BEING REFERRED FOR JOINT SURGERY

STANDARD 8

Referring you for joint surgery is only done if your symptoms and quality of life haven’t improved after all possible conservative care options have been exhausted. While joint replacements are successful for many people, non-urgent surgery should be considered as an option only after other osteoarthritis treatments have stopped working. Your surgeon will help you understand the benefits and risks of surgical options and help you understand how joint surgery can help you.

Home 9 Individual Standards: Toolkit Introduction 9 8. Being Referred For Joint Surgery

OVERVIEW

As we talked about earlier, the goal of using conservative options to manage your osteoarthritis is to slow the progression of your symptoms. Some people may get to a point that their symptoms don’t get any worse. However, others may still find that their symptoms are progressing. This can cause them to lose more movement, which affects their quality of life.

Once all possible Core and Adjunct Treatment options have been tried but haven’t helped, a referral for joint surgery may be next. Surgery isn’t usually an option until you’ve tried at least 3 months of treatment options. Remember that it can take over 3 months of dedication to most osteoarthritis treatments to see results (Standard 3). Surgery isn’t the final goal of Core and Adjunct Treatments; a referral for joint surgery means that all treatments haven’t worked or have stopped working.

The decision to refer you for joint surgery also depends on how ready you are, and how your symptoms (your pain, movement, and joint function) are doing. Even after all care options have been tried, your symptoms may not be any better or may have continued to get worse. This is a good sign that it is time to talk to a surgeon.

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Being Referred to an Alberta Hip and Knee Clinic

You and your primary clinician will make the decision when it’s time to be referred to a surgeon This is why it’s important to make sure your primary clinician understands your priorities, needs, expectations, values, and preferences when talking about surgical options. Your primary clinician will let you know that there are both Risks and Benefits to Hip and Knee surgery. However, it’s the surgeon who will go into more detail about these risks and benefits.

Once you agree to be referred, you’ll be guided through the process. There are 11 Hip and Knee Clinics in Alberta that follow the same Hip and Knee Surgical Care Path. You’ll be referred to the clinic closest to where you live.

Your primary clinician will send in the referral form with your medical history. Give your primary clinician a copy of your log with the history of the conservative treatments you’ve tried so far so they can attach it to the referral form (Standard 3).

If you haven’t had any x-rays of your affected joints in the last year, you’ll have x-rays done so they can be sent with the referral (Standard 1). Once all this is done, the information is sent to the Hip and Knee Clinic closest to you.

Your primary clinician should hear about a week later what the wait time will be. Wait times can change, which can be frustrating. This is why we’ve created a Common Question document that explains why this may happen.

The Hip and Knee Clinic will assess whether you’re a candidate for surgery. At some clinics this means you might have 2 appointments before you help make the decision that surgery is the best option for you. Make sure you talk to all the doctors that you’ll see at the Hip and Knee Clinic about your other health diagnoses too.

Since your health or joint status can change, it’s important that your clinicians (including the screening specialist and/or surgeon) know if your osteoarthritis symptoms or your quality of life changes. It’s also important to keep your care plan up to date.

Waiting for Surgery

Once your surgeon approves you for surgery, you’ll be assigned a Case Manager. Your Case Manager will guide you through the blood tests, x-rays, and anything else you need to have done before surgery. The Case Manager is there to answer your questions while you wait for surgery.

You’ll also go to a pre-surgery teaching class, where you’ll be given helpful education booklets (Alberta Hip or Knee Surgery booklets) that describe the surgical journey. The booklets also have the pre-surgery exercises you can do to get ready. The pre-surgery teaching class isn’t the same as the osteoarthritis conservative education.

Note: Don’t have a steroid injection within 6 weeks of your surgery date.

After Surgery

You’ll be helped to walk 10 steps on your new joint a few hours after surgery, a very important step to starting your recovery. The surgical pain should get a little better every day. You’ll also be monitored by your hospital care team while in the hospital and then by your Case Manager from the Hip and Knee Clinic from when you leave the hospital up to when you have your 2 week appointment.

Your staples are taken out about 2 weeks after surgery. It’s around that time that you may really notice that your walking starts to improve. This is because before then, your leg movement was likely stiff, and you may not have been putting your full weight on your leg yet.

You can expect the pain to improve starting 6 weeks after surgery. You should be moving much better after 3 months. While your joints will likely start to feel stronger, they can take up to 1 year to be at their strongest. You may still have some pain in the affected joint, but you’ll be able to manage it.

Everyone heals differently. Healing takes time, patience, and a lot of rehabilitation work on your part before you see a change (or improvement) in your function, mobility, and pain in your affected joint.

