The Fears that Keep Candidates for TKA Out of the OR

    Every joint replacement surgeon has stories about patients who need a total knee arthroplasty (TKA), but for a myriad of reasons, can’t seem to commit to having the procedure done.

    Maybe it’s the fear of pain, or concerns about the length of the recovery, or even worries about exposure to infection in the hospital.

    Whatever the cause, delaying a much-needed knee replacement can leave the patient suffering unnecessary pain and disability before the procedure, and can result in a poor outcome once he or she has the procedure.

    Understanding why patients might delay knee replacement surgery will help orthopaedic surgeons effectively address their concerns. A study recently reported at the annual meeting of the International Society for Pharmacoeconomics and Outcomes Research sought to define these concerns.

    Using an online survey, the researchers asked a cross-section of candidates for TKA in the U.S. questions about the severity of their pain from osteoarthritis, how much the pain interfered with their activities, their attitudes toward pain management, and their reasons for delaying surgery. They also collected demographic information (age, gender, household income, education level, and region of the country.

    The 654 respondents were predominantly female (66%), had an above-average income (62% household income of $50,000 or more), and were well educated (55% bachelor or graduate degree). The mean age was 64 years old.

    They rated their pain level, and the degree to which the pain interfered with their activities, as moderate. More than half were using non-steroidal anti-inflammatory drugs to manage their pain. Although nearly a quarter of respondents were taking an opioid for pain, most said they wanted to minimize the use of opioids after surgery. In fact, 92% said they wanted their surgeon to be able to effectively manage their pain without opioids during the rehabilitation period.

    Not surprisingly, the fear of pain in the first several weeks after surgery (versus pain right after surgery) was one of the top reasons for delaying the procedure (OR: 1.64, 95% CI: 0.881-3.06). The potential for the procedure to interfere with work was another significant predictor of the decision to delay surgery (OR: 1.219, 95% CI: 1.095-1.356). The more concerned respondents were about work, the greater the probability that surgery would be delayed.

    The researchers said gender, income, and education did not significantly factor into the decision to delay surgery. 

    The conclusion from this study is clear: During the initial patient appointment, surgeons need to proactively address the fear of postoperative pain by reviewing their pain management protocols and emphasizing the role of non-opioid drugs, particularly after discharge, during the rehabilitation period.

    If the patient is still working, surgeons should also provide a realistic and individualized timetable for return to work.


    Zhao R, Carlson AM, Ilfeld BM, Berend KR, Stultz MR. Patient factors in the decision to delay total knee arthroplasty. Presented at the International Society for Pharmacoeconomics and Outcomes Research 20th Annual International Meeting, May 16-20, 2015, in Philadelphia, Pennsylvania.