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Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 62-66

A qualitative study of impediments to total knee replacement among indians with severe knee osteoarthritis

1 Department of Orthopaedic Surgery, Sunshine Bone and Joint Institute, Sunshine Hospitals, Secunderabad, Telangana, India
2 Department of Orthopaedic Surgery, Michigan State College of Osteopathic Medicine, Michigan State University, USA

Date of Submission03-Dec-2021
Date of Acceptance04-Dec-2021
Date of Web Publication27-Jan-2022

Correspondence Address:
Praharsha Mulpur
Sunshine Bone and Joint Institute, Sunshine Hospitals, PG Road, Opposite Parsi Dharamsala, Paradise, Secunderabad - 500 003, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joasis.joasis_29_21

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Objective: The objective of this study is to determine the barriers for seeking a total knee replacement (TKR) in Indians with osteoarthritis, despite an increasing need for the surgery. Materials and Methods: Interviews were conducted with 350 Indian patients (109 males, 241 females) who underwent TKR at a tertiary care orthopedic center. The interviews were conducted with each individual based on a questionnaire of 18 questions, which emphasized the patient's reasoning and perceptions regarding TKR. Questions were asked after the patients were admitted but before undergoing TKR. Pain severity and disability before receiving TKR were measured with the Lequesne Index and Oxford Knee Score. Results: Patients requiring TKR were undergoing surgery 13 months after being advised for surgery. Multiple barriers in choosing surgery were identified: (i) wanting to manage pain and disability for as long as possible, (ii) loss of autonomy in making the decision to undergo surgery, (iii) financial issues in affording surgery, (iv) belief that the patients themselves are unfit for surgery and fear of postsurgical complications and morbidity. Conclusions: Despite there being several barriers to the surgical treatment of knee osteoarthritis, physicians must develop strategies to help bridge the gap between patients requiring TKR and the patients electing to undergo the surgery.

Keywords: Factors influencing treatment, Indian patients, osteoarthritis, total knee replacement

How to cite this article:
Reddy MV, Mulpur P, Guravareddy AV, Gudapati D, Reddy VY, Dinakar M. A qualitative study of impediments to total knee replacement among indians with severe knee osteoarthritis. J Orthop Assoc South Indian States 2021;18:62-6

How to cite this URL:
Reddy MV, Mulpur P, Guravareddy AV, Gudapati D, Reddy VY, Dinakar M. A qualitative study of impediments to total knee replacement among indians with severe knee osteoarthritis. J Orthop Assoc South Indian States [serial online] 2021 [cited 2022 Jun 30];18:62-6. Available from: https://www.joasis.org/text.asp?2021/18/2/62/336657

  Introduction Top

Knee osteoarthritis is one of the leading factors leading to pain and disability in many countries, especially India.[1] In a study conducted in 2016, the overall prevalence of knee osteoarthritis in Indian patients has been shown to be 28.7%. Factors that increase prevalence of knee osteoarthritis include obesity, a sedentary lifestyle, and age.[1] With all three of these factors rising in India, the need for a total knee replacement (TKR) for knee osteoarthritis has been rising. In addition, Indian patients can consult an orthopedic specialist without the need of the primary care physician (PCP) serving as a gatekeeper between the patient and the orthopedic surgeon. The absence of a gatekeeper PCP gives Indian patients requiring a TKR freedom to directly consult their orthopedic surgeon, whereas patients from countries such as the United States or Canada require a referral from their PCP to be even considered for surgery.[2] Overall, Indian patients who wish to undergo TKR for osteoarthritis have easier access to their surgery if they elect to proceed with the surgical route. However, despite the increasing need for TKR surgery and the ease of access to the orthopedic surgeon, the number of patients electing to undergo surgery in India is severely undervalued. This study aims to explore factors involving decision making for TKR and factors that are serving as barriers for patients to undergo a surgery that can greatly improve their quality of life.