Exercise and physical activity are important for building your muscle strength while healing from surgery—and it helps you feel better overall. Your Case Management team will speak with you about the type of exercise that’s best for you. You’ll likely be able to return to most of the activities you did before your OA symptoms stopped you, such as golfing, biking, swimming, or dancing. Your surgeon may ask you not to do things that put a lot of stress on the new joint, like running or playing tennis. Your Hip or Knee Surgery booklet tells you more about exercise and activity after a joint replacement.

Surgery usually works well for most people. You’ll likely have much less pain and be able to do most of your daily activities more easily. But recovery does take time and patience. The Alberta Hip and Knee Program has over 10 years of feedback from other Albertans who’ve had surgery, have less pain, and are able to do many more of their everyday activities.

Most artificial hip joints will last for 10 to 20 years, sometimes even longer. It depends on things you can control, like how well you continue to manage your OA, the Core and Adjunct Treatments you choose, and how much stress you put on the joint. It also depends on things that you can’t control, like your age and how well your new joint and bones heal.

Managing Your Osteoarthiritis

Throughout your surgery journey, it’s important to keep managing your osteoarthiritis symptoms with the treatments you and your primary clinician chose for you.

Continuing your Core and Adjunct Treatments will:

help you get back to your best level of health and wellness before surgery
improve your chances for greater functional recovery after surgery
improve your general health and joint care long after the surgery. Joint care includes caring for the replaced joints as well as your other affected joints.
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Q

Being a Candidate for Surgery

You are not a good candidate for surgery if:

  • you haven’t tried OA treatments for at least 3 months
  • you have problems with memory or your ability to learn information and use that information, etc.(cognitive skills)
  • there are issues with your joint or the surgery you need,such as:
    • you’ve had an infection in that joint
    • the surgery will be hard to do
    • a replacement won’t help because of the condition of the joint.
  • you’re not willing or able to follow the care path, which includes:
      • following all instructions the surgeon gives you to get ready for the surgery
      • going to the Hip and Knee Surgical Care Path pre-operative teaching class to prepare you for the surgery

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  • you’re not willing to commit to the rehabilitation process after the surgery
  • you have other health issues that make surgery too risky
  • your joint movement or pain level hasn’t gotten any worse

Surgeons usually won’t recommend elective joint replacement surgery for people that have unmanaged health conditions that make the surgery too high-risk. These include:

  • brain diseases
  • diabetes
  • cancer
  • heart disease
  • kidney disease
  • liver disease
  • obesity

If you’re managing your risk factors, the surgeon will speak with you to decide if surgery is an option for you. If you have a health conditions that’s not well-managed, you’ll likely have to work on managing it before you’re a candidate for surgery, either through the Hip and Knee Clinic or with your primary clinician. If you’re able to manage your other medical conditions and reduce your risk for joint replacement surgery, then you may be able to become a good candidate for surgery.

The surgeon will talk to you about their recommendations for non-surgical OA treatments. They will also write a letter to your primary clinician with their recommendations Your clinician will then work with you to review your non-surgical OA care plan, choose new treatments, and keep supporting you to meet your OA goals.

Q

Ongoing OA Management

The 12-week (3 month) trial of OA treatment supports the success of your surgical outcomes if you do go on to have surgery.

  • Education about OA can support you to:
    • understand your condition
    • continue to care for your joints after surgery
    • understand the purpose of surgery and how it complements, but is different from, the purpose of non-surgical treatments
  • Exercise and physical activity can support you to:
    • reduce your risks for the surgery
    • improve healing after surgery
    • continue to care for your joints and well-being after the surgery.
  • Managing your weight can support you to:
    • reduce your risks for the surgery
    • continue to care for your OA, your replaced joint, and manage your well-being after the surgery.
Q

Surgical Candidacy

An individual with osteoarthritis (OA) is not an appropriate candidate for elective hip or knee joint replacement surgery in Alberta if:

  • At least 12 weeks of conservative OA management treatments have not been trialled and documented
  • Cognitive/neurologic impairment is present
  • Orthopaedic challenges are present, such as:
    • A history of infection in the joint
    • The surgery is technically unfeasible or
    • The joint cannot be reconstructed
  • The individual is not willing or able to be compliant with the care path, which includes:
    • Being willing to undergo the surgical optimization and health management protocols prescribed by the surgeon
        • This includes attending the Hip and Knee Surgical Care Path prescribed pre-operative teaching class and

      Note that the ‘pre-operative teaching class’ is not equivalent but complementary to conservative non-surgical OA education, for the appropriate audience of confirmed surgical candidates.

    • Being willing to commit to the rehabilitation after the surgery
  • An extreme medical risk is present (see below) and/or
  • There is no demonstrated decline in patient reported outcome measures (PROMs) (Standard 9)

Note: capture of formal PROMs varies across the province and may represent some administrative obstacles to a clinic/clinician. With the full implementation of these standards these obstacles will be overcome with time through the support of the Bone and Joint Health Strategic Clinical Network (BJH SCN) and its collaborators (Standard 9).