Factors influencing UK arthroplasty surgeons' decision‐making between total and medial unicompartmental knee surgery: a vignette‐based behavioural experiment
Author(s)
Type
Journal Article
Abstract
Purpose
Surgical options for end-stage knee osteoarthritis (OA) include total and medial unicompartmental knee replacement (TKR and UKR). Deciding which surgery to perform is complex and ill-defined, yet it has important implications for patients and the health service. The study aimed to identify clinical and surgeon factors predicting surgeons' preferences.
Methods
Based on a preliminary survey of 162 UK surgeons, we identified clinical features frequently considered when deciding between TKR and UKR. By systematically varying patient age, obesity, site of pain, anaesthetic risk and anterior cruciate ligament (ACL) integrity, we constructed 32 clinical vignettes. We used these in a new survey, where surgeons indicated which surgery they would recommend on an 11-point rating scale with end points anchored at ‘definitely TKR’ and ‘definitely medial UKR’. Data were analysed with mixed-effects linear regressions.
Results
Eighty-three UK arthroplasty surgeons completed the vignettes. Preference for UKR over TKR was significantly lower for patients over 50 years (b = −0.57 [−0.82 to −0.33], p < 0.001) with abnormal ACL (b = −1.93 [−2.17 to −1.68], p < 0.001) and severe systemic disease (b = −0.46 [−0.70 to −0.21], p < 0.001). Obesity was a weak and unreliable predictor, and we did not detect any influence of site of pain. The surgeons' habitual practice (proportion of UKRs over all knee replacements performed in a typical year) was the second strongest predictor after ACL (b = 1.26 [0.54–1.99], p = 0.001).
Conclusions
ACL integrity was the most important determinant of surgeons' preferences between TKR and UKR. Their habitual practice was also a strong predictor, outweighing most clinical factors in the vignettes.
Level of Evidence
Level II, prospective cohort study.
Surgical options for end-stage knee osteoarthritis (OA) include total and medial unicompartmental knee replacement (TKR and UKR). Deciding which surgery to perform is complex and ill-defined, yet it has important implications for patients and the health service. The study aimed to identify clinical and surgeon factors predicting surgeons' preferences.
Methods
Based on a preliminary survey of 162 UK surgeons, we identified clinical features frequently considered when deciding between TKR and UKR. By systematically varying patient age, obesity, site of pain, anaesthetic risk and anterior cruciate ligament (ACL) integrity, we constructed 32 clinical vignettes. We used these in a new survey, where surgeons indicated which surgery they would recommend on an 11-point rating scale with end points anchored at ‘definitely TKR’ and ‘definitely medial UKR’. Data were analysed with mixed-effects linear regressions.
Results
Eighty-three UK arthroplasty surgeons completed the vignettes. Preference for UKR over TKR was significantly lower for patients over 50 years (b = −0.57 [−0.82 to −0.33], p < 0.001) with abnormal ACL (b = −1.93 [−2.17 to −1.68], p < 0.001) and severe systemic disease (b = −0.46 [−0.70 to −0.21], p < 0.001). Obesity was a weak and unreliable predictor, and we did not detect any influence of site of pain. The surgeons' habitual practice (proportion of UKRs over all knee replacements performed in a typical year) was the second strongest predictor after ACL (b = 1.26 [0.54–1.99], p = 0.001).
Conclusions
ACL integrity was the most important determinant of surgeons' preferences between TKR and UKR. Their habitual practice was also a strong predictor, outweighing most clinical factors in the vignettes.
Level of Evidence
Level II, prospective cohort study.
Date Issued
2025-01-01
Date Acceptance
2024-12-05
Citation
Journal of Experimental Orthopaedics, 2025, 12 (1)
ISSN
2197-1153
Publisher
Wiley
Start Page
e70178
Journal / Book Title
Journal of Experimental Orthopaedics
Volume
12
Issue
1
Copyright Statement
© 2025 The Author(s). Journal of Experimental Orthopaedics published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
License URL
Identifier
https://www.ncbi.nlm.nih.gov/pubmed/40028417
PII: JEO270178
Subjects
decision‐making
knee arthroplasty
osteoarthritis
total knee arthroplasty
unicompartmental
Publication Status
Published
Coverage Spatial
United States
Article Number
e70178
Date Publish Online
2025-02-28