2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate‐to‐Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

Abstract

ObjectiveTo develop evidence‐based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient‐important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate‐to‐severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).MethodsWe developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.ResultsThe panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.ConclusionThis guideline provides evidence‐based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate‐to‐severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient‐important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Healthcare disparities: patients’ perspectives on barriers to joint replacement

“…Therefore, the barriers for utilization of joint replacement are related but not limited to the procedure for joint replacement but also to the disparities that exist across medical care for chronic conditions. Despite the recommendation of the American College of Rheumatology/American Association of Hip and Knee Surgeon Guideline advising against strict cutpoints for medical conditions [ 42 ], poor control of chronic conditions may make surgeons less likely to offer these procedures to these patients until they achieve better glycemic control or better weight [ 43 , 44 ], while many of them lack the access or best resources to achieve those goals.…”

Efficacy of virtual reality exercise in knee osteoarthritis rehabilitation: a systematic review and meta-analysis

“…The fundamental objectives within clinical treatment paradigms entail alleviating pain, slowing disease progression, and enhancing knee joint functionality ( Hunter and Bierma-Zeinstra, 2019 ). For severe KOA cases, intervention measures typically encompass single-joint or total knee arthroplasty ( Katz et al, 2021 ; Hannon et al, 2023 ), despite the considerable economic burden and postoperative challenges associated with surgical modalities. This issue is particularly pronounced in the elderly population, as postoperative persistent pain and inadequate recovery are common dilemmas ( Old et al, 2017 ), further exacerbated by the potential pain-weakness-pain vicious cycle.…”