  Materials and Methods Top

The sample size includes 350 patients (109 male, 241 females) who underwent TKR at a tertiary care orthopedic center. These patients underwent surgery during the time period: December 2015-February 2016. All patients presented with severe disabling arthritis and required TKR while having no contraindications for surgery. Before surgery, patients were interviewed based on a questionnaire administered by an arthroplasty fellowship-trainee surgeon. In addition, The Lequesne Index[3] and Oxford Knee Score were used to evaluate severity of knee pain and range of disability due to knee osteoarthritis.

The questionnaire given to each patient before surgery is given in [Table 1].
Table 1: Patient questionnaire

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The Lequesne Index for Knee Severity and the Oxford Knee Score were also used to evaluate patients before surgery. The Lequesne Index evaluated three sections [Figure 1]a, [Figure 1]b, [Figure 1]c including (i) pain or discomfort [Figure 1a], (ii) maximum distance walked and walking-aids used [Figure 1b], (iii) activities of daily living [Figure 1]c.
Figure 1: (a) Lequesne Index - Pain and disability scoring (b) Lequesne Index - Assessment of walking distance and Walking-aids (c) Lequesne Index - scoring for activities of daily living

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Lequesne index scores were determined by the sum of points for all three parameters: (i) pain or discomfort, (ii) maximum distance walked, (iii) activities of daily living. The cumulative scores are assessed and interpreted as per [Table 2].
Table 2: Interpretation of Lequesne index score

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  • Minimum points for each parameter: 0
  • Maximum Points for each parameter: 8
  • Minimum index score: 0
  • Minimum index score: 24.

Patients were graded on a Likert scale of 1–5 for each question in the Oxford Knee Score, which is a patient-reported outcome measure. Higher OKS scores are indicative of improved outcome or better functional status of the subject. Interpretation of the Oxford Knee Score is according to [Table 3].
Table 3: Grading of Oxford knee score

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  • Minimum points for each question: 0
  • Maximum points for each question: 4
  • Minimum Oxford Knee Score: 0
  • Maximum Oxford Knee Score: 48.

  Results Top

Three hundred fifty patients who gave written consent to undergo primary total knee arthroplasty were included in this study. Patients were interviewed by an Orthopedic surgery resident and a qualified arthroplasty fellowship candidate before surgery. Data were collated and analyzed in Excel 2016 (Microsoft Corp.)

Patient demographics

Of the 350 patients who underwent total knee arthroplasty, 109 patients were male and 241 patients were female with the average age of the patient being 63.73-year old, range of 45–84 years.

Lequesne Index Score and Oxford Knee Score

The average Lequesne index score for the patients involved in the study was 16.2 points, with a score >14 points, indicative of extremely severe pain and handicap. The average Oxford Knee Score was 16.79 points, with scores <19 points being an indication of severe arthritis. Therefore, according to the Lequesne Index Score and the Oxford Knee Score, all of the patients fall under the category of extremely severe arthritis.

Results from the Sunshine Hospital demographic questionnaire indicate that the average time interval between surgery being advised to the actual procedure is 13.86 months. Despite being offered professional advice to undergo surgery, patients are waiting an average of over a year to choose to have surgery and the factors influencing their decision-making for surgery are listed below.

Major factors influencing patients to undergo surgery

Pain and disability

The average duration of pain for patients undergoing TKR was 5.4 years, with the maximum duration of pain before electing to undergo surgery being 20 years. 95% (n = 333) of patients were dealing with severe pain when they chose to have surgery, indicating pain plays an important role in the decision-making of patients who finally decide to have surgery. In addition, disability-affecting activities of daily living were present in 89.42% (n = 313) patients with many patients choosing surgery only when their personal hygiene such as utilizing the toilet was affected. In regards to methods used prior to choosing surgery, patients underwent physiotherapy 73.14% (n = 256) of the time, whereas 36% (n = 136) chose to use methods of alternative medicine such as Ayurveda and acupuncture. A high use of alternative methods of treatment displays a majority of patients willing to prolong surgery even though they qualify for a TKR. An increase of pain despite other methods of physiotherapy or alternative medicine was eventually one of the biggest factors in patients who currently chose to have surgery. According to the Sunshine Questionnaire, “Increased Pain” despite trying other methods was the predominant factor (97.7%, 342 patients) for bringing patients in for surgery.

