of the Knee Clinical Care Standard, which aims to steer people away from surgical intervention.

The new Monash University study led by Dr Sean Docking from the School of Public Health and Preventive Medicine at Monash University, examined the costs and health outcomes of a national physiotherapy program compared to knee replacements.

The program under review, GLA:D Australia, focuses on education and exercise that participants can incorporate into daily activities, helping them develop self-management skills for osteoarthritis. It is an initiative led by Associate Professor Christian Barton of La Trobe University, a co-author of the study.

“Unlike joint replacement surgery, physiotherapy-led programs are rarely subsidised by the government. Even if someone has private health insurance, there are still costs to access these programs, creating a significant barrier to their uptake,” Dr Docking explained. “This barrier can push people to have surgery before trying other things.”

Knee osteoarthritis is a growing concern in Australia, with over 53,500 knee replacements performed annually, a figure that continues to rise. By 2030, knee replacements are expected to surge by 276%. While surgery can offer significant relief when performed on the right candidates at the right time, ~10% – 20% of patients remain dissatisfied due to unmet expectations following joint replacement.

Gold Coast orthopaedic surgeon Adjunct Professor Christopher Vertullo, who is the Deputy Clinical Director of the Australian Orthopaedic Association (AOA) National Joint Replacement Registry, said “In my practice, about a third of referred patients don’t need to see me, and about 60% of all my patients have undergone inappropriate imaging or scans without any initial management for osteoarthritis. I regularly discuss the need to maximise non-surgical management.”

The findings of the new study suggest that delaying or avoiding knee replacement surgery for individuals with lower pain levels could save the Australian healthcare system an estimated $100 million each year.

“Our results suggest that structured education and exercise therapy is cost-effective for the first nine years and also over the lifetime in individuals with low pain levels. Our findings highlight the need for considered approaches that improve the sustainability of care and ensure that the right patient gets the right care at the right time,” Dr Docking added.

Reducing unnecessary joint replacements could lead to shorter surgery wait times, as 30% of public patients are currently waiting over a year for a knee replacement.

Co-author Professor Ian Harris from UNSW Sydney’s School of Clinical Medicine highlighted the broader implications, noting that one in four knee replacement surgeries in Australia may be unwarranted. Joint replacement surgeries consume more of the healthcare budget than any other procedure.

“Funding these physiotherapy-led programs would align with the government’s own best practice recommendations and improve the quality of care for knee pain. It could produce significant cost savings for our health system by avoiding unwarranted surgeries and enabling more timely access for those who really need surgery,” Professor Harris concluded.

Professor Vertullo added, “A patient should only be considered for joint replacement once they have maximised non-operative management as much as possible and reached a point where their pain is untenable or unmanageable. No one should enter surgery lightly. It is fantastic for end-stage osteoarthritis of the knee when someone has severe pain, but for an occasional ache, you are likely to be dissatisfied with the outcome,” he said.

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