When to Have a Joint Replacement
A proposed guideline offers recommendations for timing of joint replacement surgery.
By Linda Rath | April 12, 2023
The American College of Rheumatology and American Association of Hip and Knee Surgeons have proposed a new guideline about the best time for total hip and knee replacement surgery for patients with advanced osteoarthritis or osteonecrosis, a serious condition that can lead to the death of bone tissue.
The organizations say the guideline is needed because it’s not clear whether patients benefit when surgery is postponed as they continue trying nonsurgical treatments that haven’t been helpful, including physical therapy, nonsteroidal anti-inflammatory drugs, gait aids and corticosteroid or hyaluronic acid injections. The recommendations in the guideline apply to patients with moderate to severe pain or dysfunction who have tried nonsurgical therapies at least once. The final guideline is expected this summer after peer review is complete.
The proposed guideline also tackles the question of whether people should have surgery if they have obesity. Some research shows that patients with a higher body mass index (BMI) have more complications and poorer outcomes than normal-weight people. Yet a 2021 analysis of nearly half a million patients in a United Kingdom joint replacement registry found little difference in outcomes based on weight.
The guideline was produced by a panel of rheumatologists, orthopedic surgeons and patients who based their conclusions on a combination of medical research, clinical experience and patient values and preferences. A core principle is that the decision to have surgery should be equally shared by doctors and patients and the particular risks and benefits for each patient should be fully discussed.
Although there was agreement on the recommendations, all are conditional, meaning the evidence is low quality or not definitive enough to make a strong determination one way or the other.
Key recommendations include:
The American College of Rheumatology and American Association of Hip and Knee Surgeons have proposed a new guideline about the best time for total hip and knee replacement surgery for patients with advanced osteoarthritis or osteonecrosis, a serious condition that can lead to the death of bone tissue.
The organizations say the guideline is needed because it’s not clear whether patients benefit when surgery is postponed as they continue trying nonsurgical treatments that haven’t been helpful, including physical therapy, nonsteroidal anti-inflammatory drugs, gait aids and corticosteroid or hyaluronic acid injections. The recommendations in the guideline apply to patients with moderate to severe pain or dysfunction who have tried nonsurgical therapies at least once. The final guideline is expected this summer after peer review is complete.
The proposed guideline also tackles the question of whether people should have surgery if they have obesity. Some research shows that patients with a higher body mass index (BMI) have more complications and poorer outcomes than normal-weight people. Yet a 2021 analysis of nearly half a million patients in a United Kingdom joint replacement registry found little difference in outcomes based on weight.
The guideline was produced by a panel of rheumatologists, orthopedic surgeons and patients who based their conclusions on a combination of medical research, clinical experience and patient values and preferences. A core principle is that the decision to have surgery should be equally shared by doctors and patients and the particular risks and benefits for each patient should be fully discussed.
Although there was agreement on the recommendations, all are conditional, meaning the evidence is low quality or not definitive enough to make a strong determination one way or the other.
Key recommendations include:
- Surgery shouldn’t be postponed in favor of nonsurgical treatments that haven’t proved effective after one or more trials.
- A high BMI shouldn’t prevent or delay surgery, but weight loss is strongly recommended for people who are overweight or obese.
- Surgery should be postponed until a patient can reduce or quit smoking due to the risk of serious complications.
- Surgery should be postponed until blood sugar is well-controlled in people with diabetes due to the risk of serious complications and poor healing.
- Patients with bone loss, severe deformity or degenerative joint disease should not postpone surgery.
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