The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) have released a summary of their new guidelines titled “Optimal Timing of Elective Hip or Knee Replacement for Patients with Moderate to Severe Arthritis or Osteonecrosis. Failed Non-Surgical Treatment.” The ACR and AAHKS have worked together before, developing guidelines for the perioperative management of antirheumatic drugs in patients with rheumatic diseases undergoing total hip replacement or total knee arthroplasty in 2017 and 2022. While these guidelines focus on medications that should be addressed during surgery and withheld prior to hip or knee arthroplasty for patients with rheumatic diseases such as systemic lupus erythematosus (SLE), spondyloarthritis (SpA) and rheumatoid arthritis (RA), this guideline focuses on the timing of hip and knee arthroplasty, and when Additional non-surgical treatment or medical delay improvement is appropriate for patients with advanced osteoporosis and osteonecrosis who have failed non-surgical treatment.
For patients with moderate to severe osteoarthritis or osteochondrosis of the hip or knee who are indicated for total hip or total knee arthroplasty, effectiveness said Charles B. Hannon, MD, MBA, assistant professor of orthopedics at Washington University in St. Louis and chair of the joint guideline literature review Additional non-surgical therapies, such as physical therapy, anti-inflammatories, and injections are not known. In addition, for patients with certain risk factors, such as obesity, which are associated with increased risk and poorer outcomes, the benefit of delaying surgery to modify these risk factors is not well established. For these reasons, guidelines need to be established.”
All recommendations in the guideline are conditional. While there are no strong recommendations, there was a large consensus on all of the recommendations.
One of the main recommendations is that patients with osteoporosis or osteonecrosis with moderate to severe symptoms who are indicated for joint replacement and who have failed non-surgical treatment should proceed directly to surgery without delay to obtain additional non-surgical treatment of the joint problem.
There is no evidence that delaying surgery for any of the additional nonsurgical treatments studied, including physical therapy, walking aids, oral anti-inflammatories, or injections, produces better outcomes, and may burden patients with no apparent benefit.”
Susan M. Goodman, MD, a rheumatologist at the Hospital for Special Surgery and co-principal investigator for the guideline
Another key recommendation is that patients with nicotine addiction or diabetes should delay surgery to achieve either nicotine cessation or reduced use of nicotine products, as well as to allow for better glycemic control.
“For patients with nicotine addiction, there is a potential benefit of delaying total arthroplasty to reduce or stop nicotine use,” said Dr. Hannon. “The patient should be educated about the increased surgical risks associated with nicotine use and ideally engage in nicotine reduction strategies.”
Like many ACR guidelines, a patient committee was consulted in the development of this guideline. The Committee stressed the importance of joint decision-making between the patient and his physician when referring a patient for a full arthroplasty.
“The shared decision-making process should comprehensively discuss the unique risks and benefits of the procedure for the individual patient,” said Dr. Goodman. “Patients with medical or surgical risk factors as described in this guideline should be counseled regarding their increased risk, and preoperative attempts to modify these risk factors should be encouraged through efforts such as losing weight, controlling blood sugar, or quitting smoking.”
A full manuscript of the peer-review guideline has been submitted to the journal and is expected to be jointly published in ACR and AAHKS journals in 2023. A full summary of the guideline recommendations can be found on the ACR and AAHKS websites.
