Objectives
- Determine if appropriate non-surgical care has been accessed and completed
- Be able to discuss with patients OA and management options using appropriate language and communication
- Be able to explain to patients different surgical options and inappropriate surgical options as per current guidelines
- Understand criteria for when is appropriate to refer and not appropriate to refer for orthopaedic opinion for surgical management
- Understand impact of co-morbidities on surgery and potential complications
- Be able to identify potential predictors of poor outcome of surgery
- Be able to outline to patients potential risks and complications from arthroplasty
- Be able to explain to patients overall average success rate and outcomes of arthroplasty, including revision rates and average longevity of arthroplasty
- Know the evidence for surgery (Arthroplasty and Arthroscopy) compared with alternative treatment (e.g non surgical / placebo)
Benefits of surgery vs. exercise
Exercise:
Since 2002, there has been strong evidence for exercise therapy and that it is effective for knee OA. It has been proven to reduce pain and improve physical functioning.
Exercise is also safe for anyone with OA regardless of their severity (but co-morbidities must also be considered). It can be aerobic, resistance, neuromuscular, aquatic or mind-body (tai-chi, yoga); they all have different benefits.
Current evidence has recommended individuals with OA to have at least 12 sessions of supervised exercise. However, individual, class-based and home exercise programs can all improve pain and function.
Surgery:
There is greater improvement in KOOS score with TKR + exercise vs. exercise alone. However
- up to 24% of patients exeprience serious adverse events (Skout et al., 2015)
- Approximately 20% of patients experience ongoing pain and dissatisfaction (Beswick et al., 2015; Gunaratne et al., 2017; Bourne et al., 2010).
Risk factors for surgery
Post-Operative Outcome:
There are several risk factors that can predict the outcome for the patient post-operatively. Lewis et al. 2014, and McGrory et al., 2016 listed these as risk factors for poor outcome after surgery:
However, there is also some evidence that risk of revision is higher in younger patients.
Post-Operative pain:
Depression is a strong predictor of post-operative pain and has been linked to:
- Decreased pain tolerance
- Increased postoperative infection (as depression has an impact on the body’s immune response)
- Mortality
TKR patients with pre-operative anxiety and/or depression had 6 times higher risk of dissatisfaction with long term post-operative outcomes and had a longer length of stay by 1 day comparted to patients without depression and anxiety.
Post-Operative complications:
Click on the info button below to learn more about the risk factors that can contribute to post-operative complications (McGrory et al., 2016; Edwards et al., 2018):
Selecting patients for surgery
The criteria for TKR :
According to Adie et al (2019), the minimum requirement for a TKR are:
- Intractable pain affecting quality of life
- Severity of pain suggests potential benefits of surgery outweigh the risks
- Radiographically evident knee osteoarthritis (KL Grade 3 or 4)
- Other signs including stiffness, instability and deformity to which symptoms can be attributed.
More severe radiographic changes are most likely to have substantial gains in pain relief and improved function as a result of TKR (Dowsey et al., 2012).
Medication, lifestyle factors and other considerations
Other factors to consider when deciding whether patients are appropriate for surgery are:
Victorian Musculoskeletal Clinical Leadership Group
Victorian Model of Care for Osteoarthritis of the Hip and Knee (2018)
Reference:
Royal Australian College of General Practitioners
Guideline for the management of knee and hip osteoarthritis (2nd edition) (2018)
Reference:
S. Adie, I. Harris, A. Chuan, P. Lewis, J. M. Naylor
Medical Journal of Australia (2019)
Selecting and optimising patients for total knee arthroplasty
Reference:
R.B. Bourne, B. M. Chesworth, A. M. Davis, N. N. Mohamed, K. D. J. Charron.
Clinical Orthopaedics and Related Research (2010)
Patient satisfaction after total knee arthroplasty: who is satisfied and who is not?
Reference:
B. J. McGrory, K. L. Weber, D. S. Jevsevar, K. Sevarino
American Academy of Orthopaedic Surgeons (2016)
Surgical management of osteoarthritis of the knee: Evidence based guideline.
Reference:
B. Antonelli, A. F. Chen
Arthroplasty (2019)
Reducing the risk of infection after total joint arthroplasty: preoperative optimization
Reference:
National Institute for Health and Care Excellence (2014)
Osteoarthritis Care and Management in UK
Reference:
R. A. C. Siemieniuk, I. A. Harris, T. Agoritsas, R. W. Poolman, R. Brignardello-Petersen, S. Van de Velde, R. Buchbinder, M. Englund, L. Lytvyn, C. Quinlan, L. Helsingen, G. Knutsen, N. R. Olsen, H. Macdonald, L. hailey, H. M. Wilson, A. Lydiatt, A. Kristiansen
British Medical Journal (2018)
Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline.
Reference:
Strong evidence exercise therapy is effective in knee OA; known since 2002.
Strong evidence exercise:
-reduces pain
-improves physical functioning
Exercise is safe, although consider co-morbidities
Main adverse event with exercise-flare of pain
Type of exercise can be aerobic, resistance, neuromuscular, aquatic or mind-body (e.g. tai chi, yoga) -all have benefits
Recommended at least 12 sessions of supervised exercise
Individual, class based and home programs of exercise all improve pain and function.
