Change in willingness for surgery and risk of joint replacement after an education and exercise program for hip/knee osteoarthritis: A longitudinal cohort study of 55,059 people
Authors: Belinda J Lawford, Ali Kiadaliri, Martin Englund, Kim L Bennell, Rana S Hinman, Michelle Hall, Andrea Dell'Isola
Journal: PLoS Medicine (2025)

Background Numerous studies report that education and exercise interventions can shift people’s willingness to undergo joint replacement surgery for osteoarthritis. We aimed to investigate whether becoming unwilling to undergo surgery following an education and exercise intervention for hip and knee osteoarthritis is associated with lower probability of receiving actual surgery. Methods and findings This was a register-based cohort study including people from the Swedish Osteoarthritis Register who underwent a 3-month education and exercise intervention for knee or hip osteoarthritis. Participants self-reported their willingness to have joint replacement surgery (‘yes’ or ‘no’) and were grouped based on their response pre- and post-intervention (always willing for surgery; became unwilling for surgery; never willing for surgery; became willing for surgery). Data on joint replacement surgery was obtained through the Swedish Arthroplasty Register. The probability and hazard of surgery occurring, as well as the mean time without surgery was calculated up to 5-years (primary outcome) and 9-years (secondary outcome) post-intervention. We adjusted for age, sex, body mass index (BMI), education, joint pain, quality of life, walking difficulties, number of prior visits with an orthopedic surgeon, prior joint surgeries in the knee or hip (other than joint replacement), and comorbidities. 55,059 people were included, 69% were female (N = 37,739), with a mean age 66years (standard deviation [SD] = 9.3), and a BMI of 27.5 (SD = 4.9). In total, 70% (N = 38,386) were never willing for surgery, 14% (N = 7,736) were always willing for surgery, 10% (N = 5,649) became unwilling for surgery, and 6% (N = 3,288) became willing for surgery. Compared to those who were always willing for surgery, participants who became unwilling had a 20% (95% confidence interval [CI]: 18, 22%) lower probability of having surgery by 5-years post-intervention. This corresponded to delaying surgery by 1.1 (95% CI: 1.0, 1.1) years. Compared to those who were always willing for surgery, the hazard of surgery occurring at 1-year post-intervention was lower in those who became unwilling (hazard ratio (HR) 0.5 [95% CI: 0.4, 0.5]), though was then higher at 5-years (HR 1.4 [95% CI: 1.2, 1.7]). Estimates remained stable from 5 to 9 years. Limitations of our study include the inability to account for all potential confounders, and to infer the contribution of the intervention to change in willingness for surgery due to the absence of a control group. Data were collected in Sweden, generalisability to other countries may be limited. Conclusions Becoming unwilling for joint replacement surgery following an education and exercise program for hip and knee osteoarthritis could reduce the number of joint replacement surgeries by 20% at 5 years post-intervention, with the possibility of maintaining most of this reduction up to 9 years post-intervention. Interventions that can shift willingness to undergo surgery may thus result in relevant delays and reductions in future joint replacements.