The Devil Is in the Detail: Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty

Abstract

What is the optimal timing for hip or knee total joint arthroplasty (TJA) in people with symptomatic and moderate-to-severe radiographic osteoarthritis (OA) or osteonecrosis (ON) who have not responded to nonoperative treatments? The new clinical practice guidelines by the American College of Rheumatology (ACR) and American Academy of Hip and Knee Surgeons (AAHKS) (1), published in this issue of Arthritis Care & Research, sought to provide evidence-based recommendations to address this question. This is an important topic. With rising prevalence of symptomatic knee OA, including at younger ages, the rates and associated costs of TJA are skyrocketing (2). Policies that restrict access to TJA have emerged to combat rising TJA costs, ideally while also ensuring access and quality of care. The new recommendations aim to inform shared decision-making (SDM) between patients and clinicians regarding TJA while also challenging health insurance coverage policies that restrict timely access to TJA. The conditional recommendations are based on low or very low-quality evidence. Thus, they provide little substance to guide TJA shared decision-making, other than underscoring the importance of SDM in the context of TJA. However, they do serve to highlight the tremendous burden on patients imposed by advanced, symptomatic hip and knee arthritis and the injustice of imposing undue delays to receipt of TJA to candidates deemed "appropriate" for surgery.In essence, the guideline recommends that people who are deemed "appropriate" for TJA at surgical consultation should not have their surgery delayed for additional trials of nonoperative treatments, e.g., physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. At face value, this seems reasonable. But, as is often the case, the devil is in the details. Whether or not these recommendations will shift coverage policy makers' stance is unclear for the following reasons:First, the authors are careful to state, and restate, that their recommendations do not apply to patients who are not