Surgery:
Outcomes: Greater improvement in KOOS with TKR + exercise compared to exercise alone
-TKR
-up to 24% of patients experience serious adverse event (Skou et al., 2015)
-approx 20% of patients experience ongoing pain and dissatisfaction (Beswick et al., 2015; Gunaratne et al., 2017, Bourne et al., 2010)
For poor outcome after surgery: (Lewis et al. 2014; McGrory et al., 2016)
- Catastrophising, mental health issues (depression and anxiety)
- High preoperative knee pain,
- Poorer levels of pre-operative function
- Pain at other sites/chronic pain conditions
- Obesity
- Some evidence clinical results inferior in younger patients
Depression is a strong predictor of postoperative pain and has been linked to decreased pain tolerance and increased postoperative infection (has an impact on body’s immune response) and mortality. TKR patients with preoperative anxiety and/or depression had 6 times higher risk of dissatisfaction with long-term postoperative outcomes and had a longer LOS by 1 day compared to patients without depression or anxiety
For complications after surgery: (McGrory et al., 2016; Edwards et al., 2018)
- Diabetes -higher risk of deep infection, impaired wound healing, DVT, aseptic loosening
- Liver problems including cirrhosis and hepatitis C
- Cardiac issues-previous MI and heart failure most strongly associated with mortality post TKR. Heart failure and valvular disease (particularly aortic stenosis) represent high risk of peri-operative cardiac mortality-should be referred for specialist assessment
- COPD -higher risk of respiratory complications
- Chronic kidney disease (associated with more co-morbidities; have higher risk of superficial wound infection and 90 day readmission rate (Miric et al., 2014)
- Obesity -smaller improvements, increased rate of adverse events, higher re-admission rate, higher prosthetic infection and revision rate; higher DVT rate (Dowswey et al., 2010; Kerkhoffs et al. 2012).
Some services in Australia have a policy of not offering joint replacement to patients with BMI >40kg/m2 - Malnutrition
- Opioid use
- Smoking (higher risk of any post-operative complication and peri-operative mortality). At least 4 weeks of smoking cessation required to reduce surgical complications
- Poor dentition
- Peripheral vascular disease -higher risk of 90 day mortality and deep infection; would healing problems and risk of arterial injury
- Infection e.g. staphylococcus aureus colonization
- Neurocognitive
- Psychological and behavioural problems
- Rheumatoid arthritis- impacts immune system function and adversely affects wound healing. The immunosuppression prescription medications often given to rheumatoid arthritis patients also contributes to increased infection risk
Criteria for TKR
Summary: severe pain present for at least 3/12
severe radiological change (KL score Gr 3 or 4)
symptoms attributable to knee OA
tried non-operative management for at least 3/12
Minimum requirement: “intractable pain affecting quality of life”, severity of pain suggests potential benefits outweigh the risks, radiographically evident knee osteoarthritis (KL GR 3 or 4), and other signs including stiffness, instability and deformity to which the symptoms can be attributed. (Adie et al., 2019)
More severe radiographic changes are most likely to have substantial gains in pain relief and improved function as a result of TKR (Dowsey et al., 2012)
-Anti-coagulants
-immunosupression
-Smoking: not just anaesthetic risk; also have significantly more postoperative complications and infection-related loosening with greater rates of revision surgery
-Alcohol intake: excessive alcohol intake associated with increased immediate postoperative complications such as stroke, surgical infections, blood clots, delirium, pneumonia, arrhythmia, gastrointestinal bleeding, and shock, as well as longer LOS, and behavioral issues. Excessive alcohol consumption is associated with organ dysfunction, cardiac insufficiency, and immunosuppression -hence higher risk of infection. Increased postoperative deep venous thrombosis and increased 1 year mortality rates.
-Social situation/supports
-Allergies-including metal, latex, tapes, medication
-If have diabetes, check BSL are controlled.
-dental hygeine-particuarlly if smoker, malnurished or alcohol intake
Victorian Musculoskeletal Clinical Leadership Group. (2018). Victorian Model of Care for Osteoarthritis of the Hip and Knee. Retrieved from Melbourne: http://www.acsep.org.au/content/Document/MOVE_MoC_WebVersion_WithHyperlinks.pdf
Infographic from BJSM re exercise versus arthroscopy for meniscal tears
Add Eva’s video re mensical tears and arthroscopy GLAD website
? Add video of TKR
Australian Commission on Safety and Quality in Health Care knee osteoarthritis -consumer fact sheet
Australian Commission on Safety and Quality in Health Care knee osteoarthritis -clinician fact sheet
Australian Commission on Safety and Quality in Health Care knee osteoarthritis-infographic
?? podcast from joint action info podcast David Hunter interviewing Peter Choong and Michelle Dowsey: https://www.jointaction.info/podcast/episode/615af58f/should-i-have-my-joint-replaced
Decision aid tools-good responders, middle group and poor responders-and what can change e.g. obesity, mental health