Noting the prevalence of osteoarthritis and a general lack of consistency in which patients are referred, orthopedic surgeon Claudio Diaz Ledezma, MD, lays out efficient evaluation strategies for primary care providers. He explains which imaging techniques have most value; how to determine whether conservative treatments have failed; and ways to assess whether patients are good candidates for surgery, providing evidence-supported tools to use in everyday practice. He also supplies answers to patients’ common questions, such as whether physical therapy before joint replacement brings a better outcome.
My name is Claudio Diaz. I'm an adult reconstruction, which means that I do hip and knee replacement. I was, I am a Chilean surgeon. I did medical school and residency in Chile. And I did my fellowship at the Rothman Institute in Philadelphia, Thomas Jefferson University. I went back and worked in my home country for 10 years, and now I'm back to California and so happy to be part of the USA CSF team. And As Ben told you, uh, we value a lot the work that you guys do for our patients, and most of the patients that we are getting in our clinics came from referrals, uh, that you saw before. So, I'm happy to share some visions that we as a team have regarding strategies for what is called a high-yield orthopedic referrals, um, particularly focused on, uh, knees and hip replacement. I have no disclosures. And the question that came to my mind was how we can make referrals less variable and more expedite for the benefit of patients. And the outline of this presentation is 6 points. We're going to talk about the magnitude and the surgical volume, and the projection for the future about knees and hip replacements. How we diagnose osteoarthritis, uh, what is conservative treatment, who is a good candidate for surgery, what is the pre-operative optimization that we're looking for, and some words about rehabilitation, which is, uh, one of the strategies that many patients ask before the operation. So having said that, Uh, we'll start with the magnitude and the volumes that we are projecting for the future. Uh. As you know, uh, we're going to talk about hips first. Uh, hip osteoarthritis is a prevalent disease in North America. 8% of the Patients have. Radiographic osteoarthritis? And if we look at the American Joint Registry, which has been working for the last 10 years, uh, the volume of total hip arthroplasties done in the US in 2022 was, uh, that number that you can see in here. It was done by 2800 surgeons, and this is a very interesting data to share. All over the country, the mean, uh, or the average number of cases per year, per surgeon. Is less than one case per week. The mean age for patients undergoing total hips is 65 years old. If we look at the knee side, uh, some data says that 30% of us who are 45 years old or older have radiographic knee osteoarthritis at different stages. The same data from the American Joint Registry says that almost 200,000 total knees were done by uh Uh, 3000 surgeons. And the average number of cases per year per surgeon is 56, which is just one, knee per week per surgeon. The average age is 67 years old, and there is an interesting procedure that probably you have heard about it, and many patients ask about it. It's, it is called partial knee replacement, where it is Replacing the medial compartment, the lateral compartment, or the patellofemoral one. It's a lot less frequent, just 8, 8000 procedures a year. 1/3 of the surgeons actually perform this procedure, and the average number of cases is just 7 cases per year per surgeon. I want you to, to know that because in real life, we like to say that we operate a lot more than we actually do. The projection, this is a very nice study uh published recently in the, which is the most prestigious journal in orthopedics. Uh, uh, these authors use the national inpatient sample, uh, over 15 years. More than 100 million discharges were evaluated, and total hip, using those numbers, uh, they projected the growing of total hip replacement by the year 2030. And that's, they said that it will increase 71%, and for total knees, it will be even bigger, 85%. So, we expect by the year 2030 to be doing more than a million procedures per year. So, having said that, you can imagine that in your practices, and also in mine, and, and whoever uh is practicing in primary care, Uh, hip and knee osteoarthritis is one of the most frequent musculoskeletal conditions, and in consequence, replacements are, are really frequent, uh, surgeries to be seen in everyday practice. If we talk about diagnosis, you will encounter uh many patients in daily practice that they are requesting different tests other than X-rays, which is the workhorse for us, and it still is. Uh, and probably the main recommendation is do not employ ultrasound. It's actually not very valuable for the diagnosis of, uh, osteoarthritis. Rarely, we order for CT scans, probably as part of what we call the pre-operative planning. Some colleagues of mine are doing robotic, uh, hip and knee replacement, and a CT scan is required to do that robotic surgery, but it's actually a second line, uh, type of diagnostic image. And MRI's are also useful, but in a very Few number of cases, a very reduced number of cases, we actually ask for MRIs, but you will encounter many patients with pain, uh, severe function, uh, compromise, whose X-ray don't look as bad, probably in those patients, uh, MRI is a reasonable, uh, alternative to ask for. So probably you know this, but we use what we call the AP pelvis. Uh, by convention we define arthritis whenever the joint space width is less than 3 millimeters. One of the key features of the X-rays are the osteophytes or bone spurs, as you can see in here. And the other one is the subchondral cyst, which are those, I can, if you can see my, my arrow there, are those little cysts that we can see below the surface of the, of the, the cartilage, and they are actually a, a very good fit to diagnose uh osteoarthritis. These are other views that we ask for. It's called the AP hip and the axial view, and you can see in here in the axial what the Uh, what is the look for the osteophytes or the bone spurs, which is, I, I choose that one because it's really, uh, evident. On the knee side, also, the convention said that joint space with less than 3 millimeters is critical for diagnosis. Same thing with osteophytes as you can see in here, and some subchondral cysts that actually are not able to, to be seen here. We use, also use the lateral view, as you can see here, with osteophytes in the popliteal fossa. And you can see if you, if this is the same patient, it's just the, the X-ray was put the other way, but take a look at the lateral compartment. When the patient is on AP and this one is a very good view, it's called the Rosenberg's view after a very famous knee surgeon called Aaron Rosenberg from Chicago. He described that if you put the patient on a weight-bearing position using 30 degrees of flexion, it's called the Rosenberg's view, you can see actually a lot more uh osteoarthritis and joint space narrowing that you can see in the regular AP. So that's one, it's a good one to have in your armamentarium. Uh, as you know, we orthopedic surgeons have a lot of imagination. Uh, we call the one on the left side, the sunrise view. It's a critical part of our, uh, radiographic diagnosis. You can see. How the joint space width look underneath the patella? That is the trochlear fossa, part of the femur. The scannograms are also those long X-ray films in which we look for the alignment, and you can see that on the right leg of that patient, the alignment is normal, and on the left one, he's got a very valgus deformity. Um, The third point is what is called conservative treatment, which is also uh very variable. We see a lot of differences between one practice and another, and probably, The good thing to share with you guys is that you will encounter many different guidelines. We have one at the American Association of Orthopedic Surgeons. Uh, there's plenty of others, but in my humble opinion, this one from the American College of Rheumatology is the best one. this is the last version I can share with you afterwards, the, the papers if you want. But they have very good information to be shared, and these graphics are very, are very useful. As you can see here, they use different grades of green color to say what is strongly recommended and what is conditionally recommended for hand, knee, and hip osteoarthritis. And as you can see on top, exercise, self, self-efficiency, efficacy and self-management program, weight loss, Tai Chi, using a cane, knee braces are very recommended. Uh, you can see that oral NSAIDs and topical NSAIDs are also recommended. But you can see that other uh sort of therapies like heat, therapeutic cooling, cognitive behavioral therapy, acupuncture, or taping are actually recommended, but they are not the priority. Probably they are second-line therapies. You can find in here yoga as well, the use of different medications such as acetaminophen, tramadol, duloxetine, and chondroitin, even topical capsizing. But very interestingly, they also have red colors to be shared. And this is what they are strongly against, and as you can see here, like uh the transcutaneous electrical nerve stimulation, which many patients may buy even at Amazon or other webpage, those little machines actually are not recommended at all. You can see other, like, very, like, old-fashioned type of conservative treatments such as modified shoes or wedge insoles are not, not recommended. Uh, other types of medications that patient ask for is Uh, glucosamine, which is very useful and you can use it like over the counter in patients' mind, it's actually not recommended. So, even though they think it's helping them, I think it's just a waste of money, to be honest with you. Other alternatives like using a PRP or stem cell injections are not recommended. Hyaluronic acid is a hot topic. You will see many colleagues of mine doing it, and it's actually, as you can see here, not recommended. Uh, there are other type of, uh, therapies, and this is like a, like a summary, um, Table and you can see like, like bracing is uh enclosed here and you can see that it's actually uh well recommended for knees recommended for knees. So how to describe a failed conservative treatment? How, when, how is, uh, to pull the trigger and say that to the patient that he or she will actually, uh, need an operation and probably my recommendation is to ask the patient directly. And my question is always the same, is, would you say that the strategies we have employed have failed to improve your quality of life, considering the symptoms on, on your joint? If the patients are aware of the knee or the hip all day and even at night, probably we have failed conservative treatment. And it's part of what can happen. I think it's not that we fail, it's just The stage of the osteoarthritis is too far gone to respond with a, a conservative treatment. So if we look at uh The literature, this, this is a very uh interesting recent article. There's no formal definition for a failed conservative treatment. It's just sort of an agreement between the patient and, and the provider, and In here, uh, Madrid described in probably one of the most, um, Important journals for osteoarthritis is uh published by the Osteoarthritis Research Society International, which is a huge organization. They said that surgery is indicated if a patient suffered from persistent pain and functional limitations. A patient who's also have severe joint damage, which is confirmed using X-rays. And probably the most important thing is that the patient uh failed that multimodal conservative approach, which is not providing adequate relief of the symptoms anymore. If a patient uh can comply with those conditions, I think it's a good decision to advise them surgery. So, who is a good candidate for surgery? And you will encounter a lot of variability. This is a very interesting study, uh, looking for surgical referrals for total joints, uh, arthroplasty, knees and hips. It was conducted in the United Kingdom and reported that only 50% of the patients referred by primary care physicians to orthopedic surgeons to consider a hip replacement actually ended up in a surgery within a year. So probably we are not very good giving you guys information of what we are looking for. Bock also described what are the perceptions of primary care physicians regarding uh clinical indications, contraindications, effectiveness, and risk of an operation such as total joint replacement, as well as the confidence that this provider have in referring patients. So, those uh colleagues of ours were uh very variable in their vision. They were substantially, uh, variable. And the more relevant finding was that the confidence that primary care physician have in deciding or in making the decision for whom it's actually a good idea to be referred is only moderate. I can share with you after, uh, uh, uh, after finishing the presentation, and you can see a little video on this phenomenal tool. It's called the AI tool. It's the Arthroplastic Candidacy Health Engine tool, tool that was developed in the UK. So, they use a score that can be uh done by you, the provider, or even by the patient. You have to feel like your age, your, uh, Health condition and they will be asking you about symptoms related to your joint. It gives you a score, and as you can read here, it gives the patient information regarding the probability of having a good outcome after the surgery. So, for this patient, uh, there was a 93% probabilities of having a good outcome, which is pretty good. There is economic evidence uh uh supporting the use of the AI tool. Uh, these authors use the AI tool to identify patients with more than 70% chance of a good outcome after a total hip, and they described that using those criteria, they can have 13,000 additional referrals in the English, uh. Sort of, uh Health system With a surgical assessment for 5000 additional patients. This strategy, if used, would increase the total number of operations by 7%. The total cost of referrals would be around 25 million pounds, but using those beautiful algorithms that they use to, to evaluate cost efficiency, they described that the, the system would gain 16,000 quality-adjusted life years if you use this tool to refer your patients. So, you can use the link afterwards and I would be happy to, to, to, to encourage you to use this tool because it's, it, it's really an advance for us. At the American Academy of Orthopedic Surgeons, we also have one. It's called ortho guidelines. Uh, they call it the appropriate use criteria for the management of osteoarthritis. There is one for knees and one for hips. You can fill out some questions. They evaluate the age of the patient, the function, uh, limiting pain, the radiographic evaluation, the limited limitation in range of motion. And the risk of negative outcomes looking at modifiable and non-modifiable risk factors, and they can suggest you like 9 different types of uh management alternatives. And I run a study in Chile using this tool among 22 primary care physicians using an RCT study. So, on the one hand, we need formal educations for the primary care physicians. On the other, uh, branch, we have 2011, uh, primary care physicians who just used the tool with no formal education before. And we demonstrated that the performance of referring adequate patients for surgery was equal between those colleagues that were educated, that received education versus those that just use this uh tool. So, in our uh opinion, this tool is tremendously valuable for your practice. It's really fast, and it can give you like an like an immediate assessment. of the alternatives that are good for the patient. As you can see here, this patient would benefit for risk factor assessment and optimization, modification of his activities, using assistive devices, using some sort of medication, maybe steroids, and also, he could be a good candidate for arthroplasty, but not for hip preservation surgery or for arthrodesis, which is an end-stage procedure. So what is what we call preoperative optimization? It's a process that helps the patients decreasing the risk of complications, readmissions, and re-operations by controlling the modifiable risk factors. And I'm going to share with you some tactics, tactics in my personal strategy to decrease complications. When you ask people who know about strategy, they will tell you that strategy is to do something new, to improve what we do, or to react to emergent opportunities. There is plenty of literature about what is considered modifiable among risk factors for complications in, in, in arthroplasty, but I will summarize in some of them that are very critical. Obesity is part of our daily practice. Uh, we do have, I'm sorry, I, I put that in Spanish. When you have a BMI uh around 35, we said, probably you're a good candidate. With a BMI over 40, most of us says no. But we also uh have to take into consideration the comorbidities. So if a patient is Uh, with a BMI of 42, but with no other comorbidities, probably we will say yes. Uh, unfortunately, with all the literature and with all the evidence we have so far, it is very difficult to establish a clear cut, uh, cut point or threshold to decide, uh, when a patient is a good candidate for surgery or not. Diabetes is part of our daily life as well. We ask for our patients having a hemoglobin A1C under 8, and the morning glycemia, the morning of the operation should be under 200, and we have what I think a pretty good uh diabetes control, uh, in the hospital. Anti-rheumatic drugs are very complicated to be managed. Uh, there are guidelines, uh, written by the American College of Rheumatology and the American Association of Hip and Knee Surgeons. As you know, the variability is high because all of those drugs, uh, behave really different, so, I don't, I don't know it by heart, but we have the chart and we look for the specific drug, and we sort of accommodate our surgical schedule for these patients. In regards of uh tobacco use, we ask the patients to have 6 weeks cessation prior to the operation. Hopefully, we get it. Some colleagues of mine asked for, for uh For, for nicotine levels, but I don't use it regularly. We like to avoid transfusions. When I was a resident 20 or 15 years ago, uh, transfusions were part of this operation. Nowadays, it's very rare to, to transfuse a patient because we use tranexamic acid, which is probably a game-changer in our practice. But the better assessment we have and the avoidance of preoperative anemia and malnutrition will also help the results of our patients. Uh, we do decolonization, nasal, using nasal mupirocin to avoid the risk of, uh, MSSA and MRSA as well. It's a very uh affordable. alternative, and it's been proved to work pretty well. And also, we like to calculate the risk and inform the patients, and there are plenty of calculators out there, but this is probably one of the best ones. It's really easy to use, it's free to use. And it's uh done by the American College of Surgeons. You can find, as you can see on top, the procedure, the total knee arthroplasty, and you can click to classify your patients. And it will give you different types of complications. And for instance, in this case, we calculated the risk of a surgical site infection for this patient, which is 0.7. And as you can see in, in here, it says, it's the average for this type of procedure, which is good. Uh, the last word, it's about rehabilitation, uh. is regarding the questions that you may have had priorly with your patients, and the question is, should I do physical therapy before the operation? Will it help with my recovery? And when you look at the literature, there are some uh RCTs, well-done RCTs like this one, which is published in JEMA uh recently this year. And as you can see here on this busy table, unfortunately, this strategy is not able to help the patients like, like consistently. So probably, it's not good for an, for improving the outcome 6 months after the surgery or even 12 months after the surgery. There's also a systematic review on this topic. Uh, it was recently published last year. And it says that we need more evidence. It remains unclear if rehabilitation actually improves the outcome for patients. Um, but, At this point, my opinion, my humble opinion is no, uh, it will not help, and thus, I do not consider it necessary. So, as a conclusion, uh, and before thank you guys for, for, uh, having me, uh, tonight, I think there are different tactics that can help to expedite and make referrals for total joint replacement more consistent and more reproducible. We have to use a structured approach and There are no current established frameworks, but it's actually something in which we can work for the benefit of our patients. That is my email. I'm happy to answer all your questions. Uh, Doctor Cox has this presentation, and I asked him specifically if someone of you guys want it. Please feel free to use it, and this is just things that we like to do for Our colleagues, and I hope this presentation will be somewhat valuable for your daily practice. Thank you so much.
