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Who should have a joint replacement? A plea for more ‘phronesis’

2010; Elsevier BV; Volume: 19; Issue: 2 Linguagem: Inglês

10.1016/j.joca.2010.08.018

1522-9653

Paul Dieppe,

Orthopedic Infections and Treatments

Recently I met up with my old friend Eddie, whom I had not seen for over a year. “How have you been?” I asked “I’ve just had my hip replaced” he responded “Oh, I didn’t realise you had been having hip pain” “No, no, it was never painful” Eddie explained “Just slowing me up a bit and interfering with the long walks I like to take, and with my cricket on a Sunday. And apparently the X-ray showed it was bad, so I thought I would get it done” “Are you pleased with it?” “Yes, it’s great” he enthused “I can do anything I want to again, and I scored a half century last Sunday” Should he have had a hip replacement I wondered? Who should? The answer seems to be both beguilingly simple and fiendishly complex. In this edition of the journal there is an article by Laure Gossec and colleagues1Gossec L, Paternotte S, Maillefert JF, Combescure C, Conaghan PG, Davis AM, et al. The role of pain and functional impairment in the decision to recommend total joint replacement in hip and knee osteoarthritis: an international cross-sectional study of 1909 patients. Report of the OARSI-OMERACT Task Force on total joint replacement. Osteoarthritis and Cartilage 2011;19:147–54.Google Scholar describing a large multi-national study which tried to find cut-off levels of pain and disability that correspond to an indication for total hip or knee joint replacement. They failed to find any cut-point, there being a huge overlap in levels of pain and function recorded in those who were recommended for surgery, compared with those who were not. Obviously. Previous studies have shown that there is a huge variation in the levels of pain and disability experienced by people coming to total joint replacement2Kennedy G.L. Newman J.H. Ackroyd C. Dieppe P.A. When should we do a knee replacement?.Knee. 2003; 10: 161-166Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 3Dieppe P. Judge A. Williams S. Ikwueke I. Gunther K.-P. Hawker G. et al.Variation in the pre-operative status of patients coming to primary hip replacement for osteoarthritis in European orthopaedic centres.BMC Musculoskelet Disord. 2009; 10: 19Crossref PubMed Scopus (86) Google Scholar, 4Ackerman I.N. Dieppe P.A. March L.M. Roos E.M. Nilsdotter A.K. Brown G.C. et al.Variation in age and physical status prior to total knee and hip replacement surgery: a comparison of centres in Australia and Europe.Arthritis Rheum. 2009; 61: 166-173Crossref PubMed Scopus (49) Google Scholar, with some, like my friend Eddie, seemingly having very little wrong with them. As part of a programme of work on joint replacement, we conducted qualitative studies investigating the views of patients and the public on who should have a joint replacement5Woolhead G.M. Donovan J.L. Chard J.A. Dieppe P.A. Who should have priority for a knee joint replacement?.Rheumatology. 2002; 41: 390-394Crossref PubMed Google Scholar, 6Sanders C. Donovan J.L. Dieppe P.A. Unmet need for joint replacement: a qualitative investigation of barriers to treatment among individuals with severe pain and disability of the hip and knee.Rheumatology. 2004; 43: 353-357Crossref PubMed Scopus (71) Google Scholar, 7Woolhead G.M. Donovan J.L. Dieppe P.A. Outcomes of total joint replacement: a qualitative study.Rheumatology. 2005; 44: 1032-1037Crossref PubMed Scopus (98) Google Scholar, 8Sansom A. Donvan J. Sanders C. Dieppe P. Horwood J. Learmonth I. et al.Routes to total joint replacement surgery: patients’ and clinicians’ perspectives of need.Arthritis Care Res. 2010; 62Crossref Scopus (32) Google Scholar. The answers they gave were often seemingly very simple – “those who are going to benefit most from the surgery”, for example. So, it is quite easy then – we operate on those who are going to get the most benefit – the answer is ‘capacity to benefit’ (see below). But how are we to assess what the likely improvement is going to be, and how do we cope with people like Eddie (who says he benefited greatly)? This is particularly difficult as there is a notable absence of good data on the determinants of good or bad outcomes after joint replacement9Judge A. Cooper C. Williams S. Dreinhoefer K. Dieppe P. Patient-reported outcomes one year after primary hip replacement in a European Collaborative Cohort.Arthritis Care Res. 2010; 62: 480-488Crossref PubMed Scopus (97) Google Scholar. More detailed analysis of what the patients and the public told us revealed some further, fascinating perspectives. For example, some people held the view that it should depend on the length of time that someone had put up with pain and disability in the past (the ‘area-under-the-curve’ of pain and disability), rather than reported severity of symptoms at the time of decision making. That is an interesting and quite sophisticated viewpoint I think, as it relates to issues such as a short-lasting ‘flare-up’ of symptoms leading to an ill-judged decision to have surgery, and of the problem that a patient who wants the surgery, for whatever reason, can generally get it by saying he or she has awful night pain just now. Many people told us that they thought it wrong that some other people were able to get a joint replacement by ‘shouting a lot’7Woolhead G.M. Donovan J.L. Dieppe P.A. Outcomes of total joint replacement: a qualitative study.Rheumatology. 