Shared Decision Making and Total Joint Replacement

What is Shared Decision Making? Shared decision making (SDM) is a collaborative process that allows patients and their providers to make health caredecisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.

For patients to be able to make an informed decision about undergoing total hip, knee or shoulder replacement, it is critical that they understand the potential risks of surgery including the consequences that result from complications associated with these risks. In addition, to experience an optimal outcome that is in line with a specific patient’s expectations for joint replacement, preparation of the body and mind for surgery is essential.

As the number of patients requiring joint replacement continues to increase, studies have been able to define risk factors that lead to a higher complication rate. Risk factors can be both modifiable and non-modifiable. Modifiable risk factors are things that patients can change or correct in order to lower their risk for complications during and after surgery. Complications that occur as a result of modifiable risk factors are considered preventable by insurance companies. Increasingly, insurance companies are refusing to pay for treatment of such complications, which puts patients at risk for the financial burden of care.

Therefore, it is extremely important that every effort is made in advance of surgery to address modifiable risk factors to minimize potential complications and maximize the outcome of surgery. This requires that patients acknowledge these risks and take some personal responsibility for their correction as part of the long-term care goals surrounding joint replacement surgery. As the goal of joint replacement is to provide long-term pain relief and improvement in function, adopting a holistic outlook that includes optimal preparation for surgery is essential to ensure that long-term goals are met.

The following is a list of the top modifiable risk factors that should be addressed prior to surgery.

  1. Obesity: increased body mass index (BMI)and percent body fat are associated with a higher risk of infection, wound healing problems, blood clots, prolonged hospital stays, hospital readmissions, persistent pain and earlier implant failure after joint replacement surgery. When the BMI is more than 40, the risk for infection rises 6 times normal. These risks are compounded by the presence of other risk factors like diabetes which often occurs in obese patients.
    Optimally, joint replacement surgery should not be undertaken until a patient’s BMI is 35 or less. Patients above this level should either consider surgical weight loss options, formal weight loss programs and or nutritional counseling. Ideally, surgery should be delayed until this goal has been met.
  2. Smoking: tobacco use has also been linked to delayed wound healing and a higher infection rate. Poor lung function also raises the risk for pneumonia after surgery, a medical complication that can delay discharge or lead to a hospital readmission. Smoking cessation within a month of surgery can reduce these risks significantly. Patients who smoke or use other nicotine products should not undergo joint replacement surgery until they successfully stop regular use within a month of the surgical date.
  3. Diabetes: poorly controlled diabetes increases the risk of infection. Average blood glucose can be monitored by measuring the Hemoglobin A1c. Ideally, this lab value should be 7.0 or less prior to undergoing joint replacement surgery. Patients whose diabetes is not in optimal control should delay surgery until better regular control can be achieved. Furthermore, patients must be committed to maintain improved blood glucose control throughout the recovery period for at least 3 months after surgery.
  4. History of Regular Narcotic Pain Medication Use: Studies have conclusively documented that patients who regularly use narcotic pain medications prior to joint replacement have inferior outcomes. Regular use of these medications predisposes patients to worsening postoperative pain due to a tolerance to these medications. This makes it very difficult to control immediate postoperative pain requiring very high doses of medications that can lead to difficulty breathing and other medical complications of surgery. In addition, long-term, patients on chronic pain medications continue to have more baseline pain and lower satisfaction scores compared to patients not on narcotics. We strongly recommend that any patient considering joint replacement surgery wean off of all narcotic pain medications several weeks prior to surgery.
  5. Cardiovascular Disease: Patients with significant heart disease including prior heart attack, angina, heart failure or prior stents are at a higher risk of medical complications after surgery. It is essential that a patient’s cardiac health is optimized prior to surgery through a comprehensive approach to minimize the risk of cardiovascular events. This may include a formal cardiology evaluation including specialized testing when deemed appropriate for risk screening. Patients with moderate to severe congestive heart failure or severe peripheral vascular disease may be too high risk to consider elective joint replacement.
  6. Chronic Obstructive Pulmonary Disease: Lung disease also places patients at a higher risk of medical complications after joint replacement surgery. Specifically, patients are at a higher risk of developing a postoperative pneumonia which may prolong the hospital stay or require readmission to the hospital. Lung disease also restricts patients exercise tolerance. This makes physical therapy more difficult and, in turn, may negatively affect long-term outcomes. Patients with severe lung disease who are dependent on supplemental oxygen may not be a suitable candidate for joint replacement surgery
  7. Depression: Research has shown that patients with depression that is not well managed do poorly after joint replacement surgery. Depression can aggravate pain and impair patient’s coping mechanisms for dealing with the stress of surgery and the demands of the postoperative recovery. Depression tends to reduce patient’s energy level and motivation. It also leads to a poor outlook. These factors have been shown to correlate with less satisfaction after joint replacement surgery. If patients are experiencing a significant depression episode, elective joint replacement should be delayed until this is successfully evaluated and treated
  8. Alcohol and Drug Dependence/Addiction: Alcoholism and recreational drug use lead to poor results after joint replacement surgery. Higher rates of infection, dislocation and other complications have been reported in patients who experience these problems. Patients who continue to exhibit abuse or dependency on alcohol or other drugs have a higher likelihood of being noncompliant with postoperative instructions and limitations. A major orthopedic surgery such as joint replacement represents of unique opportunity to address these problems in advance for the purpose of achieving an optimal outcome.

The goal of joint replacement is to provide durable and lasting pain relief and improvement in function. Essential to this goal is a patient’s active participation in approaching their surgery in the best possible mental and physical condition. Pursuing surgery in the setting of any one or combination of the above risk factors may lead to long-term dissatisfaction with the outcome of surgery and in some cases can make patients worse then they were before surgery. In order to lower the risk and maximize the benefits of surgery, patient’s make take responsibility for their own well-being, understand the impact of these conditions on outcome and take and active role in addressing them. Openly discussing these issues and concerns with your surgeon and primary care physician can help us direct the proper resources to patients to put everyone on a path for success.