Know the bias of your surgeon. It dramatically affects the care you are offered.
Surgeons are like any other skilled professional. They like to do what they are best at, what works in their hands, what they have observed over their lifetime of practice. They chafe at the bit when told, by insurance companies or hospital administrators, what they can and cannot offer to patients or which implants they are allowed to use. They want the best outcomes for their patients and for themselves. Their desires are often well aligned with their patients’ interests — and sometimes at odds with the system.
That being said, it’s important to know what their biases are so you, the patient, can decide if their bias fits with your own desires. Here are a few examples:
Total knee replacement vs. partial knee replacement: Joint replacement surgeons in general (and pardon my gross generalities) want to be “one and done.” If you show up with an arthritic knee that is bone-on-bone in all or part of the joint, the surgeon may suggest a total joint replacement to replace all of the exposed surfaces with metal and plastic. This surgeon’s experience with partial knee replacements may be minimal, or they have heard about poor outcomes.
But other joint surgeons who specialize in partial knee replacement will ask you, “Why replace the whole knee when only part of it is worn out? Just resurface the part that is worn. We can always do more later if you need it — and you may not.”
The truth is that the results of full knee replacement are not as good as advertised, with 50 percent of people having pain after 10 years. What also has changed is that today, with robotic surgery, partial knee replacements are much more accurate — and most are performed as outpatient procedures. So knowing the surgeon’s bias in advance will determine which procedure you are offered.
Biologic vs. artificial joint replacement: Arthritis develops over time. Knees begin to wear out due to loss of first the meniscus, then ligaments and then the articular cartilage. A surgeon who has experience replacing these tissues will offer the suffering knee patient these soft tissue replacement options. The surgeon without this experience may offer an osteotomy, a surgical procedure where the angle of the leg is changed by cutting the bone and wedging it open or closed in order to buy time before a knee replacement is required. (Or they may offer an artificial knee replacement up front.) The surgeon’s skill set determines, in part, what you are offered.
Injections vs. cortisone or surgery: Recent interest in biologic stimulation of joint healing has led to a plethora of new joint injections. These include growth factors called PRP, stem cells from fat, bone and amniotic fluids, and lubricating injections (usually using hyaluronic acid and protein injections of albumin). The data and outcomes of these injections are variable. In our estimation, 30 percent of the world seems to have a super response to some of these injections, 30 percent have a mixed response, and 30 percent do not respond. If you are a responder, the benefits of pain relief and improved function are dramatic. Surgeons without this bias may offer cortisone — which shuts down inflammation but does not stimulate healing — or just progress to a surgical solution.
Rehab vs. surgery: Rehabilitation techniques have improved significantly over the years. All of the patients in our clinic work with our rehab team in addition to the medical and surgical team to either optimize their recovery or avoid surgery completely. The team works with them not just to the recovery stage but beyond, to achieve a “fitter, faster, stronger” goal. If a surgeon does not have a rehab team or the experience working closely with physical therapists, the option of avoiding surgery may not be offered as frequently — and physical therapy might not even be prescribed at any point in the care.
In sum, bias is a good thing: Surgeons generally stick to what works best in their hands. But knowing this bias is an important data point to understand why you are offered some solutions and not others. Knowledge about the diagnosis, treatment options and your surgeon’s bias is your smartest strategy.
Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco.