Background
Methods
Search strategy
Selection of publications
Data extraction
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➢ Ia evidence from meta-analysis of randomized controlled trials
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➢ Ib evidence from at least one randomized controlled trial
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➢ IIa evidence from at least one controlled study without randomization
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➢ IIb evidence from at least one well-designed quasi-experimental study
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➢ III evidence from at least one non-experimental descriptive study, such as comparative studies, correlation studies, and case-control studies
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➢ IV evidence from expert committee reports or opinions or clinical experience of respected authorities or both
Quality of the guidelines
Results
Guidelines
Guideline | Year of publication | OA specific | Evidence | Indication criteria | ||||
---|---|---|---|---|---|---|---|---|
Pain | Function | Radiological changes | Failed or futile conservative therapy | Other criteria | ||||
Knee | ||||||||
British Orthopedic Association [24] | 2013 | Yes | Level IV | Moderate or severe pain | KL > III in at least one of the knee joints compartments | Yes | Patients outside these criteria may still be considered for surgery but a second opinion/ recorded case discussion is advised. Cases focus on patients without pain (primary indication) but who present with: functional disability in the presence of end stage cartilage disease. Progressive deformity of the knee (varus/valgus) with functional disability. | |
Eular [19] | 2003 | Yes | Level IV | Refractory pain | Disability | Radiological evidence of knee OA | ||
NZ [40] | ? | No, but based on BOA guidelines which is OA specific | Level IV | Severe pain | Disability | Radiological changes | Yes | Occasionally there may be an indication to replace a knee because of progressive deformity and/or instability, and pain may not necessarily be the most significant factor. Where comorbidities exist risk benefit considerations may rule out the operation in an individual patient. |
Hip | ||||||||
British Orthopedic Association [41] | 2013 | No | Level IV | Inadequately controlled by medication | Restriction in function | Narrowing of the joint space | Yes | Compromised quality of life |
Eular [20] | 2005 | Yes | Level IV | Refractory pain | Disability | Radiological evidence of hip OA | ||
NOV [42] | 2010 | No | Level IV | Pain | Function loss | Radiological changes | Yes | Younger age and obesity are relative contraindications. Delay of surgery in high age is not advisable in view of reduced functional outcome and increased mortality. In addition when progressive loss of function (with or without contractures) predominates over pain, surgery should not be delayed in view of reduced postoperative functional outcome. |
NZ [43] | ? | No | Level IV | Significant pain | Disability | Radiological changes | Yes | |
Joint | ||||||||
OARSI (hip-knee) [3] | 2008 | Yes | Level IV | No adequate pain relief | No adequate functional improvement | Yes | ||
NICE [23] | 2014 | Yes | Level IV | Pain | Stiffness and reduced function | Yes | Substantial impact on quality of life |
Indication criteria concerning THA and TKA
Quality of the guidelines
Publications
Reviews
Author | Year of publication | Study group region | Systematic review | Evidence | Indication criteria | ||||
---|---|---|---|---|---|---|---|---|---|
Pain | Function | Radiological changes | Failed or futile conservative therapy | Other criteria | |||||
Knee | |||||||||
Hanssen [34] | 2000 | USA | No | Level IV | As the indications continue to expand, the decision to proceed with total knee arthroplasty in young, active patients’ needs to be individualized after careful consideration of alternatives. | ||||
Kirschner [44] | 2011 | Germany | No | Level IV | Pain during activities or rest | Radiologic evidence of arthritis | |||
van Manen [30] | 2012 | USA | No | Level IV | Severe, refractory knee pain, often at night | Difficulty with activities of daily living; decreased mobility | Radiographic evidence of primary or inflammatory degenerative joint disease: Narrowed joint space; osteophytes (spurring) and bone cysts; squaring of condyles; bone sclerosis | Failure to respond to conservative measures | Current health status: Medically optimized for surgery; no evidence of infection; intact extensor mechanism; informed consent obtained |
