March 15, 2019
6 min read

Visual aids may improve patient perception of risk in knee replacement

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Liana Fraenkel

When explaining the procedural benefits and risks to patients considering total knee replacement, supplementing statistical information with visual aids was associated with stronger preferences for the procedure, according to recent findings published in Arthritis Care & Research.

Principal investigator Liana Fraenkel, MD, MPH, of the Yale School of Medicine, along with W. Benjamin Nowell, PhD, director of Patient-Centered Research at CreakyJoints, and colleagues, suggested that although most patients who undergo the procedure report high satisfaction afterwards, prior to surgery patients have frequently underestimated the potential benefit while overestimating potential risks of total knee replacement (TKR).

W. Benjamin Nowell, PhD
W. Benjamin Nowell

To determine whether additional visual aids would impact patient TKR preferences, the researchers randomized members of an online arthritis network (n = 648) to receive descriptive information alone or in combination with an icon array, images or spinner. At the outset of the study, participants were asked to read three paragraphs and choose among possible outcomes of TKR:

  1. Most patients (about 42 in 50) do great. They have significant pain relief and are very satisfied with the surgery. These patients would have the surgery again without hesitation.”
  2. “Some patients (about 7 in 50) don’t do as well as they expected. They continue to have a fair amount of pain and are not very satisfied with the surgery. They don’t think they would have this surgery again if they had bad arthritis in their other knee.” 
  3. “A few patients (about 1 in 50) have a serious complication after the surgery (such as an infection in the replaced knee). These patients regret having had the surgery.”

Patients in the first group received only written risk/benefit information. Those in the second received the written information and a color-coded icon array depicting risks and complications. Those in the third group read the written information and were shown stock images of patients looking happy, sad or without complication. For the fourth group, in addition to the written information, participants were shown a donut-shaped spinner figure with the three potential outcome groups numerically coded and randomly generated as participants clicked on them.

Supplementing statistical information with visual aids was associated with stronger preferences for the procedure when explaining the risks and benefits of TKR to patients, according to recent findings.
Credit: Adobe

In an analysis that controlled for baseline factors, preferences for TKR were higher among patients in the icon array group (LS mean = 7.17, [SE = 0.1]; P = .0002), the images group (LS mean = 7.14 [SE = 0.1]; P = .0005), and the spinner group (LS mean = 7.19 [SE = 0.1; P = .0001), compared with patients who only received statistical information (LS mean = 6.66, SE = 0.1).

This trend persisted in an analysis that adjusted for age, insurance status, knowing someone who did poorly after TKR, and knee pain, according to the findings. Similarly, preferences were not different for patients with uncertain or strong preferences during baseline assessment. No significant differences in preferences were observed across formats for participants with an uncertain or very strong preference for TKR at baseline.

Other findings indicated that the format of visual presentation influenced knowledge of risks of different outcomes for TKR (F = 13.62; P < .0001). Using a scale of 0 to 3, the mean knowledge score was higher in the icon array group (2; SD = 1.1) compared with the numeric only group (1.4; SD = 1.2), the images group (1.4; SD = 1.1), and the spinner group (1.3; SD = 1.1).

Healio Rheumatology spoke with Fraenkel and Nowell about knowledge gaps among prospective TKR patients, the impact of advances in the therapeutic armamentarium on TKR preferences, and the ways clinicians can use visual information to increase patient awareness of real or perceived risks associated with TKR.

Q: Could you talk about the nature of the visual aids you use, and how these could impact patient preferences for TKR?

Fraenkel: If a patient does not already have a preference for joint replacement, our study suggests there is value in developing visual decision-making tools that help patients better understand the benefits and risks of total knee replacement surgery to make choices about their care in consultation with their physician. In our study, participants recruited via email from the CreakyJoints member database and the CreakyJoints Facebook page were randomized into four groups and all reviewed outcome risk information, which we called the numeric option. Preference and knowledge of risk for TKR were then tested in all participants.