Lack of autonomy in decision making

Although increasing pain severity and disability have to be shown to be one of the biggest players in a patient's decision to choose surgery, it is important to evaluate a patient's familial, cultural, and ethnic values as these factors have an impact on patient-decision making. According to the data from the Sunshine Questionnaire, only 52.28% (n = 183) patients took the decision themselves to undergo surgery. In a majority of female patients, the decision to have surgery was influenced by family members rather by the patients themselves being able to decide if they want to have surgery. Based on our study, 21.42% (n = 75) had their spouse, 12.28% (57) had their son, and 10% (35) had their other family members decide for them if surgery was needed. With only 52.28% of patients making their own decision to have surgery, there is an evident loss of autonomy in patients who require TKR. This loss of autonomy is seen to be primarily a result of family members as only 35.14% (123) patients stated that a nonfamily member played an influence in the patient's decision making in having surgery.

Perceptions of being unfit for surgery

Physical, cultural, and social aspects are essential factors influencing a patient's decision-making process for surgery, but it is crucial to also examine the patient's psychological and emotional perceptions to having surgery. According to our questionnaire, only 11% of patients consider themselves as being too old to undergo surgery, and only 16% of patients are afraid of death during surgery, morbidity, and pain during physiotherapy after surgery. Despite only a few percentages of patients displaying age and postsurgical complications as a barrier between receiving surgery, a large 85% of patients feel that they are psychologically unfit to undergo surgery. Although psychological perceptions of surgical readiness are shown to play a role in decision-making, the etiology of these assumptions is not examined in this study.

Financial burden of surgery

Through our sunshine questionnaire, it was determined that financial burden was a barrier for 43.4% of patients. It is important to evaluate the factors that contribute to financial burden such as cost of the surgery, length of stay in the hospital, and postsurgical medication and rehab. The patient's individual financial status was not documented in the study.

Minor factors influencing patients to undergo surgery

Only 16% of patients are afraid of death during surgery, morbidity, and pain during physiotherapy, and only 11% of patients consider age to be a factor affecting their decision to undergo surgery. Furthermore, before surgery, almost all of the patients (96%) have positive expectations of the surgery.

  Discussion Top

Utilizing our demographic questionnaire, Lequesne Index Score, and Oxford Knee Score, it is evident that there are certain factors hindering patients from using TKR surgery as a primary treatment option for their knee osteoarthritis. The average time frame to have surgery from the time it was first advised from a physician is 13.86 months. Patients are suffering from pain for an average of 5.385 years and it is important to determine what factors are preventing patients from seeking treatment and having a decreased quality of life. Increasing severity of pain and disability is illustrated as the greatest factors for Indian patients to choose surgery as an option for their knee osteoarthritis. A majority of patients only tend to seek surgery as a “last resort” as they choose TKR only when their personal hygiene is compromised due to pain or disability. Many elderly individuals believe that pain and disability are a normal part of the aging process[2],[4] and thus are hesitant to seek treatment, especially if it is involving surgery.

In addition to increased pain and disability, cultural identities also play a critical role, especially in Indian patients undergoing surgery. According to the Sunshine Questionnaire, only 52.28% of patients made the decision themselves to get the TKR as a treatment to their pain and increasing symptoms of osteoarthritis. This indicates that about 48% of patients are not the decision makers for their own surgery illustrating a lack of autonomy. This loss of autonomy can be seen primarily in female patients, where their husband or son makes the final decision of undergoing surgery, as they are the financial source of income for the household. An inability for the patient to make their own decision can further lead to an emotional burden as their quality of life continues deteriorates over time.

