Nonoperative Care Including Rehabilitation Should Be Considered and Clearly Defined Prior to Elective Orthopaedic Surgery to Maximize Optimal Outcomes

Abstract

Orthopaedic surgery has revolutionized the expectations for restoration of physical function after musculoskeletal injury and, along with physical therapy, has transformed the limits of recovery. Many orthopaedic procedures have a high success rate for improving quality of life and patient-reported outcomes, yet these procedures carry some level of risk, including postoperative complications. The stepped-care model of health care delivery, when applied to musculoskeletal care, recommends implementing less-intense and lower-risk treatments with known efficacy, such as promotion and education of self-management strategies and physical therapy, before more-invasive and higher-risk treatments such as surgery. This model of managing musculoskeletal disability can improve efficiency of care delivery and reduce medical costs at the health system level. Unfortunately, there is a documented lack of implementing an appropriate course of conservative care, especially physical therapy, prior to surgery across multiple orthopaedic disciplines including sports, spine, and trauma medicine and joint arthroplasty. Failure to respond to nonsurgical treatment has been suggested as a requisite component of the surgical appropriateness criteria, yet practical application can be elusive. Multiple barriers to adequate utilization of conservative treatment exist, including U.S. payment models that increase out-of-pocket expense for patients, negative patient perception of therapy, unreasonable patient expectations from therapy versus surgery, and communication barriers between patient, surgeon, and therapist. Surgeons should ensure that high-quality guidelineappropriate care is delivered early and adequately to their patients. Rehabilitation professionals have a responsibility to deliver high-value care, properly documenting the type and extent of treatment to improve surgical decision-making between surgeons and patients. Criteria to determine appropriateness for surgery should include a standardized and extensive assessment of failed therapies prior to certain elective surgeries. Improved collaboration between surgeons and rehabilitation professionals can result in improved outcomes for patients with musculoskeletal disorders. Level of Evidence: V, expert opinion

Osteoarthritis Literacy and Equity Issues: A Post COVID-19 Analysis and Update

“…Features of osteoarthritis that may be especially important to possibly mitigate are those of joint inflammation, excess weight gain or loss, muscle and bone attrition, nerve damage and impairments of those sensory mechanisms designed to foster joint protection and avert injury, common in vulnerable older adult osteoarthritis populations [23][24][25][26][27][28][29][30][31][32]. As put forth by Hunter et al [33], the appropriate selection and use of evidence-based management options is critical in this regard, but for helping the osteoarthritis client to obtain the full benefits from their treatment recommendations, they have to understand what is needed, and be able to act on these imperatives.…”

"You're stuck in the middle here": A qualitative study of GPs' experiences of managing knee pain attributed to a degenerative meniscal tears

“…The principal reason cited was failure to respond to conservative management. A thorough understanding of what therapies have been tried and failed and the extent of 'buy in' on the patient's behalf is important information to inform GP decision making, before stepping up to more invasive levels of care (31). In other painful musculoskeletal disorders such as hip arthroscopy (32) and knee arthroplasty (33) patients may not receive optimal non-surgical care before being escalated to surgery.…”

Untitled

“…In addition needed possible home based safety modifications, such as ensuring lighting is optimal, may be very challenging to undertake for many in the higher age ranges as well as those with multiple affected joint sites and medical conditions without appropriate assistance and guidance and discussion with the key provider. [40][41][42] However, given that subnormal joint loading is a key factor influencing the osteoarthritis disease process, 43 and may have multiple origins, it seems reasonable to assert that efforts to eliminate the most detrimental forces falling on the affected joint surface, as well as improving the ability of the surrounding osteoarthritis joint tissues, such as the muscles, to absorb stresses, is likely to prove especially helpful for most older moderately impaired healthy adults, including those who require surgery, irrespective of causative mechanisms underpinning this joint disease. 44 Similarly, encouraging periodic, rather than continuous bouts of movements, incorporating safe movement approaches into one's daily routine in place of formal regimented exercise routines that may be challenging and unsafe for some, plus other supplementary efforts designed to optimize a healthy joint state, such as the use of appropriate footwear and splints, plus the adoption of sound nutrition and sleep hygiene practices appears to have considerable merit in efforts to relieve pain, fatigue, and stiffness, particularly during the early disease stages.…”