We found that after controlling for baseline preferences, patients who viewed the icon array, the images, or the spinner had a greater preference for TKR than people who read the numeric option only. Further, the participants exposed to visual information, particularly the icon array, had more knowledge — meaning, they remembered more — about the risk for different outcomes. Providing enhanced decision support at the point-of-care is being increasingly recognized as a vital component of care. Future studies should continue to evaluate the kinds of visual aids that resonate best with patients and include larger, diverse patient populations.


Q: What are some of the knowledge gaps patients have regarding joint replacement, and some of the concerns they voice when considering this option?

Nowell: We need to do much better at informing patients about many aspects of joint replacement, especially in those areas where the patient is the primary decision maker. For example, patients themselves typically choose whether to have the surgery and when. Patients need guidance in these decisions and in being realistic about their expectations of joint replacement as well as the relative potential benefit and risk.

Patients are also usually in a position to choose which surgeon to go to. While some patients are aware that it’s important to ask or learn about specific indicators of a surgeon’s success — for example, infection rate or readmission rate following arthroplasty — many are not. Outside of those three areas — whether to have surgery, timing and which surgeon — there are a number of decisions that are important to patients and that they know are being made, but patients do not understand how they are being made.

A concern we have heard raised many times in a series of focus groups that we conducted was which device would be used for their joint. Patients tend to trust their surgeon to choose, but they still want to understand the rationale for a particular device.

Q: Are there any potential benefits of joint replacement that patients overlook?

Fraenkel: We know from previous research that most patients have an excellent clinical response to TKR surgery, with satisfaction rates ranging from 75% to 90%. Most patients are introduced to the idea of TKR by their primary care providers, who outline what to expect from surgery and the risk for excellent, moderate and bad outcomes. Despite best efforts, which include additional education provided by the surgeon, we know that some patients remain hesitant to agree to surgery because they underestimate the potential benefits or overestimate their risk for complications.

Our study aimed to evaluate tools that a physician might use to help patients better understand the risk profile of TKR. Ideally, if we identify better ways to communicate, we will be able to ensure that patients make well-informed decisions about whether or not to undergo TKR. 

Q: Which arthritic conditions are most likely to require joint replacement over time?

Fraenkel: Most candidates for joint replacement are people living with osteoarthritis. These patients have persistent and disabling pain despite treatment by other therapies, such as weight management, physical therapy, injections or medications. People living with inflammatory forms of arthritis, such as rheumatoid arthritis, are also potential candidates for joint replacement surgery. However, with the increased use of biologic medications, which protect the joints better, we would expect to see fewer patients progressing to need an invasive intervention like surgery.

Q: Are advances in therapy for rheumatic disease — including biologics and TNF inhibitors — reducing the need for joint replacement?

Fraenkel: Yes, the availability of biologic and targeted synthetic DMARDs has improved the prognosis for people living with inflammatory forms of arthritis. Studies have shown that these patients are having fewer joint replacement surgeries, a trend we are also seeing in clinical practice. Our goal in treating people living with rheumatoid arthritis and other forms of inflammatory arthritis is to diagnose more quickly, initiate treatment faster and, thereby, prevent joint damage.

Q: Do patients frequently experience flare-ups of arthritis following surgery?

Fraenkel: In my experience, patients do not experience flare-ups of arthritis following surgery. Medications are either continued through surgery or started again soon afterwards. Data also show that most patients have high satisfaction with total knee replacement, meaning they have reduced pain and more functionality from the joint. Flare-ups would indicate dissatisfaction. – by Rob Volansky

For more information:

  • Liana Fraenkel, MD, MPH, can be reached at 333 Cedar St, New Haven, CT 06510; email:
  • W. Benjamin Nowell, PhD, can be reached at 515 N. Midland Ave, Upper Nyack, NY 10960; email:


  • Fraenkel L, et al. Arthritis Care Res (Hoboken). 2019;doi:10.1002/acr.23605.

Disclosures: Fraenkel and Nowell report no relevant financial disclosures.