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Cover of Evidence reviews for the indicators for referral for possible joint replacement surgery

Evidence reviews for the indicators for referral for possible joint replacement surgery

Osteoarthritis in over 16s: diagnosis and management

Evidence review O

NICE Guideline, No. 226

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-4740-9

1. Referral for joint replacement

1.1. Review question

What are the indicators for possible joint replacement surgery?

1.1.1. Introduction

Knowing when to refer a person with osteoarthritis for consideration for a joint replacement is a challenge for healthcare professionals working in primary care. There are few contraindications to surgery now that it can be performed without a general anaesthetic. Joint replacement can have significant benefits to function, pain and quality of life. It is unclear which prognostic factors demonstrate that surgery would be beneficial, and surgeons do not have the resource to evaluate everyone. Decision making for referral does not usually occur on the basis of imaging, rather on clinical assessment. Musculoskeletal interface services often sit between primary care and orthopaedic services to support appropriate use of noninvasive approaches before referral onto surgery.

Current practice for people with osteoarthritis is to refer when patients have significant pain and functional limitation. This review aims to determine which risk factors presenting in primary care accurately predict the progression to joint replacement surgery being carried out.

1.1.2. Summary of the protocol

Table 1. PICO characteristics of review question.

Table 1

PICO characteristics of review question.

For full details see the review protocol in Appendix A.

1.1.3. Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in Appendix A and the methods document.

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

1.1.4. Prognostic evidence

1.1.4.1. Included studies

Six prospective cohort studies were included in the review;14, 20, 34, 35, 45, 52 these are summarised in below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3). All studies conducted a multivariate analysis for each prognostic value.

No relevant clinical studies investigating the effects of the following prognostic factors were identified:

  • Presence of night pain
  • Instability symptoms
  • Presence of flares
  • Shoulder scores (including the Oxford Shoulder Score, Constant Score, Shoulder Pain and Disability Index, The Disabilities of the Arm, Shoulder and Hand Score)
  • WOMAC (summary score)
  • EQ-5D/EQ VAS

The outcome measure was reported as time-to-event and dichotomous outcomes. Due to studies reporting different measures of prognostic variables and different types of outcome data, no studies were meta-analysed and results were instead reported individually.

Indirectness

The majority of outcomes were downgraded for indirectness for a range of reasons:

  • Prognostic variable indirectness:
    • The combination of scores that were stated in the protocol to be investigated separately (for example: Oxford Hip and Knee score combined)35
    • The reporting of subscales of a score rather than the summary score (for example: KOOS/HOOS pain score)14, 20
    • The reporting of previous medication use as a surrogate measure for non-response to pharmacological interventions14, 34, 52
    • The reporting of pain at baseline or for a period of time (for example 3 months) as a surrogate measure for longer duration of symptoms34, 45
    • The reporting of pain (visual analogue scale) in a cohort that all underwent an exercise program as a surrogate measure for non-response to non-pharmacological intervention14

See also the study selection flow chart in Appendix A, study evidence tables in Appendix D, forest plots in Appendix E and GRADE tables in Appendix F.

1.1.4.2. Excluded studies

See the excluded studies list in Appendix J.

1.1.5. Summary of studies included in the prognostic evidence

Table 2. Summary of studies included in the evidence review.

Table 2

Summary of studies included in the evidence review.

See Appendix D for full evidence tables.

1.1.6. Summary of the prognostic evidence

Table 3. Clinical evidence summary: non-response to analgesics/intra articular injections for people with hip osteoarthritis.

Table 3

Clinical evidence summary: non-response to analgesics/intra articular injections for people with hip osteoarthritis.

Table 4. Clinical evidence summary: non-response to non-pharmacological interventions for people with hip osteoarthritis.

Table 4

Clinical evidence summary: non-response to non-pharmacological interventions for people with hip osteoarthritis.

Table 5. Clinical evidence summary: longer duration of symptoms for people with hip osteoarthritis.

Table 5

Clinical evidence summary: longer duration of symptoms for people with hip osteoarthritis.

Table 6. Clinical evidence summary: longer duration of symptoms for people with mixed osteoarthritis (hip and knee).

Table 6

Clinical evidence summary: longer duration of symptoms for people with mixed osteoarthritis (hip and knee).

Table 7. Clinical evidence summary: Oxford Hip/Knee Score for people with mixed osteoarthritis (hip and knee).

Table 7

Clinical evidence summary: Oxford Hip/Knee Score for people with mixed osteoarthritis (hip and knee).

Table 8. Clinical evidence summary: KOOS/HOOS (summary score) for people with mixed osteoarthritis (hip and knee).

Table 8

Clinical evidence summary: KOOS/HOOS (summary score) for people with mixed osteoarthritis (hip and knee).

See Appendix F for full GRADE tables.

1.1.7. Economic evidence

1.1.7.1. Included studies

No health economic studies were included.

