ACR, AAHKS: Most patients indicated for hip, knee surgery should proceed without delay
Click Here to Manage Email Alerts
Patients indicated for hip or knee arthroplasty who have moderate to severe osteoarthritis and have not responded to nonsurgical therapies should proceed to surgery without delay, according to new recommendations.
The new recommendations, covering the optimal timing of elective hip or knee replacement, come from the American College of Rheumatology and the American Association of Hip and Knee Surgeons.
“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,” Susan M. Goodman, MD, attending rheumatologist at the Hospital for Special Surgery and co-principal investigator of the guideline, said in an ACR press release.
However, another key recommendation urged that patients with nicotine dependence or diabetes should delay surgery to achieve either nicotine cessation or decreased use of nicotine products, as well as to allow for improved glycemic control.
All of the recommendations included in the guideline are conditional — there are no “strong recommendations.” However, every recommendation achieved a high level of consensus among the governing task force, according to the ACR. The panel that developed the recommendations included rheumatologists, orthopedic surgeons and patient representatives.
The ACR and AAHKS approved a total of 13 recommendations. Among them are provisions urging that indicated patients should proceed to hip or knee arthroplasty instead of delaying the procedure for 3 months. In addition, indicated patients should proceed to surgery rather than delay the procedure to test a trial of physical therapy, or to trial NSAIDs, intra-articular glucocorticoid or viscosupplementation injections, or attempt therapy with braces or other ambulatory aids.
The organizations also recommend that indicated patients who have a BMI of more than 50 should undergo surgery without delaying the procedure to achieve a BMI lower than 50. Similar recommendations also urge moving on to surgery for patients with BMI between 40 and 49 — without delaying to reduce BMI to less than 40 — and between 35 and 39 — without delaying to reduce BMI to less than 35.
Other recommendations include:
- Indicated patients with diabetes mellitus that is not controlled well should delay surgery while attempting to improve glycemic control.
- Indicated patients demonstrating nicotine dependence should delay surgery until nicotine use can be reduced or stopped completely.
- Indicated patients who have bone loss with deformity or severe ligamentous instability should proceed to surgery without delaying in an attempt to optimize care.
- Indicated patients with one or more neuropathic joints should undergo surgery without delaying the procedure in an attempt to optimize care.
The full manuscript, including methodology and recommendation list, will be published in Arthritis & Rheumatology, Arthritis Care & Research and the Journal of Arthroplasty later this year, according to the ACR.
“This shared decision-making process should comprehensively discuss the unique risks and benefits of the procedure for the individual patient,” Goodman said in the release. “Patients with medical or surgical risk factors as described in this guideline should be counseled as to their increased risks, and preoperative attempts to modify these risk factors through efforts such as weight loss, glycemic control, or smoking cessation should be encouraged.”
Perspective
Back to Top
David A. McLain, MD, MACR, FACP, FRCP
The guidelines for optimal timing of total joint arthroplasty (TJA) reported above are straightforward and very reasonable. It is of interest that the data supporting them is of low or very low quality. Apparently, there are few quality studies on the timing for TJA. Another timing issue relates to the period that the patient needs to remain under care after the procedure, as well as the setting for the procedure. I have seen patients undergoing TJA who were the first morning case at an outpatient surgery center and were home by 1:30 p.m. the same day. This is quite remarkable, although former President George W. Bush famously had outpatient partial knee replacements on both knees back in 2014.
A study published in 2019 by Hoeffel and colleagues on the outcomes of the first 1,000 total hip (THA) and total knee arthroplasties (TKA) at an ambulatory surgery center revealed the outcomes to be comparable to inpatient surgery. The outcomes that were comparable were hospital readmission rate (1.5%), access to early or unplanned care (11.7%), improvement in the Oxford Knee and Oxford Hip scores, and pain score improvements. The pain scores for TKA improved 71% while THA improved 81% at 6 months after the surgery.
With the aging baby boomer population, total THA are expected to increase 19% over the next 5 years — and a prodigious 74% in 10 years — while TKA will increase even more, at 28% and 89%, respectively. The guidelines in the ACR/AAHKS summary have no mention of age or health contraindications for surgery, even though severe medical illnesses, particularly cardiac and pulmonary, prevent surgery frequently due to an unacceptable risk. TJA has come a long way since its infancy in the 1970s. Will the next big thing be the regeneration of the patient’s own cartilage?
Click Here to Manage Email Alerts