Joint Arthroplasty Guidelines by American College of Rheumatology and American Association of Hip and Knee Surgeons
SUMMARY:
Osteoarthritis and osteonecrosis are ubiquitous and progressive joint diseases that can lead to joint pain, loss of function, and disability. Many patients rely on total knee or hip arthroplasty to alleviate their symptoms and improve their quality of life. The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) have worked together to create a guideline discussing recommendations for the timing of elective hip and knee arthroplasty in patients with symptomatic moderate to severe joint disease who have failed non-operative treatment. All recommendations are conditional but were reached with high consensus within the work group.
Clinical Actions
- Non-operative therapies for osteoarthritis (OA) and osteonecrosis (ON) include
- Physical therapy | Weight loss | Intraarticular injections | NSAIDs | Activity modification | Gait aids | Bracing
- Non-operative therapies may assist with pain control and mobility, but they are not disease modifying and do not alter the course of joint destruction
- Total knee or hip arthroplasty (TKA | THA), unlike non-operative therapies, can reduce pain and restore function of the joint long term in indicated patients
- Severity of joint disease is established radiographically using standard radiographic grading metrics (e.g., as Kellgren-Lawrence | Tonnis)
- Clinician should utilize shared decision making when discussing surgical treatment options with patients who have OA or ON
- The ACR and AAHKS recommend the following in patients with symptomatic moderate to severe OA or symptomatic advanced ON who have failed to improve with non-operative therapy
- Clinicians should not delay elective knee or hip arthroplasty in patients who have failed previous non-operative therapy to trial alternative non-operative therapies
- Clinicians should not delay TKA or THA for patients to lose weight to meet a strict weight goal prior to surgery, regardless of initial BMI
- Clinicians should not delay TKA or THA to optimize non-life-threatening medical conditions in patients with: Bone loss with deformity | Severe ligamentous instability | Neuropathic joint
- Clinicians should consider delaying TKA or THA in patients who have poor glycemic control or high levels of nicotine use until diabetes control improves or patient is able to reduce (or quit) nicotine usage
- While it is recommended for patients to proceed with total joint arthroplasty (TJA) regardless of BMI when otherwise indicated, patients with an elevated BMI should be counseled on increased risk medical and surgical complications prior to surgery
- They should also be counseled on how to lose weight if their weight is contributing to poor health or decreased function
- Despite these recommendations, it is not uncommon for patients to have their TJA delayed by a third party (e.g., Insurance companies) requiring further non-operative treatment or weight loss prior to approving surgery
- Rigid BMI, A1c and nicotine cut offs for surgery likely increase healthcare disparities and lead to lower utilization of TJA, a definitive medical therapy, in patients of color or of lower socioeconomic status
KEY POINTS:
- Elective hip or knee arthroplasty in patients with symptomatic moderate to severe joint disease, which has failed non-operative management, should not be delayed for weight loss, optimization of non-life-threatening medical conditions, or a trial of alternative non-operative therapies
- Elective hip or knee arthroplasty may be delayed to improve glycemic control or decrease nicotine dependence prior to surgery
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