Factors influencing surgeons' decisions in the indication for total joint replacement in hip osteoarthritis in real life

Abstract

Objective. To evaluate factors influencing orthopedic surgeons' decision in daily practice to recommend or not recommend total hip arthroplasty (THA) in patients with hip osteoarthritis (OA). Methods. General practitioners and rheumatologists were asked to prospectively include 1 patient with hip OA for whom a consultation with an orthopedic surgeon was planned to determine whether or not THA was indicated. The following variables were obtained: age, sex, occupational status, body mass index, comorbidities, duration of hip OA, patient's global assessment, Western Ontario and McMaster Universities Osteoarthritis Index pain and functioning subscale scores, New Zealand score, quality of life, and structural parameters on radiographs. The surgeon's decision was obtained by followup questionnaires. Statistical analysis evaluated potential predictors of the surgeon's decision (indication for THA within the next 6 months, yes or no) using univariate and multivariate analysis. Results. A total of 558 patients were included (249 men, 300 women, mean age 68.4 years, mean disease duration 4.9 years). The surgeon's decision, available for 486 patients, was to prescribe THA in 60.7% of patients. On multivariate analysis, the variables related to the surgeon's decision were the presence or absence of severe cardiovascular disease, Short Form 12 physical subscale score, and amount of joint space narrowing. Conclusion. While the amount of structural degradation is only slightly or not at all taken into account in numerous criteria and/or recommendations on indications for THA, it is an independent predictor of the surgeon's decision in daily practice. Such a discrepancy should be evaluated and understood in further studies.

The role of pain and functional impairment in the decision to recommend total joint replacement in hip and knee osteoarthritis: an international cross-sectional study of 1909 patients. Report of the OARSI-OMERACT Task Force on total joint replacement

“…This indicates that the level of symptoms in this population was not the only driver for such a TJR indication 30-32 . Possibly, the surgeons paid greater attention to the radiographic severity than to the symptom levels 10, 27, 33 and several studies have indicated a discordance between radiographs and symptoms in lower-limb OA 27, 34-37 . In the present study however, stratifying the analyses on radiographic severity did not modify our conclusions.…”

“…We considered that if surgery was recommended or if the surgeon considered symptoms were severe enough for surgery (although because of comorbidity 10 or patient refusal 9 , the patient was not referred for surgery), a state of indication for TJR was attained. However, we did not collect data regarding actual carrying-out of surgery in these patients, which may differ widely 2-10 .…”

“…Performance of TJR is a measure of utilization and not of a health state. Numerous non-health related factors have been shown to influence utilization including patient race, ethnicity, income, activity level and preferences among others, and other non-musculoskeletal health factors influence the decision to undergo TJR including comorbidity 2-10 . Thus, a better alternative might be to change “time to TJR” to “time to fulfill the criteria for TJR” 11 .…”

Validity and responsiveness of radiographic joint space width metric measurement in hip osteoarthritis: a systematic review

“…While arthroplasty is usually performed in patients with advanced symptomatic and structural disease, surgeons have reported that they are weakly or moderately influenced by X-rays when deciding whether joint replacement is indicated or not 29,30 . It has also been shown that in clinical practice, JSW is a major predictive factor of the decision to perform hip replacement 31 . Thus, JSW and joint replacement might not be truly independent.…”

GP referral of patients with osteoarthritis for consideration of total joint replacement: a longitudinal study

“…There is evidence of wide variation in orthopaedic surgeons' decision for TJR, 36,37 and a lack of consensus on patient characteristics for TJR. 11 Currently in the UK, there is little guidance about who should have TJR.…”