Medical Advisory Secretariat [26] | 2005 | Canada | Yes | Level IV | Pain | Functional ability | |||
Schneppenheim [28] | 2001 | Germany | No | Level IV | Debilitating pain | Severe restrictions on the activities of the patients in daily life | Significant radiographic findings | Yes | |
Hip | |||||||||
2011 | Germany | No | Level IV | Hip: pain during activities or rest | Constricted range of motion | Radiologic evidence of arthritis | |||
Lane [33] | 2007 | USA | No | Level IV | Substantial functional impairment | Chronic discomfort | |||
Levine [31] | 2013 | USA | No | Level IV | Pain refractory to nonsurgical management | Functional impairment | Radiographic findings (joint space narrowing, bone sclerosis, bone cysts femoral/ acetabular osteophytes | Yes | Physical exam findings (groin pain and decreased internal rotation), ruled out causes of referred pain including spine problems and bursitis |
Passias [32]a | 2006 | USA | No | Level IV | Incapacitating pain not responsive to conservative therapy | Function limiting symptoms: a significant deterioration in the ability to perform certain activities that are deemed important to the patient, and major lifestyle changes | Evidence of joint degeneration | Yes | |
Pivec [14] | 2012 | USA | No | Level IV | Pain | Functional impairment | Radiographic findings | Initial course of conservative therapy should always be attempted with analgesia, activity modification, ambulatory aids, and weight loss. | |
Knee and Hip | |||||||||
Altman [25] | 2005 | USA, France, Portugal, Belgium, Spain, Germany, Austria, Czech Republic, The Netherlands | Yes | Level III | The criteria for when to perform such surgery are not clear. | ||||
Dowsey [27] | 2014 | Australia | No | Level III | Selection of suitable candidates for TJA is critical but appropriate criteria are not clearly defined. | ||||
Mandl [29] | 2013 | USA | No | Level IV | There are no definitive recommendations for deciding which patients should be referred for TJA. |
Original publications
TKA appropriateness
Symptoms | Radiology | Age | Mobility | Localisation | Total knee arthroplasty |
---|---|---|---|---|---|
Slight or moderate | Ahlbäck I-III | Inappropriate | |||
Slight | Ahlbäck IV-V | Inappropriate | |||
Moderate | Ahlbäck IV-V | <55 | Inappropriate | ||
Moderate | Ahlbäck IV-V | ≥55 | Uni | Inappropriate | |
Moderate | Ahlbäck IV-V | ≥55 | Bi-tri | Appropriate | |
Intense-severe | Ahlbäck I-III | <55 | Uni-bi | Inappropriate | |
Intense-severe | Ahlbäck I-III | <55 | Tri | Uncertain | |
Intense-severe | Ahlbäck I | ≥55 | Normal | Inappropriate | |
Intense-severe | Ahlbäck II-III | ≥55 | Normal | Uncertain | |
Intense-severe | Ahlbäck I | 55-65 | Limited | Uncertain | |
Intense | Ahlbäck I | >65 | Limited | Uncertain | |
Severe | Ahlbäck I | >65 | Limited | Appropriate | |
Intense-severe | Ahlbäck II-III | ≥55 | Limited | Appropriate | |
Intense-severe | Ahlbäck IV-V | <55 | Uni | Uncertain | |
Intense-severe | Ahlbäck IV-V | <55 | Bi-tri | Appropriate | |
Intense-severe | Ahlbäck IV-V | ≥55 | Appropriate |
THA appropriateness
Pain | Non-surgical procedure | Functional limitation | Surgical risk | Age | Total hip arthroplasty |
---|---|---|---|---|---|
Severe | Correctly | Severe | Appropriate | ||
Severe | Correctly | Minor or moderate | Appropriate | ||
Severe | Not done or not done correctly | Severe | Appropriate | ||
Mild or moderate | Correctly | Severe | Low | Appropriate | |
Mild | Minor | Inappropriate | |||
Mild | Moderate | High | Inappropriate | ||
Mild | Moderate | Low | Inappropriate | ||
Moderate or severe | Not done or not done correctly | <50 years | Inappropriate | ||
Moderate or severe | Not done or not done Correctly | Minor | >50 years | Inappropriate | |
Mild or moderate | Not done or not done correctly | Severe | Low | Uncertain | |
Mild or moderate | Not done or not done correctly | Severe | High | Uncertain | |
Mild or moderate | Correctly | Severe | High | Uncertain | |
Severe | Not done or not done correctly | Minor or moderate | Uncertain | ||
Moderate | Correctly | Minor or moderate | High | Uncertain | |
Moderate | Correctly | Minor or moderate | Low | Uncertain | |
Moderate | Not done or not done correctly | Moderate | >50 | Uncertain | |
Mild | Correctly | Moderate | Low | Uncertain |