Abstract：
To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).
We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.
The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.
This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.
The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.
This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
摘要：
目的：为髋关节和膝关节置换术的最佳时机制定循证共识建议，以改善患者重要的结局，包括：但不限于,疼痛,函数,感染,住院治疗,有症状和放射学中度至重度骨关节炎或晚期症状性骨坏死伴继发性髋或膝关节炎的患者在1年时死亡，先前曾尝试过非手术治疗，非手术治疗无效的人，并选择接受择期髋关节或膝关节置换术（统称为TJA）。
方法：我们开发了13个临床相关人群，干预，比较器,结果(PICO)问题。经过系统的文献回顾，建议评估的等级，使用开发和评估(GRADE)方法对证据质量(高，中度,低,或非常低)，并创建了证据表。投票小组,包括13名医生和病人，讨论了PICO问题，直到就建议的方向（赞成/反对）和强度（强/有条件）达成共识。
结果：专家组有条件地建议不要推迟TJA进行额外的非手术治疗，包括物理治疗，非甾体抗炎药，门诊辅助设备,和关节内注射。有条件地建议延迟TJA以减少或停止尼古丁。小组有条件地建议延迟糖尿病患者更好地控制血糖，尽管没有确定具体的措施或水平。人们一致认为肥胖本身并不是拖延的原因，但是应该大力鼓励减肥，应该讨论手术风险的增加。小组有条件地建议严重畸形或骨丢失的患者不要拖延，或患有神经性关节的患者。所有建议的证据都被评为低质量或非常低质量。
结论：本指南提供了关于TJA在有症状和影像学表现的中度至重度骨关节炎或晚期症状性骨坏死伴继发性关节炎患者中的最佳时机的循证建议，这些患者的非手术治疗对改善患者重要的结局无效。包括疼痛,函数,感染,住院治疗,一年后死亡。我们承认证据的质量较低，主要是由于间接性，并希望未来的研究能够进一步完善建议。
方法：我们开发了13个临床相关人群，干预，比较器,结果(PICO)问题。经过系统的文献回顾，建议评估的等级，使用开发和评估(GRADE)方法对证据质量(高，中度,低,或非常低)，并创建了证据表。投票小组,包括13名医生和病人，讨论了PICO问题，直到就建议的方向（赞成/反对）和强度（强/有条件）达成共识。
结果：专家组有条件地建议不要推迟TJA进行额外的非手术治疗，包括物理治疗，非甾体抗炎药，门诊辅助设备,和关节内注射。有条件地建议延迟TJA以减少或停止尼古丁。小组有条件地建议延迟糖尿病患者更好地控制血糖，尽管没有确定具体的措施或水平。人们一致认为肥胖本身并不是拖延的原因，但是应该大力鼓励减肥，应该讨论手术风险的增加。小组有条件地建议严重畸形或骨丢失的患者不要拖延，或患有神经性关节的患者。所有建议的证据都被评为低质量或非常低质量。
结论：本指南提供了关于TJA在有症状和影像学表现的中度至重度骨关节炎或晚期症状性骨坏死伴继发性关节炎患者中的最佳时机的循证建议，这些患者的非手术治疗对改善患者重要的结局无效。包括疼痛,函数,感染,住院治疗,一年后死亡。我们承认证据的质量较低，主要是由于间接性，并希望未来的研究能够进一步完善建议。
