2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate‐to‐Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective
Authors: Hannon Charles P. , Goodman Susan M. , Austin Matthew S. , Yates Adolph , Guyatt Gordon , Aggarwal Vinay K. , Baker Joshua F. , Bass Phyllis , Bekele Delamo Isaac , Dass Danielle , Ghomrawi Hassan M. K. , Jevsevar David S. , Kwoh C. Kent , Lajam Claudette M. , Meng Charis F. , Moreland Larry W. , Suleiman Linda I. , Wolfstadt Jesse , Bartosiak Kimberly , Bedard Nicholas A. , Blevins Jason L. , Cohen‐Rosenblum Anna , Courtney P. Maxwell , Fernandez‐Ruiz Ruth , Gausden Elizabeth B. , Ghosh Nilasha , King Lauren K. , Meara Alexa Simon , Mehta Bella , Mirza Reza , Rana Adam J. , Sullivan Nancy , Turgunbaev Marat , Wysham Katherine D. , Yip Kevin , Yue Linda , Zywiel Michael G. , Russell Linda , Turner Amy S. , Singh Jasvinder A. 
Published: September 2023

Objective

To develop evidence‐based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient‐important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate‐to‐severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

Methods

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

Results

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

Conclusion

This guideline provides evidence‐based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate‐to‐severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient‐important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.