Overview
The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) released a summary of its new guideline titled “the When to Have Elective Hip or Knee Arthroplasty for Patients with Symptomatic Moderate to Severe Osteoarthritis or Osteonecrosis Who Have Failed Nonoperative Therapy.” In the years 2017 and 2022, the ACR and AAHKS collaborated to develop guidelines for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. This guideline focuses on the timing of hip and knee arthroplasty and when additional nonoperative treatment or delays for medical optimization are appropriate for patients with advanced osteoarthritis and osteonecrosis who are scheduled for hip or knee replacement. While those guidelines focus on which medications to take during and withhold prior to hip or knee arthroplasty for patients with rheumatic diseases such as systemic lupus erythematosus (SLE), spondyloarthritis (
“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 The assistant professor of orthopedic surgery at Washington University in St. Louis is Charles P. Hannon, MD, MBA. Louis is the co-leader of the guideline’s literature review. “Furthermore, the benefit of delaying surgery to modify certain risk factors in patients who have them is not well established. These risk factors include obesity, which is associated with higher risk and worse outcomes. This necessitated the development of a rule.”
The guideline contains only conditional recommendations. Although none of the recommendations are particularly strong, there is strong agreement on all of them.
Two Important Recommendations
One important recommendation is that patients with moderate to severe osteoarthritis or osteonecrosis symptoms who are indicated for joint replacement and have tried nonoperative therapy without success should have surgery right away in order to continue nonoperative treatment of the joint issue.
Delaying surgery for any of the additional nonoperative treatments investigated, such as physical therapy, gait aids, oral anti-inflammatories, or injections, does not appear to improve outcomes and may burden patients without obvious benefits.”
Susan M. Goodman, MD, attending rheumatologist at the Hospital for Special Surgery and co-principal investigator of the guideline
Another important suggestion is to postpone surgery for patients with diabetes or nicotine dependence in order to improve glycemic control and either quit smoking or use fewer nicotine products.
“For patients presenting with nicotine dependence, there is a potential benefit of delaying total joint arthroplasty for nicotine use reduction or cessation,” said Dr. Hannon. “The patient should be informed of the higher surgical risks brought on by nicotine use, and ideally start using nicotine reduction techniques.”
The following are the results of the survey conducted by the National Institute of Health. The panel stressed the importance of shared decision-making between a patient and their physician when indicating a patient for total joint arthroplasty.
“This shared decision-making process should comprehensively discuss the unique risks and benefits of the procedure for the individual patient,” said Dr. Goodman. “Patients who have the medical or surgical risk factors listed in this recommendation should receive counseling regarding their elevated risks, and preoperative attempts to change these risk factors through actions like weight loss, glycemic control, or quitting smoking should be encouraged.”
ACR and AAHKS journals are expected to publish the complete guideline in 2023 after it has been submitted for peer review. The ACR and AAHKS websites both have comprehensive summaries of the guidelines’ recommendations.
