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Selecting those to refer for joint replacement: Who will likely benefit and who will not?

https://doi.org/10.1016/j.berh.2014.01.005Get rights and content

Abstract

Osteoarthritis (OA) is one of the 10 most disabling diseases in developed countries and worldwide estimates are that 10% of men and 18% of women aged over 60 years have symptomatic OA, including moderate and severe forms. Total joint replacement (TJR) is considered the most effective treatment for end-stage OA in those who have exhausted available conservative interventions. The demand for TJR is continually rising due to the ageing population; in the United States, more than 1 million TJRs were performed in 2010 and the number of procedures is projected to exceed 4 million in the US by 2030. It has been estimated that of all hip and knee replacements performed, approximately one quarter of the patients may be considered inappropriate candidates. Predicting who will benefit from TJR and who will not would seem critical in terms of containing the current and projected expenditure as well as improving satisfaction in TJR recipients. Few formal predictive tools are available to aid referring clinicians to determine those likely to be good or poor responders to surgery and current available tools tend to focus on disease severity alone with little consideration of risk factors that may predict a poor outcome or impede an effective response to surgery. This review examines the tools available to assist with assessing appropriateness for TJR; investigates the modifiable risk factors associated with poor outcome; and identifies areas for future research in selecting those appropriate for joint replacement.

Section snippets

Background

Osteoarthritis (OA) is one of the 10 most disabling diseases in developed countries and worldwide estimates are that 10% of men and 18% of women aged over 60 years have symptomatic OA, including moderate and severe forms [1]. Globally, musculoskeletal (MSK) disorders are the second largest contributor to years lived with disability, with OA of the hips and knees combined being the third most prevalent MSK disorder [2]. Age is the strongest predictor of the development and progression of OA, and

Selecting TJR candidates based on disease severity

It is generally recommended that patients with severe symptomatic OA, who have pain that has failed to respond to conservative treatments and who have progressive limitation in activities of daily living should be referred to an orthopaedic surgeon for evaluation [18]. However, opinions about the indications for TJR based on the severity of joint disease and symptomatology vary greatly between referring physicians and surgeons [19], [20]. While there are no universally accepted criteria to

Modifiable risk factors for poor response to TJR surgery

The decision to refer for surgery based solely on symptoms fails to take into account individual risk factors that can impact on patient outcomes after TJR. A number of associations between individual patient characteristics and response to TJR surgery have been identified including: age [40], gender, body mass index (BMI) *[40], *[41], *[42], *[43], ethnicity [44], psychological distress [45], co-morbidity profile [42] and radiographic OA severity [29], *[46]. The extent to which modifiable

Summary and future directions

The risk factors and predictors of TJR outcome presented in this review by no means form a complete list, but rather highlight those that may be amenable to intervention prior to specialist referral. Addressing modifiable factors such as radiographic OA severity and psychological well-being, for example, prior to referral may improve response rates to TJR surgery. While some algorithms presented in this review are useful in identifying a small subset of patients in whom referral for surgery is

Conflict of interest statement

The authors have no financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work. The authors have no conflicts of interest to declare in relation to this work.

Acknowledgements

Dr. Dowsey holds an NHMRC Early Career Australian Clinical Fellowship (APP1035810).

References (101)

  • R. Schwarzkopf et al.

    Postoperative complication rates in the “super-obese” hip and knee arthroplasty population

    J Arthroplasty

    (2012 Mar)
  • R. Christensen et al.

    Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial

    Osteoarthr Cartil

    (2005 Jan)
  • B.F. Riecke et al.

    Comparing two low-energy diets for the treatment of knee osteoarthritis symptoms in obese patients: a pragmatic randomized clinical trial

    Osteoarthr Cartil

    (2010 Jun)
  • K. Johansson et al.

    Effects of anti-obesity drugs, diet, and exercise on weight-loss maintenance after a very-low-calorie diet or low-calorie diet: a systematic review and meta-analysis of randomized controlled trials

    Am J Clin Nutr

    (2014 Jan)
  • A. Kulkarni et al.

    Does bariatric surgery prior to lower limb joint replacement reduce complications?

    Surgeon

    (2011 Feb)
  • E.P. Severson et al.

    Total knee arthroplasty in morbidly obese patients treated with bariatric surgery: a comparative study

    J Arthroplasty

    (2012 Oct)
  • D.C. Ayers et al.

    Psychological attributes of preoperative total joint replacement patients: implications for optimal physical outcome

    J Arthroplasty

    (2004 Oct)
  • K. Badura-Brzoza et al.

    Psychological and psychiatric factors related to health-related quality of life after total hip replacement – preliminary report

    Eur Psychiatry

    (2009 Mar)
  • R. Gandhi et al.

