The Arthritis Newsletter

Fall 2014

Joint Replacement: When is it Appropriate?

By Gerry Sheanh


Dr. Deborah Marshall details criteria for determining the appropriateness of total hip or total knee replacement.


Arthritis Research Centre scientist Dr. Deborah Marshall, along with ten other researchers across Canada, has been involved with a multi-disciplinary research study entitled Defining patient appropriateness for total joint arthroplasty of the hip and knee. Dr. Marshall took time to share the study’s findings with the Arthritis Newsletter.



Why this study?


Surgical waitlists are long and this study was undertaken to better identify which cases are appropriate for Total Joint Arthroplasy (TJA) and which are less urgent. According to Dr. Marshall, there are some clear trends emerging.


“We are seeing TJAs at younger ages, even in the face of rising demand for and the cost of health care. It also appears that the severity of the disease seems to be decreasing. There is a real need for TJAs, and it is important that we come at that from multiple perspectives.”



What are the primary factors that would indicate a real need for joint replacement?


“We had discussions with orthopedic surgeons to get their perspectives on the demonstrated need, and we also talked to patients to make sure we got their input and perspectives, So there’s a whole series of focus groups, interviews and literature reviews that led into this. Another thing we did was to speak to decision makers. The goal was to bring all of that together to form a universal definition that considers all viewpoints.


“In the end, the decision makers said it’s really the surgeons and the patients who are really going to guide the criteria. And there are three factors: 1) There needs to be evidence of arthritis on examination of the joint; 2) Patients have to report that their symptoms have a negative effect on their quality of life; and 3) Appropriate trials of non-surgical interventions have been tried.


“Surgery is for the end stage of the disease, when other things aren’t working. Surgery is not the first point of recourse. There are lots of other things you can do. There is exercise, diet and medications that can help manage the pain and allow people to function very well. The bottom line is that you don’t want to have surgery until you really need it.”



What indicators might tell the surgeon that the patient is ready, willing and able to undergo surgery?


“There are a couple of factors. The first is that the patient’s medical state. The patient must be medically stable and a good candidate. The patient does have to have an assessment by the physician to say that generally they are good candidates for surgery. We don’t want to endanger anybody.


“Having any kind of surgery does require getting ready, doing what we call pre-hab. Exercise is important to keep the joint strong and to make sure the muscles around the joint are in good shape to support it. After the surgery, there is some hard work that people need to exercise and get the muscles back in shape. Overall, the surgeon needs to know that the patient is ready, willing and able to do the necessary work to prepare and, also, to recover well.”



The patient needs to have realistic expectations. How can a surgeon evaluate patient expectations?


“People have different expectations about what surgery is going to do. Pain and function are big issues. There are two examples:


  • The first would be someone who kneels, like a nun. That’s an important part of that person’s life. Having a knee replacement isn’t conducive to doing a lot of kneeling. So, if the expectation is “the pain will be gone, and I can kneel”, that isn’t a realistic expectation.


  • Sometimes there is an expectation by a patient that if you fix the joint, you will become some sort of bionic man and run marathons and be better than before. That really isn’t true, either, so doctors and patients need to fully explore expectations and realities.”


What are the risks of joint replacement surgery?


“First, the baseline is that any surgery has risks associated with it, so the patient needs to be aware of that. With joint replacement, surgeries are highly successful, but the reality is that the way in which the joints are placed with respect to the angle is really important. Sometimes, if it is not set the right way, the surgeon needs to go in and do a revision, or an adjustment. Sometimes, the fit of the joint isn’t as good as it should be and might need to be adjusted.


“There are also procedures called resurfacing where they aren’t replacing both components, and sometimes you get metal on metal. There have been reports that there may be metal fragments or iron released into the blood. This is a new thing, but is being monitored.”



Finally, how useful is a checklist of determining appropriateness for joint replacement?


“In terms of a checklist, it is really a way to engage the surgeon and patient in a conversation, and to think about the aspects of what makes these surgeries appropriate. Using a broad definition of what we’ve talked about, we have to 1) make sure that doctor and patient expectations are aligned; 2) make sure the patient is ready and willing to undergo the surgery; and 3) make sure the patient meets the medical criteria for undergoing surgery. 


“In the end, we want a situation where the benefits to the patient are always going to outweigh the risks.”


Reference: Hawker GA, Sanmartin C, Marshall DA, Conner-Spady B, Boem E, Loucks L, Henniger A, Dunbar M, DeCoster C, Pomey M-P, Noseworthy T. Defining patient appropriateness for total joint arthroplasty of the hip and knee. Osteoarthritis Cartilage 2014 April 22 (Suppl) S384.

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