New 2023 clinical guideline for elective TJA approach in patients with symptomatic moderate-to-severe OA or ON, and failed nonoperative therapy

30 Mar 2023

A new 2023 clinical practice guideline has been established by the American College of Rheumatology (ACR) and the AmericanAssociation of Hip and Knee Surgeons (AAHKS) for the recommendation of elective total hip or knee arthroplasty in patients withsymptomatic moderate-to-severe osteoarthritis (OA) or osteonecrosis (ON), who have also previously failed nonoperative therapy.1The guideline focuses on the optimal timing of undergoing hip and knee total joint arthroplasty (TJA) based on vital patient outcomeswith evidence, such as pain, function, infections, hospitalization, and death.1

Based on the 2019 ACR guideline for the management of OA of the hand,hip and knee, strong recommendations were for lifestyle modifications,such as exercise and weight loss in overweight or obese patients, inaddition to other management for knee OA, such as tibiofemoral bracing,topical nonsteroidal anti-inflammatory drugs (NSAIDs), and intraarticularglucocorticoid injections.2 OA may be classified based on the Tonnis orKellgren-Lawrence radiographic grading scale.1 For example, the Tonnisgrading for hip OA includes 3 progressive degrees of degenerative changesto the hip, in addition to grade 0 (absence of arthrosis at the hip) - grade 1 (slight joint space narrowing, slight joint margin lipping, and slightsclerosis at acetabulum or femoral head), grade 2 (small bony cystspresent, greater joint space narrowing, and moderate femoral headsphericity loss), and grade 3 (most severe, with large cysts, severe jointspace narrowing and femoral head deformity, and avascular necrosis).3 The2023 clinical guideline by ACR and AAHKS highlights the recommendationsfor moderate-to-severe OA or ON of the hip or knee.1

The guideline includes conditional recommendations of when to proceedwith TJA, of which evidence being all graded as low or very low qualitydue to the indirectness.1 The decision to proceed with TJA should be ajoint decision-making process between the physician and patient, wherebythe risks and benefits have been discussed.1 The panel conditionallyrecommends that TJA should not be delayed to pursue other nonoperativetreatment, which includes physical therapy, NSAIDs, ambulatory aids, andinjections.1 According to Dr. Susan M. Goodman, co-principal investigatorof the guideline, there is no evidence that delaying surgery in favor of othernonoperative treatments as mentioned above will improve outcomes, andthat it may instead burden patients in the absence of an explicit benefit.4

Another conditional recommendation is to delay TJA in favor ofnicotine cessation or reduction.1 Dr. Charles P. Hannon, co-literaturereview leader of the guideline, stated that in patients with nicotinedependence, doing so presents a potential benefit, such that thereshould be education for the patient who is on the greater surgicalrisks associated with the use of nicotine, and to encourage nicotinereduction.4 It is also conditionally recommended that TJA is delayedto improve glycemic control in diabetes mellitus patients, althoughthere is no specific measure or threshold suggested based on theliterature review.1 Although TJA is conditionally recommended not tobe delayed for the reasons of obesity, it is suggested that weight lossis highly encouraged in obese patients, with no weight or body massindex (BMI) target requirement.1 Regardless, currently there is a lackof evidence to support the recommendation of losing weight prior toTJA in obese patients.5 Furthermore, it is conditionally recommendedthat TJA is not delayed in patients with severe deformity, bone lossor neuropathic joint.1

In summary, the clinical guideline serves as a recommendation forpatients with radiographically moderate-to-severe OA or ON of thehip or knee, who are indicated for elective TJA following a jointdiscussion with their physician and a lack of success in at least 1 nonoperative therapy.1 Of note, all recommendations have a low orvery low quality of evidence, and are only conditionally recommended,due to the indirect correlation.1 The guideline is, however, basedon the systematic literature review that has taken into account theavailable evidence, clinical expertise and experience, along with thepreferences of patients.1

Get access to our exclusive articles.