Credit: Original article published here.
Strong evidence suggests that patients with moderate to severe symptomatic osteoarthritis (OA) who have failed nonoperative treatment should proceed directly to surgical care, without additional nonoperative therapies, according to new guidelines from the American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS).
Elective Joint Replacement for Osteoarthritis
The new guideline addresses the optimal timing of elective joint replacement for patients with symptomatic moderate to severe OA or osteonecrosis who are indicated for surgery after failure on nonoperative therapy. Along with information on surgical timing, the guideline also offers recommendations for when additional nonoperative treatment are appropriate for in this patient population.
“For patients with symptomatic moderate to severe osteoarthritis or osteonecrosis of the hip or knee who have been indicated for total hip or total knee arthroplasty, the efficacy of additional nonoperative treatments, such as physical therapy, anti-inflammatories, and injections is unknown,” said Dr. Charles P. Hannon, MD, MBA, co-literature review leader of the guideline. “In addition, for patients with certain risk factors, such as obesity, which are linked to increased risk and poorer outcomes, the benefit of delaying surgery to modify these risk factors is not well established. For these reasons, a guideline needed to be created.”
Highlights of the ACR/AAHKS Guideline
The guidelines recommend a shared decision-making process between physician and patient regarding the decision of when to proceed with total joint arthroplasty (TJA).
“This shared decision-making process should comprehensively discuss the unique risks and benefits of the procedure for the individual patient,” said Susan M. Goodman, MD, co-principal investigator.
There are also conditional recommendations regarding whether to delay total joint arthroplasty (TJA) based on patient or treatment factors:
- Do not delay TJA to attempt additional nonoperative treatments (e.g., physical therapy, nonsteroidal anti-inflammatories, ambulatory aids, and injections).
- For patients with a nicotine dependence, delay TJA to achieve nicotine cessation or reduction.
- For patients with diabetes mellitus, delay TJA to improve glycemic control—however, the guideline does not recommend a specific measure or threshold of glycemic control based on its systematic review.
- Do not delay TJA due to patient obesity alone; however, weight loss should be strongly encouraged.
- Do not delay surgery in patients who have severe deformity, bone loss, or a neuropathic joint.
Regarding the recommendation about further non-operative therapies, Dr. Goodman stated, “There is no evidence that delaying surgery for any of the additional nonoperative treatments studied, including physical therapy, gait aids, oral anti-inflammatories, or injections, leads to improved outcomes, and may burden patients without clear benefit.”
On the nicotine cessation guideline, Dr. Hannon commented: “For patients presenting with nicotine dependence, there is a potential benefit of delaying total joint arthroplasty for nicotine use reduction or cessation. The patient should be educated about the increased surgical risks associated with nicotine use and ideally engage in nicotine reduction strategies.”
The full manuscript of the guideline has been submitted for publication in ACR and AAHKS journals later this year. A summary of the guidelines is available here.
