optimal timing for hip/knee replacements

 The 2023 American College of Rheumatology and the American Association of Hip and Knee Surgeons recently released guidelines specifically addressing the optimal timing for elective hip or knee arthroplasty

(see knee or hip replacement guidelines ArthCareRes2023 in dropbox, or https://doi.org/10.1002/acr.25175). Patients were also involved in this collaboration

 

Details:

-- this guideline pertains to patients who meet the following criteria:

    -- have moderate to severe pain and loss of function

    -- have moderate to severe radiographic osteoarthritis (OA) or advanced osteonecrosis (ON) with secondary arthritis

    -- who have also completed at least one trial of an appropriate nonoperative therapy

    -- and have had detailed discussions with the surgeon along with shared decision-making, agreeing to the surgery

-- this consensus document required at least 70% agreement either for or against a recommendation. In fact, “there was high or unanimous consensus for all recommendations”

 

Recommendations:

 

-- all of these recommendations were based on low or very low quality of evidence, leading to recommendations there were “conditional” instead of being more definitive

-- and these recommendations only apply to those patients meeting all of the above criteria

 

-- do not wait three months prior to total joint arthroplasty for hip or knee replacements (collectively referred to as TJA, total joint arthroplasty).

    -- The basic issue here is that delaying TJA, in this population of patients who have already attempted nonoperative treatment, might lead to increased pain, loss of function, and worsening of medical comorbidities due to limited mobility.

    -- The only exception, other than patients’ own decisions to delay TJA for whatever reason, would be for those patients who have received a recent intra-articular steroid  injection, where it is appropriate to wait at least three months to decrease the risk of infection from the surgery

 

-- physical therapy: do not delay TJA for a trial of physical therapy (though one of the criteria for doing TJA is that patients have already tried at least one nonoperative therapy)

    -- the issue here is that physical therapy may provide some benefit, but the nonoperative approaches (NSAIDs or acetaminophen, physical therapy, intra-articular steroids, bracing, weight loss, gait aids) are not disease-modifying therapies and are likely to postpone appropriate the surgery

     -- physical therapy is appropriate pre-op (prerehabilitation); observational studies have confirmed the appropriateness for patients to build up their muscle strength prior to surgery, whenever this is possible

 

-- NSAIDs: do not delay TJA for a trial of NSAIDs, given their array of associated adverse events (peptic ulcer disease, acute kidney injury, increased cardiovascular risk, bleeding, etc). these risks are often much higher in many of these usually older patients who have an amalgam of significant medical comorbidities

 

-- braces or other ambulatory aids: do not delay TJA for a trial of braces or other ambulatory aids

    -- the issue is that some of these aids may lead to altered gait mechanics, increased pain, and worsened function especially if they are used improperly. I would add here the concern that braces may also lead to muscle atrophy from nonuse of the muscles, a potential negative in terms of surgical outcomes

 

-- intra-articular glucocorticoid injections: do not delay proceeding to TJA for a trial of intra-articular glucocorticoid injections

    -- as per above, three months is an appropriate delay after the last steroid injection in order to decrease the risk of infection

    -- steroids might also lead to more hyperglycemia in diabetics, so it is appropriate to wait a bit until glucose control is improved

 

-- viscosupplementation: do not delay proceeding to TJA for a trial of viscosupplementation

    -- these interventions offer limited benefit for pain and function

 

-- obesity: do not delay TJA independent of the levels of obesity, specifically noting any BMI >35 (i.e. the use of absolute BMI or rigid thresholds is discouraged), though weight loss should be strongly encouraged

    --  they do note that greater BMI is associated with greater medical and surgical risks, including increased risk of a periprosthetic joint infection (and patient should be informed of these risks), but it is not clear that postponing TJA for weight reduction improves outcomes

     -- pain and function improvements are similar, independent of BMI

     -- and, baseline, many patients are not able to lose a substantial amount of weight for a variety of reasons

    -- in addition, the improve mobility from TJA may help with losing and maintaining weight loss

 

--  diabetes: it is appropriate to delay TJA to improve glycemic control

    -- patients with diabetes have worse outcomes with uncontrolled hyperglycemia, though the optimal laboratory measure and optimal threshold of glycemic control to reduce surgical complications is unknown

 

-- nicotine: it is appropriate to delay TJA for nicotine use reduction or cessation

    -- nicotine use is associated with increased medical and surgical risks in TJA

    -- the decision to proceed with TJA should not be contingent on complete nicotine cessation, but the patient should be informed about the increased surgical risks associated with nicotine, and ideally they should engage in nicotine reduction strategies.

