Delaying primary arthroplasty compromises outcome

By Juliana Brandys

Although there are no firm guidelines for when primary arthroplasty should be performed, the authors of podium presentation 001 conclude that waiting too long compromises optimal outcomes.

In this Level II prospective cohort study, researchers followed a group of 62 patients who had a unilateral total hip replacement and 65 patients who had total knee replacement. Patients were selected from a joint registry maintained by the senior author and had a mean age of 64.5 years (14.2 years); 68 percent of the sample was female. Assessment tools included the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), the Short Form 36 (SF-36) and the Quality of Well Being (QWB) index.

Patients with preoperative WOMAC scores less than 51 points (severe or extreme functional impairment) were grouped in a delayed-presentation (DP) category. Patients with mild or moderate functional impairment (WOMAC scores 51 points or greater) made up the remaining cohort (RC) group. All surgeries were performed by the senior author following a conservative treatment protocol prior to surgical intervention. Age and gender were covariates in repeated measures analyses from preoperative to 3-year post-operative follow-up.

For both groups, the greatest improvement of perceived function and pain occurred between the presurgical visit and the 1-year follow-up, although the DP group did not improve postoperatively to the same magnitude as the RC group. After 3 years, the DP group consistently performed worse overall. For example, at 3-year follow-up, the DP group had QWB score of 0.530 [ SE 0.01], while the RC group had QWB score of 0.592 [0.006]; WOMAC scores among the DP group averaged 16.7 [1.9] compared to 29.9 [4.1] among the RC group.

With the number of primary total hip and knee replacements estimated to increase to more than 748,000 per year by 2030, optimizing the timing of joint arthroplasty could improve surgical outcomes and reduce overall costs. As the authors point out, “In most reconstructive surgery programs, the surgeons are trained to wait ‘as long as possible’ until offering a joint replacement to a patient.” This study, however, “presents clear evidence that this advice may not be the wisest. Waiting too long definitely produces suboptimal outcome…early surgical intervention may result in better surgical outcomes that endure for years.”

The authors suggest using larger studies to evaluate the responsiveness of clinical tools and using randomized clinical trials to identify optimal surgical timing for patients with end-stage arthritis.

The authors include Carlos J. Lavernia, MD; Michele D’Apuzzo, MD; Victor H. Hernandez, MD; Mark D. Rossi, PhD; and David Lee, PhD—all of Miami. Dr. Lavernia received institutional support from Mercy Hospital, Zimmer and the Arthritis Surgery Research Foundation, Inc.; he also serves as a consultant to Zimmer and receives royalties from the company.

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