Finally, a majority of patients believe that they are unfit to undergo a surgical procedure. Despite awareness of total joint arthroplasty as an option, patients are unwilling to directly approach a specialist as they consider themselves unfit for surgery. In the analysis by Hudak et al.,[2] patients were willing to consider surgery only if cleared by a medical physician.

Sanders et al.[4] showed in their study population that a high proportion of patients considered themselves unfit for surgery. This was attributed to either age, comorbidities or both. However, in our study majority of the patients (n = 299, 85.4%) did not consider themselves unfit for surgery based on age or comorbidities. This psychological hurdle can be originating from a multiple of factors but it is important to provide counseling and develop an adequate physician-patient relationship where the patient can overcome his/her psychological stressors and proceed to surgery with a positive mindset.

Patient perception of outcomes of surgery is an important factor influencing decision making. In our study, 143 patients (40.9%) had inputs from patients who had undergone TKA surgery in their communities, which influenced their decision for surgery. Jüni et al.[5] reported that negative perceptions about the surgery could be the reason for reduced acceptance of surgery. They suggested improvement in physician-patient communications as the remedy. In the current study, patients were well informed about the benefits of surgery and 336 (96%) had positive perceptions about total knee surgery and its outcomes.

Jayadev et al.[6] showed that communication between the surgeon and patient, and addressing knowledge-gaps with decision-aids helps the patient to decide for/or against surgery in a well-informed manner.

  Conclusions Top

The prevalence for knee osteoarthritis and necessity of TKR is heavily on the rise in India, yet there is not a rise to take action to improve quality of life. Several factors serving as a barrier for patients to undergo treatment include delay of surgery until severe pain and disability, lack of autonomy in decision-making, negative perceptions of being unfit for surgery, and financial burden. In an attempt to combat these burdens, education of surgical outcomes to the patient is quintessential and a development of trust between the patient and physician must be honored. Individualized decision aids can be made for patients undergoing TKR exemplifying the positive outcomes and improved quality of life that surgery can bring. In addition, postoperative rehab and follow-up should be consistent to ensure adequate mobility and recovery time. With an increasing rise of knee osteoarthritis, especially in India, it is vital for physicians to educate patients and their families on the role of surgery for osteoarthritis and the greatly improved quality of life that it can bring.

Ethical clearance

Ethical clearance was obtained from the Institutional Ethical Committee to conduct this observational study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian J Orthop 2016;50:518-22.  Back to cited text no. 1
[PUBMED]  [Full text]  
Hudak PL, Clark JP, Hawker GA, Coyte PC, Mahomed NN, Kreder HJ, et al. “You're perfect for the procedure! Why don't you want it?” Elderly arthritis patients' unwillingness to consider total joint arthroplasty surgery: A qualitative study. Med Decis Making 2002;22:272-8.  Back to cited text no. 2
Lequesne MG, Mery C, Samson M, Gerard P. Indexes of severity for osteoarthritis of the hip and knee. Validation – Value in comparison with other assessment tests. Scand J Rheumatol Suppl 1987;65:85-9.  Back to cited text no. 3
Sanders C, Donovan JL, Dieppe PA. Unmet need for joint replacement: A qualitative investigation of barriers to treatment among individuals with severe pain and disability of the hip and knee. Rheumatology (Oxford) 2004;43:353-7.  Back to cited text no. 4
Jüni P, Dieppe P, Donovan J, Peters T, Eachus J, Pearson N, et al. Population requirement for primary knee replacement surgery: A cross-sectional study. Rheumatology (Oxford) 2003;42:516-21.  Back to cited text no. 5
Jayadev C, Khan T, Coulter A, Beard DJ, Price AJ. Patient decision aids in knee replacement surgery. Knee 2012;19:746-50.  Back to cited text no. 6


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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