Managing hip and knee osteoarthritis (OA) advise extensive non-surgical treatment prior to surgery.

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Non-surgical treatment before hip and knee arthroplasty remains underutilized with low satisfaction regarding performance of work, sports, and leisure activities.
Guidelines for managing hip and knee osteoarthritis (OA) advise extensive non-surgical treatment prior to surgery. We evaluated what percentage of hip and knee OA patients received non-surgical treatment prior to arthroplasty, and assessed patient satisfaction regarding alleviation of symptoms and performance of activities.

Patients and methods — A multi-center cross-sectional study was performed in 2018 among 186 patients who were listed for hip or knee arthroplasty or had undergone surgery within the previous 6 months in the Netherlands. Questions concerned non-surgical treatments received according to the Stepped Care Strategy and were compared with utilization in 2013. Additionally, satisfaction with treatment effects for pain, swelling, stiffness, and activities of daily life, work, and sports/leisure was questioned.

Results — The questionnaire was completed by 175 patients, age 66 years (range 38–84), 57% female, BMI 29 (IQR 25–33). Step 1 treatments, such as acetaminophen and lifestyle advice, were received by 79% and 60% of patients. Step 2 treatments, like exercise-based therapy and diet therapy, were received by 66% and 19%. Step 3—intra-articular injection—was received by 47%. Non-surgical treatment utilization was lower than in 2013. Nearly all treatments showed more satisfied patients regarding pain relief and fewer regarding activities of work/sports/leisure. Hip and knee OA patients were mostly satisfied with NSAIDs for all outcomes, while exercise-based therapy was rated second best.

Interpretation — Despite international guideline recommendations, non-surgical treatment for hip and knee OA remains underutilized in the Netherlands. Of the patients referred for arthroplasty, more were satisfied with the effect of non-surgical treatment on pain than on work/sports/leisure participation.
Worldwide guidelines for managing osteoarthritis (OA) of the hip and knee advise extensive non-surgical treatment prior to surgery (Zhang et al. 2010, Smink et al. 2011, McAlindon et al. 2014). Non-surgical treatment is cost-effective and may lower the rapidly increasing OA-related healthcare expenditure by delaying or even replacing surgery (Berwick and Hackbarth 2012).

The global Choosing Wisely initiative aims to optimize healthcare usage and costs by advocating the use of proven but underused healthcare modalities, including preventive care (Berwick and Hackbarth 2012, Bernstein 2015). Regarding hip and knee OA, studies have found underuse of non-surgical treatments (Snijders et al. 2011, Hofstede et al. 2015). For example, 1 study showed that 81% of hip and knee OA patients did not receive all recommended non-surgical treatments (Snijders et al. 2011). In the Netherlands, a Stepped Care Strategy (SCS) was developed to stimulate the use of non-surgical treatment before hip and knee replacement (Smink et al. 2011). Moreover, providing adequate non-surgical treatment before hip and knee replacement was recommended by the Dutch Orthopedic Association for their Choosing Wisely Campaign (NOV 2015). Yet, the actual utilization of non-surgical treatment in hip and knee OA patients prior to arthroplasty in the Netherlands is described only by a cohort study from 2013 (Hofstede et al. 2015). Furthermore, no previous study has simultaneously assessed patient satisfaction with non-surgical treatments regarding their effect on symptoms like pain and swelling, and participation as in daily life and work. This is of importance given the increasing number of hip and knee OA patients who want to eliminate their pain and also wish to remain active in daily life, work, and sport/leisure (Kurtz et al. 2009, Otten et al. 2010, Culliford et al. 2015, Witjes et al. 2017). Given the impact of surgery on work participation, the effect of non-surgical treatment on work participation is also of interest (Kuijer et al. 2016, Stigmar et al. 2017).

Therefore, the main aim was to assess preoperative non-surgical treatment by hip and knee OA patients referred for arthroplasty in 2018, as well as compared with 2013, and their satisfaction regarding alleviation of symptoms and performing activities of daily living (ADL), work, and sports/leisure activities.

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