Contemplation Stage
This patient is in the Contemplation stage of the Transtheoretical Model of Change. 1
Understanding the Contemplation Stage
The patient is aware that knee surgery is being recommended and recognizes the problem exists, but he is actively weighing the pros and cons without having made a commitment to proceed. 1 This is the defining characteristic of Contemplation—the patient is seriously considering action but remains hesitant and is gathering information about potential consequences of both proceeding with and delaying surgery. 1
Why Not Other Stages?
Pre-contemplation would apply if the patient was unaware of the problem or in denial about needing surgery, which is not the case here since he's been consulted and is actively considering the decision. 1
Action would only apply if he had already undergone the surgery or committed to a specific surgery date and was taking concrete steps toward it. 1
Preparation would be appropriate if he had already decided to proceed and was planning specific steps (scheduling surgery, arranging time off work, etc.), but he remains uncertain. 1
Critical Information About Delaying Knee Surgery
For patients with moderate-to-severe symptomatic osteoarthritis who are indicated for total joint arthroplasty (TJA), delaying surgery leads to increased pain, worsening function, and progression of medical comorbidities due to limited mobility. 2, 1
Specific Consequences of Delay:
Progressive functional decline: Patients experience continued pain and loss of mobility during the waiting period. 2, 1
Worsening medical comorbidities: Limited mobility from untreated knee disease can worsen conditions like diabetes, cardiovascular disease, and obesity. 1
Increased technical difficulty: In cases with severe deformity or bone loss, delaying surgery may increase juxtaarticular bone loss and instability, making the procedure more technically challenging and increasing revision risk. 2
No benefit from additional conservative treatment: For patients already indicated for TJA who have failed nonoperative therapy, mandated delays for additional physical therapy, NSAIDs, or braces provide limited clinical benefit while prolonging suffering. 2
Appropriate Clinical Response in Contemplation Stage
The surgeon's role is to facilitate shared decision-making by providing balanced information about both performing and delaying surgery, explicitly discussing the risks of not operating. 1
Key Communication Strategies:
Present both advantages and disadvantages of surgery versus conservative management in a balanced manner. 1
Explicitly discuss risks of delay, particularly when delay carries risk of irreversible consequences such as progressive bone loss, worsening deformity, or continued functional decline. 1
Emphasize that there should be no arbitrary waiting period mandated before surgery, as patients indicated for TJA have typically already attempted nonoperative treatment for an extended period. 1
Educate about realistic timelines: The 2023 ACR/AAHKS guidelines recommend proceeding directly to surgery without delay for additional nonoperative treatment in patients who have already failed conservative management. 2
Common Pitfalls to Avoid
Do not mandate additional nonoperative treatments (physical therapy, NSAIDs, braces) as a requirement before surgery in patients already indicated for TJA, as this creates barriers to care and prolongs suffering without improving outcomes. 2
Avoid rigid cutoffs for BMI or other modifiable risk factors as absolute contraindications, as these limit access to care and increase disparities, particularly among vulnerable populations. 2 Instead, counsel patients about increased risks while still offering surgery.