 

--  bone loss and deformity, or severe ligamentous instability: proceed to TJA for those with bone loss and deformity, or severe ligamentous instability

    -- they note that of this recommendation is based on experience with no evidence in the literature

    -- the concern is that increasing joint instability and articular bone loss or deformity by waiting for surgery may increase the technical difficulty of the procedure and the potential risks for failure or need for subsequent revision

 

-- neuropathic joints: it is appropriate to  proceed to TJA for patients with neuropathic joints

    -- another recommendation based on no substantive support in the literature

    -- patients with Charcot neuroarthropathy may well have increased joint destruction by continuing to use these joints, again making the surgery more difficult and potentially less successful

    -- and it should be noted that patients with these neuropathic joints may not have much pain or loss of function initially despite severe joint destruction. The symptoms might appear later, but again the procedures become much more technically difficult as the joint and its environs become more deformed

        – fyi, this suggestion for doing earlier TJR in these patients is actually contrary to their defined criteria for surgery, since they may not have "moderate to severe pain and loss of function"

        – and, i would add, there is overall not a great correlation between symptomatic knee pain and radiologic osteoarthritis anyway: https://www.nature.com/articles/s41598-018-19470-3 or  https://www.acpjournals.org/doi/full/10.7326/0003-4819-133-8-200010170-00016

 

Comments:

-- it is abundantly clear from the above that these recommendations are based on very low quality of evidence, and some with no evidence

   -- as such, they are all strewn with caveats that they do not necessarily apply to all patients, but are just overall guidelines that may be used to help develop a more consistent approach to performing TJA (they explicitly note that there are “exceptions” regarding patients being able to decrease their smoking)

    – these guidelines also expose the lack of important evidence: for example, there are no studies or consensus on the effectiveness of specific additional nonoperative treatments after an initial nonoperative treatment as been ineffective

-- the evidence used is from observational studies, thereby only revealing associations and not causality: eg, the cited issue above that people with uncontrolled diabetes do worse with surgery, but there are no controlled studies finding that improved glucose control (or the degree of improvement) is associated with improved outcomes

-- as with many recommendations in the medical literature, a large percentage of recommendations are based on low quality evidence. For example, a study done assessing the American Heart Association and its European equivalent found no improvement in the level of evidence in their cardiology guidelines, comparing 2018 to 2008, with only a significant minority (26.5%) being based on RCTs at both time assessments: https://gmodestmedblogs.blogspot.com/2019/04/guidelines-lacking-evidence-based.html .

-- one important feature in these current recommendations is that they include the American College of Rheumatology (a medical specialty), the American Association of Hip and Knee Surgeons (a surgical specialty), and 8 patients who were either TJA candidates or had had TJA, a very appropriate type of combination that should take place more often, especially when it is reasonable to combine the medical and surgical societies. patients should always be part.....

-- is also abundantly clear that recommendations such as these are really important, given the aging population, the large number of people who are living longer than before, and the increased likelihood of more and more joint problems and ultimately joint surgeries in the future

    – estimates are that up to 4 million people in the US may need TJA by 2030

--  one concern that we in primary care all confront, as well as orthopedic surgeons, is the often quite significant delay created by insurance companies (which the guidelines refer to as "creating a major barrier to care"). Perhaps guidelines such as these will help accelerate the process for patients who fit the criteria as noted above and wish to proceed with surgery.... Delays in appropriate surgery may well lead to further decreases in physical function, further disability, and perhaps more likely worse outcomes from the ultimate surgery

    -- and, the lack of a uniform set of guidelines accepted by all may well exacerbate healthcare disparities. This is particularly the case since many people with low income are working in manual jobs and may be more disabled by their joint pain than higher income people who may have desk jobs

 

Limitations:

-- the biggest limitation to these guidelines is the lack of clear evidence behind them: as noted, these are therefore all "conditional recommendations". But these seem to be the best conclusions based on a consensus of an appropriately pretty diverse panel

    – and, we are often treating patients without clear evidence-based medicine, either because the studies were never done (as frequently happens, especially with older meds that the drug companies are not interested in spending the money to perform) or because the studies done are insufficient to make a clear decision (eg the SPRINT trial finding that lower blood pressure was better but they excluded patients with diabetes, or many other trials with strict age limits for the participants or excluding patients with kidney disease, etc; these guidelines may not be generally applicable to the patient in front of us)

    – also, as per above, many of the guidelines we rely on now still include lots of recommendations that are "expert opinion": these TJA timing guidelines are not unique in that

-- another limitation of these recommendations as they only included the very specific group of patients noted, and did not include patients who have less severe disease (many of whom may well be very symptomatic) or patients with other types of arthritis that might qualify for TJA (rheumatoid arthritis, etc.)

    -- and, as mentioned above, there is a well-known discordance between symptoms of knee pain (which can be pretty severe) and radiologic findings

 

so, to me this is an important step forward:

-- there is finally some consensus guidance on when to perform TJA, hopefully leading to a more consistent approach to TJA

-- i strongly suspect that many patients have been inappropriately excluded from typically beneficial TJA because of the variability of orthopedist recommendations, which likely vary from one orthopedist to another, and perhaps from one area to another.

    – the most common issue, i believe, is from obesity.  these guidelines strongly support surgery even in those with BMI >50. and the problem is that many of these patients are unable to lose lots of weight or maintain weight loss in part because of their very limited ability to exercise. the various GLP-1 agonists are certainly a step forward to achieving major weight loss, as is bariatric surgery, but still many patients remain quite obese even with the weight loss

    – the other issues are smoking and diabetes control. though these guidelines do suggest trying to decrease smoking and improving diabetic control, these are not hard-and-fast barriers to TJA

-- the other huge issue is the inconsistency of insurance companies in approving these procedures (we really do need a consistent system overall for this issue and oh-so-many more concerns). This represents, yet again, a huge flaw in our health care system… 

geoff

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