2005; 44: 1032-1037Crossref PubMed Scopus (98) Google Scholar. They also told us that those who were caring for someone else at home should have priority, even if their symptoms were not very severe. This is another interesting perspective, raising the whole area of social circumstances, which takes us way beyond the narrow focus of Gossec et al. on severity of pain and disability, along with X-ray changes. How often do we ask about the caring role of our patients, and have you ever seen this mentioned in the plethora of consensus statements10NIH consensus conference Total hip replacement.JAMA. 1995; 273: 1950-1956Crossref PubMed Scopus (92) Google Scholar, 11Hadorn D.C. Homes A.C. The New Zealand priority criteria project.Br Med J. 1997; 314: 131-134Crossref PubMed Scopus (266) Google Scholar, 12Naylor C.D. Williams J.I. Primary hip and knee replacement surgery: Ontario criteria for case selection and surgical priority.Qual Health Care. 1996; 5: 20-30Crossref PubMed Scopus (90) Google Scholar that emerge from the professionals about the indications and prioritisation of joint replacement? Probably not. Work or care-giving is mentioned in the Canadian prioritisation criteria12Naylor C.D. Williams J.I. Primary hip and knee replacement surgery: Ontario criteria for case selection and surgical priority.Qual Health Care. 1996; 5: 20-30Crossref PubMed Scopus (90) Google Scholar, but care provision is not mentioned in most of the other documents and publications on who should have a joint replacement. But patients and the public were also aware of, and concerned about the dangers of joint replacement, and the fact that not everyone gets better6Sanders C. Donovan J.L. Dieppe P.A. Unmet need for joint replacement: a qualitative investigation of barriers to treatment among individuals with severe pain and disability of the hip and knee.Rheumatology. 2004; 43: 353-357Crossref PubMed Scopus (71) Google Scholar. Based on these perspectives, and other research on joint replacement we have tried to develop the public’s concept of ‘capacity to benefit’ further, so that it can be used as a framework for decision making about joint replacement surgery13Dieppe P. Dixon D. Horwood J. Pollard B. Johnston M. Mobile and the provision of total joint replacement.J Health Serv Res Policy. 2008; 13: 47-56Crossref PubMed Scopus (14) Google Scholar, an approach that we based firmly within a biopsychosocial framework14Engel G.L. The need for a new medical model: a challenge for biomedicine.Science. 1997; 196: 129-136Crossref Scopus (6113) Google Scholar (Fig. 1). The decision whether to have a joint replacement or not is, of course, a judgment call that has to be made by the physician and patient working together, and which has to take account of a large range of complex psychological, social and other issues, in addition to pain, disability and X-ray changes. That is obvious enough, although how to operationalise it is not. And that, of course, is the art of medicine, and why humanity is just as important as science in medicine. The Greeks (particularly Aristotle) wrote about the importance of ‘phronesis’ (practical wisdom) in health care15Aristotle. Nicomachean Ethics. Dual text with a translation by H Rachman. Harvard University Press; 1934.Google Scholar. It takes wisdom and experience, as well as scientific data, to make the right decision with people about whether they should undergo a major intervention like a joint replacement. It cannot be done with a ‘cook-book’ approach, or simply by measuring things such as pain, which are immeasurable anyway. And with respect to my friends and colleagues who contributed to the paper in this journal (and I too must share in some of the blame), I think we need more phronesis in our research as well. The study reported1Gossec L, Paternotte S, Maillefert JF, Combescure C, Conaghan PG, Davis AM, et al. The role of pain and functional impairment in the decision to recommend total joint replacement in hip and knee osteoarthritis: an international cross-sectional study of 1909 patients. Report of the OARSI-OMERACT Task Force on total joint replacement. Osteoarthritis and Cartilage 2011;19:147–54.Google Scholar must have involved a lot of time and money and was a big undertaking; furthermore, it seems that it was driven, as so much of the research we do is these days, by the agenda of the pharmaceutical industry rather than a patient-related question. Surely there should have been more reflection on the wisdom of such an undertaking. If we had listened more to what the patients and the public were telling us, and to folk like my friend Eddie before undertaking this research, we would surely have re-formulated the questions. The data that we need is on what determines good and bad outcomes after joint replacement. None. I would like to thank my friend Eddie May, of Kuwait days, for all sorts of things, including humour, bridge, cricket, and of course, his hip. The work described was funded by the UK Medical Research Council and by Arthritis Research UK .