With an ever-increasing emphasis on value-based medicine, it is important for primary care providers to understand the management of patients with hip and knee arthritis. This group represents a very large portion of the patients under the care of any primary care provider and constitutes the largest diagnosis-based spend for Medicare. This article will review many of the important topics related to the treatment of these patients, including non-surgical procedures that help reduce pain, surgical candidate qualifications and considerations, pros and cons of joint replacement surgery and dental work best practices.
Alternatives to Joint Replacement
It is generally accepted that joint replacement surgery is considered the definitive management for hip and knee arthritis once non-operative treatment options have failed. Non-surgical management options include weight-loss, general conditioning, physical therapy, anti-inflammatories, braces, heat/cold therapy and injections.
Injections, in particular, warrant a firm understanding so that patients can be provided accurate information and have reasonable expectations. There are three broad categories of injections, each with advantages and disadvantages: steroids, hyaluronic acid, and what are broadly referred to as “biologics”.
- Steroids provide very effective but relatively short-term relief of symptoms. They are inexpensive but come at the cost of a detrimental effect on cartilage and other soft tissues. Most surgeons prefer not to give these injections more than a few times a year and they are generally avoided within three months of surgery. At Wake Orthopaedics, we believe the best use of steroid injections is before an event or a trip where the goal is to provide reliable relief of symptoms for a few weeks to months.
- Hyaluronic acid injections provide more variable relief of symptoms but have minimal detrimental effects. These are only FDA approved for the knee and frequently require insurance authorization due to cost.
- “Biologics” represent a broad category of injectables that are frequently derived from plasma, adipose tissue and bone marrow aspirates. These treatments are widely advertised as alternatives to surgery. The mechanism of action for these treatments is relatively poorly understood and they demonstrate varying degrees of efficacy. They are costly and are generally not covered by insurance, so it is important to set appropriate expectations for patients. In a recent review article in Clinical Orthopaedics and Related Research by Rodeo et al., the primary conclusion is that the use of biologics has far outpaced the science.
Surgical Candidate Qualifications & Considerations
When patients fail non-operative management, they often become surgical candidates. It is important to understand that Centers for Medicaid & Medicare Service (CMS) now categorizes primary hip and knee replacement as generally being elective outpatient surgery. Most patients are expected to spend less than “two midnights” in hospitals and a growing proportion are going home the same day from hospitals or surgery centers. Prolonged hospital stays and complications, while uncommon, can result in high costs and sometimes penalties for the treating facility. To this end, it is important that patients be optimized for surgery. Most facilities have an extensive peri-operative pathway to facilitate the process, screen patients for disqualifying conditions and optimize modifiable risks. Patients are generally required to have BMI under 40 or 45, hemoglobin over 10, Hb A1C below 7.5, and stop smoking (if applicable), depending on the facility and other risk factors. If a patient’s risk factors fall outside of these parameters, that is often a hard stop to surgery. It is therefore important to make all efforts to optimize patients and manage expectations when considering referral for potential joint replacement surgery. For complex patients, a multi-disciplinary approach, involving anesthesia, cardiology, hematology and other subspecialists is often necessary.
Developments in Joint Replacement Surgery: Pros and Cons
Hip and knee replacement surgery are considered some of the most successful in all of medicine with success rates in the mid to high 90 percent range. These surgeries reliably improve patient’s pain and function. They also significantly decrease societal cost associated with prolonged non-operative treatment of debilitating arthritis and lack of ability to work and participate in healthy activities. Complication rates are low and include infection, deep vein thrombosis (DVT) and implant failure, all of which are considered to have risk of one percent or less at most high-volume facilities with experienced surgeons.
Developments in hip and knee replacement surgery have included patient optimization pathways, multi-modal pain management, more durable materials with lifespan likely exceeding 20 years and evolving techniques. Two topics that patients often ask about are the use of robotics and custom implants. There has been a steady increase in the use of robotic-assisted surgery. The primary benefit of these techniques has been a reduction in outliers, regarding implant alignment. There is an increased cost to these surgeries associated with required pre-operative imaging with CT or MRI as well as the robot itself. Improvement in patient function or other measures of success have been more difficult to demonstrate. Custom implants also come at a higher cost that often result in direct-to-patient charges. These also have not demonstrated clear advantages regarding patient outcomes.
Following surgery, patients will generally experience improvement in pain and function for a year or more, with much of that occurring within the first three months. Time out of work, beyond standard three-month FMLA, is usually not required even for jobs that require prolonged standing. Many patients will return to work much earlier. Long-term, patients can participate in most activities including many sports although high-impact exercise such as running is not encouraged. There are some small restrictions regarding bending over and pivoting with hip replacement, but these are not limiting for most patients.
Dental Work After Joint Replacement: What You Need to Know
The question of antibiotic prophylaxis after joint replacement surgery is often a point of confusion and anxiety for patients, physicians and dentists, and should be addressed. Most surgical procedures have pre-operative antibiotics administered and therefore do not require additional prophylaxis. Dental procedures are an outlier in that regard. Any dental procedure results in a transient bacteremia that can cause a hematogenous joint replacement infection. However, because the incidence is very low, the data is relatively poor and the position statements by the American Dental Association (ADA) and American Board of Orthopaedic Surgery (ABOS) have changed about every decade. The current Best Practice Guideline recommends that most patients do not require antibiotic prophylaxis for dental work after the first year but there is a decision tree. Amoxicillin is the first line agent with alternatives being cephalexin, doxycycline and azithromycin. Clindamycin is not recommended due to the risk of C. difficile. The ADA recommends that prescriptions for antibiotic prophylaxis be written by an orthopaedic surgeon.
In conclusion, hip and knee replacement are tremendously successful surgeries intended for patients that have failed other forms of management for their arthritis. These surgeries restore patient’s functionality and have long-term health benefits. Complications are uncommon but can be costly and it is important for patients and primary care providers to have appropriate expectations and knowledge of these procedures to optimize the opportunity for excellent long-term outcomes.
About Curtis Hanson, MD
Dr. Curtis A. Hanson is a board-certified, fellowship-trained orthopaedic surgeon who specializes in disorders of the knee, including sports injuries, arthritis and trauma. His specialty training includes arthroscopic surgery, joint replacement and limb realignment procedures.
He attended the University of Arizona, Tucson for his undergraduate degree and The University of Texas Medical Branch for his medical degree. He completed his orthopaedic surgery residency at the University of North Carolina at Chapel Hill, where he was named Resident of the Year by the WakeMed Department of Orthopedics and was awarded the Resident Research Award & Resident Teaching Award by the UNC Department of Orthopedics.
Dr. Hanson’s research has been published in the American Journal of Sports Medicine, as well as the Journal of Hand Surgery. He has also presented his research to the North Carolina Society for Hand Surgery and completed a fellowship in knee surgery at Royal North Shore Hospital with the Sydney Orthopedic Research Institute in Sydney, Australia.
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