Joint Replacement

Are TJA Patients Really Ready for a 37% Risk of Joint Infection?

Surgeons and patients may not be speaking the same language when discussing risks and benefits

What’s the Claim?

In a quantitative study of a very unusual design that evaluated patients’ willingness to trade risk for reward, patients appeared comfortable with risk trades that might shock (and mortify) the typical arthroplasty surgeon: “To improve physical function from 50% to 100% and reduce pain from severe to minimal because of total joint arthroplasty, patients were willing to accept a hypothetical absolute (and not merely an incrementally increased) 37% and 27% risk of infection, respectively.” Yikes.

How’s It Stack Up?

There are no real comparators here, so we’ve got to interpret this one on its own merits, which were considerable. The methodological approach is called a discrete-choice experiment. This quantitative survey technique is well-accepted in other contexts. Though it is somewhat less familiar in our specialty, it is no less applicable or useful here. It would take a graduate course in methodology to parse out the details, but CORR felt it was robust enough to feature with an Editor’s Spotlight/Take 5 with the senior author due to its broad general-interest message. The reason for this, apart from the study’s methodological rigor, was its shocking finding — patients and surgeons may not be speaking the same language here. From that Editor’s Spotlight commentary:

Anyone who has ever treated (or known someone who has experienced) a prosthetic joint infection would find this level of enthusiasm for surgery to be inexplicable. For a surgeon to be aware of it and not try to temper it — dramatically — would be unconscionable.

What’s Our Take?

This study identified which patients are most likely to be comfortable taking extraordinary risks — those with functional limitations of 50% or more and/or severe pain at baseline. This is no great surprise, but surgeons need to make sure those people really understand what’s at stake, given that severe pain and functional limitations are so common in the arthroplasty clinic.

It’s not surprising that desperate patients are amenable to risk trades. This study suggests a surprising proportion of patients with hip or knee arthritis seem to feel as though things can’t get worse. But surgeons know they can. Prosthetic joint infections are both limb- and life-threatening. When visiting with patients who have substantial limitations or severe pain, this study tells us how important it is to slow down and make sure they “get it.” Apart from issues of basic fairness, it’s not hard to imagine misunderstandings in this context leading to litigation. Both the original article and the interview with the author are worth a look, though we found the senior author’s responses in the interview especially fascinating.