    Predicting the longer term outcomes of total knee arthroplasty

    Knee

    (2010 Jan)
  • B. Caracciolo et al.

    Self-perceived distress and self-perceived functional recovery after recent total hip and knee arthroplasty

    Arch Gerontol Geriatr

    (2005 Sep–Oct)
  • M.M. Vissers et al.

    Psychological factors affecting the outcome of total hip and knee arthroplasty: a systematic review

    Semin Arthritis Rheum

    (2012 Feb)
  • K. Gooch et al.

    Comparative effectiveness of alternative clinical pathways for primary hip and knee joint replacement patients: a pragmatic randomized, controlled trial

    Osteoarthr Cartil

    (2012 Oct)
  • S.D. Gill et al.

    Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials

    Arch Phys Med Rehabil

    (2013 Jan)
  • J.A. Wallis et al.

    Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery–a systematic review and meta-analysis

    Osteoarthr Cartil

    (2011 Dec)
  • A. Judge et al.

    Pre-operative expectation predicts 12-month post-operative outcome among patients undergoing primary total hip replacement in European orthopaedic centres

    Osteoarthr Cartil

    (2011 Jun)
  • M.M. Dowsey et al.

    The association between radiographic severity and pre-operative function in patients undergoing primary knee replacement for osteoarthritis

    Knee

    (2012 Dec)
  • A.M. Valdes et al.

    Inverse relationship between preoperative radiographic severity and postoperative pain in patients with osteoarthritis who have undergone total joint arthroplasty

    Semin Arthritis Rheum

    (2012 Feb)
  • Hip and knee replacement. Health at a glance 2011

    (2011)
  • M.C. Hochberg et al.

    American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee

    Arthritis Care Res

    (2012 Apr)
  • Total hip replacement. NIH Consensus development panel on total hip replacement

    JAMA J Am Med Assoc

    (1995 Jun 28)
  • Panel NIHC

    NIH consensus statement on total knee replacement December 8–10, 2003

    J Bone Joint Surg Am Vol

    (2004 Jun)
  • F. Koechlin et al.

    Comparing Price levels of hospital services across countries: results of Pilot study

  • S. Kurtz et al.

    Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

    J Bone Joint Surg Am Vol

    (2007 Apr)
  • P.L. Santaguida et al.

    Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review

    Can J Surg Journal canadien de chirurgie

    (2008 Dec)
  • National Joint Replacement Registry Annual Report 2011

    (2012)
  • R.B. Bourne et al.

    Patient satisfaction after total knee arthroplasty: who is satisfied and who is not?

    Clin Orthop Relat Res

    (2010 Jan)
  • M.M. Dowsey et al.

    Predictors of pain and function following total joint replacement

  • R. Cobos et al.

    Variability of indication criteria in knee and hip replacement: an observational study

    BMC Musculoskelet Disord

    (2010)
  • J.M. Quintana et al.

    Decision trees for indication of total hip replacement on patients with osteoarthritis

    Rheumatology

    (2009 Nov)
  • P. Dieppe et al.

    MOBILE and the provision of total joint replacement. Journal of health services research & policy

    (2008 Oct)
  • Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines

    Arthritis Rheum

    (2000 Sep)
  • K.E. Dreinhofer et al.

    Indications for total hip replacement: comparison of assessments of orthopaedic surgeons and referring physicians

    Ann Rheum Dis

    (2006 Oct)
  • Toronto Arthroplasty Research Group Writing C et al.

    Variability in physician opinions about the indications for knee arthroplasty

    J Arthroplasty

    (2011 Jun)
  • A. Escobar et al.

    Development of explicit criteria for total knee replacement. International journal of technology assessment in health care

    Winter

    (2003)
  • C.D. Naylor et al.

    Primary hip and knee replacement surgery: Ontario criteria for case selection and surgical priority

    Qual Health Care QHC

    (1996 Mar)
  • R.H. Brook et al.

    A method for the detailed assessment of the appropriateness of medical technologies

    Int J Technol Assess Health Care

    (1986)
  • N. Bellamy

    WOMAC: a 20-year experiential review of a patient-centered self-reported health status questionnaire

    J Rheumatol

    (2002 Dec)
  • J.E. Ware et al.

    The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection

    Med Care

    (1992 Jun)
  • J.M. Quintana et al.

    Health-related quality of life and appropriateness of knee or hip joint replacement

    Arch Intern Med

    (2006 Jan 23)
  • J. Cushnaghan et al.

    Long-term outcome following total hip arthroplasty: a controlled longitudinal study

    Arthritis Rheum

    (2007 Dec 15)
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