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Determining who should be referred for total hip and knee replacements

Nature Reviews Rheumatology volume 9, pages 351–357 (2013)Cite this article

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Abstract

Total hip and total knee replacements (THR and TKR respectively), the definitive treatments for end-stage arthritis, are both safe and extremely successful in relieving pain and improving function. However, physicians who care for patients with chronic hip and knee arthritis are often the 'gatekeepers' to total joint replacement (TJR) procedures as they select patients for referral to an orthopaedic surgeon to be considered for arthroplasty. Currently, no evidence-based criteria exist to guide physicians in this decision-making process, and this situation raises the possibility that conscious or unconscious biases may influence referral patterns, potentially leading to systematic inequities regarding which patients are eventually offered TJR. This article reviews why TJRs are particularly important procedures, and highlights common misperceptions among physicians regarding TJR risk assessment. This article also underscores the benefits of ongoing discussion regarding TJR with all patients with moderate-to-severe chronic hip or knee pain and disability.

Key Points

  • Hip and knee replacements are the definitive treatments for end-stage arthritis, providing excellent pain relief with minimal risks

  • Physicians who care for patients with chronic hip and knee arthritis function as 'gatekeepers,' determining who is referred for surgical consultation

  • Conscious or unconscious biases could influence referral patterns, leading to systematic inequities regarding who is considered for surgery

  • Data that should be considered when physicians contemplate the referral of patients for consideration of joint replacement are discussed

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Figure 1: Framework for a rational approach to referral for TJR.
Figure 2: Pain and poor function do not determine who gets a joint replacement; clearly, other factors are at play in the decision-making process.
Figure 3: A wide range of WOMAC scores (i.e. variable pain and function) are found among patients having THR.
Figure 4: As osteoarthritis progresses, patients accommodate to increased pain and dysfunction and accept a lower quality of life.

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Acknowledgements

Thanks to Stuart Davidson for his help with graphics.

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    Lisa A. Mandl

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Mandl, L. Determining who should be referred for total hip and knee replacements. Nat Rev Rheumatol 9, 351–357 (2013). https://doi.org/10.1038/nrrheum.2013.27

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