Thread by @DrJohnOrchard

Knee osteoarthritis (OA) in Australia 2010-2019: A decade of (mainly) mismanagement. Updated Tweetorial for the New Year. Sadly, many other Western countries are also bad. 1/thread

How would we know whether we are managing knee OA well? Let’s start with the latest data we have on knee OA, from aihw.gov.au/reports/arthri… and aoanjrr.sahmri.com/documents/1018…

Over the last decade we’ve seen an ongoing increase in the incidence rate of knee replacement in Australia. And this is coming off a rate which is already very high by world standards

The rates by country are presented here: statista.com/statistics/236… with Australia in the top 10 worldwide. It is not great that we are amongst the highest in the world and still increasing

There are some countries in the world with pretty decent health systems that have way, way lower rates than Australia. Close to home the New Zealand Knee Replacement rate is about half the Australian rate. Israel’s rate is ¼ the Australian rate. Ireland even lower

The OECD had already called out Australia for having an excessively high rate of knee replacement early in the decade oecd.org/australia/Geog… but we have managed to keep it increasing over the 2010s

Projected burden of knee and hip replacement is that it will keep increasing ncbi.nlm.nih.gov/pmc/articles/P… particularly when it becomes clear from upcoming Tweets that we have policies DESIGNED to keep it increasing

Is TKR a good operation? Well a critical RCT from Denmark in 2015 showed it did reduce knee pain but it also increased the risk of medical complications/illnesses in those that had TKR compared to a control group that didn’t blogs.bmj.com/bjsm/2015/12/0…

Very high rates of TKR that keep increasing is a bad health outcome. We have an increasing number of people in severe knee pain and an increasing number of medical complications off the back of this. But this (bad outcome) doesn't get the attention it deserves

I will segue a bit now to another area where Australia is doing badly – carbon emissions and tackling climate change. We managed to drop emissions for 3 years with a carbon tax in place, but they have risen ever since it was dropped.

Like a good Seinfeld episode, I will come back to climate change and link these two trends later on. But you don’t have to be a rocket science to understand that when you ditch a Carbon Tax you encourage use of carbon.

So what does Australia’s health system fund and encourage, and how does do these items relate to the risk of knee arthritis progressing to the severity that it requires a knee replacement?

One of the most common treatments for knee OA is arthroscopic surgery. Knee arthroscopy increases risk of TKR at least threefold, eg pubmed.ncbi.nlm.nih.gov/27712957-incre…

Knee arthroscopy also doesn’t beat placebo knee surgery or physiotherapy when it comes to reducing knee pain. pubmed.ncbi.nlm.nih.gov/26080045-arthr…

I argued to reduce funding for knee arthroscopy based on evidence 18 years ago!!! (see clip from early 2000s editorial) ncbi.nlm.nih.gov/pubmed/12585610 but surgical procedures seemed to be quarantined from funding cuts no matter how poor the evidence is

It is important to differentiate between knee replacement, which is valuable surgery for many individuals, but preventable if knee OA is well managed, and knee arthroscopy, which appears to be unnecessary surgery in the majority of cases.

Cortisone injections are often recommended by guidelines and regularly used for knee OA, yet any beneficial effect wears off within 1-2 months and they ALSO substantially increase the risk of knee replacement. pubmed.ncbi.nlm.nih.gov/30703543-intra…

Other common painkillers used (and recommended by guidelines) for OA such as Tramadol pubmed.ncbi.nlm.nih.gov/30860559-assoc…
and Naproxen pubmed.ncbi.nlm.nih.gov/30415598-treat… increase risk of death rather than progression to knee replacement

There is one treatment for knee OA that has strong evidence of being beneficial for knee OA: moderate exercise pubmed.ncbi.nlm.nih.gov/31356585-non-p….

...but, exercise prescribed by doctors is the only consultation-based treatment that has had funding cuts in Australia’s Medicare system over the 2010s smh.com.au/business/medic…

A controversial/fascinating treatment option for knee OA is PRP injections, which has also had funding cut under Medicare in Australia publish.csiro.au/ah/Fulltext/ah…

Although PRP injections are almost certainly overused for other indications (where there is not evidence of benefit) multiple systematic reviews have shown benefit in knee OA ncbi.nlm.nih.gov/pmc/articles/P…

So Australia in the 2010s has continued to fund (and use) ineffective and harmful treatments for knee OA, and has cut funding for effective treatments. pubmed.ncbi.nlm.nih.gov/28663214-has-r… And our (already high) rate of knee replacements has increased as a result 🥺

"Should we start using terms like Postfact to describe knee OA funding?"

We could prevent some knee OA by preventing to no. 1 injury cause for OA (which is ACL injuries), hence my 3 calls to implement an ACL registry in the 2010s pubmed.ncbi.nlm.nih.gov/29716512-the-r… pubmed.ncbi.nlm.nih.gov/21439904-why-d…
pubmed.ncbi.nlm.nih.gov/21210852-high-…

It’s time to call out funding for knee arthritis not just for being ineffective but also for negatively impacting on our carbon footprint. What are the carbon emissions associated with knee arthroscopy and why do our health systems keep funding an ineffective procedure?

If doctors want to get serious about climate change, then ceasing spinal fusions, knee arthroscopy, acromioplasty, stents for stable angina & other ineffective procedures (unable to beat placebo) is our own backyard, not just expecting other sectors (only) to reduce emissions.

Exercise-based programs are not only effective for knee OA, back pain, cardiovascular disease, cancer, diabetes and depression but they have much lower carbon footprint than surgical procedures and pharmaceuticals.

In 2019, the AMA appeared to double down on blocking funding for Sport & Exercise medicine consultations, but lobbying to keep funding for ineffective surgeries smh.com.au/national/the-g… @liammannix

@liammannix ....and with our horrible standing of Australians not being physical active enough theconversation.com/140th-out-of-1…, why is the AMA still arguing against Sport & Exercise Medicine physicians getting equal rebates under Medicare?

@liammannix A recent quote from @AllenFrancesMD 's book Saving Normal sums up the problem: “The medical industrial complex” – doctors sadly promote what is profitable over what is effective. Knee OA management in Australia in the 2010s has been (sadly) driven this way

@liammannix @AllenFrancesMD So in the 2020s, let’s first admit that having a very high rate of knee replacements in Australia is a marker of a POOR health outcome, and then let’s finally work towards health policies that are evidence-based and get better outcomes /thread

@liammannix @AllenFrancesMD @threadreaderapp unroll