Up close and personal: Total knee replacement in the US vs. the UK
One month ago, I had the opportunity to return home to England for a week to help my mom as she recovered from knee replacement. Of course, I was concerned (as surely any son would be!) about her undergoing major surgery, but my concern was also based on seeing a variety of outcomes for people after knee replacement. I wanted to go and make sure everything went well; I joked with her that I was going to make sure she was behaving herself!
From hearing the experience of friends and family, you may have mixed opinions about total knee replacements (TKR/TKA). They are typically a good surgery, but I have seen some that recover in a very straightforward manner and others that really struggle. TKA should be undertaken when quality-of-life is being significantly affected by pain, difficulty in function, and has not improved with rehabilitation. This was certainly the case for my mum. When someone decides to have a TKA they are expecting a significant improvement in quality-of-life. Many find this, but imagine what it would be like to struggle to get the knee moving after surgery, or have ongoing pain. I have seen patients like this and it feels to them like they have swapped one problem for another. There are a myriad of reasons for this from medical complications, surgical errors, to poor rehab and patient compliance. My goal was to make sure Mum did not struggle and was able to reap the rewards I know are possible with TKA.
From the media, most of you will know something about the health system in the UK; It is a socialized system called the National Health Service (NHS). Getting a TKA in this system can take a long time (12 months +), which is not much fun when you are in pain. Fortunately, following retirement, my parents had maintained private health insurance for this very reason and were able to schedule surgery when they wanted. So, her experience in scheduling the surgery was the same as someone in the US. I’ve lived in the US for 10-years, but before that I lived and worked in the UK both in the NHS and private practice, so am familiar with the typical post-surgical treatment of a TKA in each country and setting. In the US, patients would typically experience daily physical therapy while in the hospital and then would start outpatient or home health therapy 2-3 x a week for anywhere from 4-8 weeks or more. This has become the norm and is relatively encouraged by the way insurance and reimbursement works. However, there is no evidence to show that this approach to rehab works any better than others. Obviously, it has been a while since I worked in the UK, but watching Mum’s rehab reminded me how different approaches can work and explains the beliefs I have on rehab and why I have structured my practice the way I have.
After 20 hours of traveling, I arrived in London Heathrow, picked up the rental car (think stick shift and the other side of the road) and drove the 60 minutes to the hospital. I arrived at the hospital the day after her surgery (I spoke with her the day of the surgery via wifi while transatlantic! Pretty cool!). She was doing well, sitting up in the bedside chair, and the biggest problem she was having was some nausea. She had PT daily, working on a simple set of exercises and her mobility. She left the hospital three days after the surgery having proven that she could walk with a pair of crutches and go up and down the stairs. She was discharged with a set of instructions, including exercises, and she was then at home on her own with Dad and I for a period of a week and a half until she started her first therapy appointment. During that period we encouraged her to do her exercises and brought her ice when she wanted it. I did try to see if I could help her move her knee, but she couldn’t relax enough to make it worthwhile so I left the work to her! Essentially, we were glorified cheerleaders. I dovetailed with a visit from my sister (Also a PT!) who stayed with them for a few days, and a week and a half after discharge she went for her first outpatient PT appointment. The therapist was impressed with how she was doing. They worked a little on improving her walking gait using one crutch and gave her a progression of her exercises. She continued to work at home and had a follow-up PT appointment two weeks later. When I spoke to her today, Oct 17th 2017, four weeks after the surgery, my sister had visited with her family (Easier for them to visit from Scotland!) and Mum had walked 1.5 miles with her one crutch! I am obviously a little biased, but I think that her progress has been exceptional!
Obviously, this is only one case, so it does not prove that one approach is superior to another. However, having worked in both countries, I do not feel like I have seen more superior results in the US. The difference in care in the UK, in this case, is not due to the socialized healthcare as some might claim; for example, all of Mum’s care was at a private hospital. (I do acknowledge there is room for improvement in both systems and you are always welcome to ask my opinion!) Instead, the philosophy is different. In the US, most people’s experience of going for PT following TKA involves 2-3 time a week of the therapist making them do the repetitious exercises, the therapist bending their knee, and some electric stimulation and some form of ice therapy. There is a lot of hand-holding and, to be honest, I see overtreatment which can have negative consequences. I see patients who have been pushed too hard by PTs who are worried about a stiff knee, but the aggressive therapy creates pain that itself leads to stiffness! In the UK, the more spaced out appointments ask the patients to be more responsible for their progress. Certainly, there is some risk with this approach when a patient does not report concerns/problems. Even though I am aware of this risk, I still favor an approach that is more similar to the UK approach with all of my patients, as I believe that my patients are smart, able, and don’t need their hand held all the way through rehab. Many of my patients are busy professionals and do not have the time for multiple visits per week! I make sure that there are adequate ways to communicate with me to reduce the risk of unintended consequences occurring between appointments. I believe that where the patient is more involved, they will see more lasting/resilient results. I will qualify this by saying that everyone is different and some people will want the hand-holding, and I am fine with that initially if it is truly needed. However, I feel it is incumbent upon me, and a professional/ethical responsibility, to promote self-efficacy and self-reliance.
When you have been practicing/working any job for a period of time (in my case 15 years now) you can’t always understand why you do everything the way you do. I have tried as a professional to stay up to date on the latest research and that is the biggest guide to my practice. But, my experiences have also guided me, and mine are quite different from most PTs having worked in two countries, various practice settings, and under two healthcare systems. If you think my approach might be a good fit to help you with any pain, injury, or rehab needs, please do send me a message. You can contact me via email or phone. I am always happy to chat!
- Hirschmann MT, Hoffmann M, Krause R, Jenabzadeh RA, Arnold MP, Friederich NF. Anterolateral approach with tibial tubercle osteotomy versus standard medial approach for primary total knee arthroplasty: does it matter?. BMC Musculoskelet Disord. 2010;11:167.
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