Abstract
Purpose
Late stage medial unicompartmental osteoarthritic disease of the knee can be treated by either Total Knee Replacement (TKR) or Unicompartmental Replacement (UKR). As a precursor to the TOPKAT study this work tested the postulate that individual surgeons show high variation in the choice of treatment for individual patients.
Method
Four surgeons representing four different levels of expertise or familiarity with partial knee replacement (UKR design centre knee surgeon, specialist knee surgeon, arthroplasty surgeon and a year six trainee) made a forced choice decision of whether they would perform a TKR or UKR based on the same pre-operative radiographic and clinical data in 140 individual patients. Consistency of decision was also evaluated for each surgeon 3 months later and the effect of additional clinical data was also evaluated. The sample consisted of the 100 patients who had subsequently undergone UKR and 40 who had undergone TKR.
Results
The specialist knee surgeon from the design centre would have performed UKR in 80% of the patients. The other surgeons would have performed a UKR in between 32-43% of the patients representing a variation in decision making of up to 59%. The choice of treatment for each surgeon remained unchanged in between 80-87% of cases after viewing additional clinical data. There was high intra surgeon repeatability in decision making when assessed 3 months later.
Conclusion
Despite being given identical information, surgeons show high variability in decision making for patients with medial OA of the knee. A knee surgeon with a special interest in partial knee replacement is twice as likely to choose UKR for a patient with medial compartment OA than a non specialist surgeon. The choice is predominantly based on radiological findings but decision making for each individual surgeon is reassuringly consistent. The implications are that if TKR and UKR have unequal efficacy, some patients may be undergoing a suboptimal procedure.