1.1.7.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix J.

1.1.8. Summary of included economic evidence

There was no economic evidence found.

1.1.9. Economic model

This area was not prioritised for new cost-effectiveness analysis.

1.1.10. Economic evidence statements

  • No relevant economic evaluations were identified.

1.1.11. The committee’s discussion and interpretation of the evidence

1.1.11.1. The outcome that matter most

This study included one critical outcome, progression to a joint replacement. This was agreed to be the outcome most appropriate to answering the question. This was examined with a range of prognostic variables, including: presence of night pain, non-response to analgesics/intra articular injections, non-response to non-pharmacological interventions, longer duration of symptoms, instability symptoms, presence of flares, EQ-5D/EQ VAS, KOOS/HOOS summary score, WOMAC summary score, Oxford Knee and Hip Score, and shoulder scores (including the Oxford Shoulder Score, Constant Score, Shoulder Pain and Disability Index and the Disabilities of the Arm, Shoulder and Hand Score). These prognostic variables were decided as these would be potential reasons that people may be referred to a surgeon that may influence the decision of the surgeon as to whether the person would require joint replacement surgery.

The evidence discussed people with hip osteoarthritis or mixed osteoarthritis, including hip and knee osteoarthritis. No studies included people with shoulder osteoarthritis.

1.1.11.2. The quality of the evidence

Evidence was reported for people with hip and mixed (hip and knee) osteoarthritis. All studies included a multivariate analysis adjusting for key confounders (age and body mass index). Only a limited number of prognostic variables were studied including:

  • Non-response to analgesics/intra articular injections – 3 outcomes for people with hip osteoarthritis that were of very low quality due to risk of bias and indirectness
  • Non-response to non-pharmacological interventions – 1 outcome for people with hip osteoarthritis that was of moderate quality due to indirectness
  • Longer duration of symptoms – 2 outcomes for people with hip osteoarthritis that were of very low quality due to risk of bias and indirectness, 1 outcome for people with mixed osteoarthritis that was of low quality due to risk of bias and imprecision
  • Oxford Hip/Knee Score – 1 outcome for people with mixed osteoarthritis of very low quality due to risk of bias and indirectness
  • KOOS/HOOS (summary score) – 1 outcome for people with mixed osteoarthritis of low quality due to risk of bias and indirectness

Outcomes were commonly downgraded for risk of bias and indirectness. Regarding risk of bias, outcomes were commonly downgraded due to study confounding, as while studies adjusted for the key confounders, no study adjusted for all of the other confounders listed in the protocol (including smoking status, multimorbidity and socio-economic factors). Otherwise, where further risk of bias was identified, studies were more commonly downgraded for study participation or study attrition bias.

The majority of included studies were deemed to have indirect evidence, in particular prognostic variable indirectness. The reasons for this included: using a combination of scores where the protocol requested them to be investigated separately (for example: Oxford Hip and Knee score combined); reporting subscales rather than a summary score and reporting surrogate measures for outcomes (for example: previous medication use as a surrogate measure for non-response to pharmacological interventions, pain at baseline and for a specified period of time as a measure for longer duration of symptoms). However, no outcomes were downgraded for imprecision or inconsistency.

As studies were not comparable (by not adjusting for the same confounding variables, including different definitions of outcomes and different populations) no outcomes were meta-analysed and instead the outcomes from each study were reported separately.

No evidence was identified for the following comparisons:

  • Presence of night pain
  • Instability symptoms
  • Presence of flares
  • EQ-5D/EQ VAS
  • WOMAC summary score
  • Any shoulder scores (including the Oxford Shoulder Score, Constant Score, Shoulder Pain and Disability Index and the Disabilities of the Arm, Shoulder and Hand Score)

1.1.11.3. Benefits and harms
Key uncertainties

The committee noted the limitations in the design of the review to answer the question. This review investigated if people with specific risk factors had joint replacement surgery. These risk factors were in part selected from expert knowledge of the factors that would be considered by surgeons when deciding if someone should have joint replacement surgery. Due to this, current practice already considers these factors important and so this may affect decision making by a GP as to whether to refer someone for joint replacement surgery, and so it is difficult to know whether the prognostic factor led to someone deciding joint replacement surgery was necessary, or if previous guidance stated that people with these prognostic factors should be considered for joint replacement surgery led to the procedure. This makes it difficult to interpret the answer from this evidence, and so the committee used their expert opinion while making the recommendations.

When examining previous use of analgesics/intra articular injections, the studies investigating this examined the use of non-steroidal anti-inflammatory drugs or analgesia, with no specification of the type. Given this, it is difficult to relate the evidence available to the use of intra articular injections. It was acknowledged that people receiving intra articular injections are likely to have worsened symptoms then people who may not need these injections, and so may introduce some confounding.

Additionally, no evidence was found for the following prognostic variables:

  • Presence of night pain
  • Instability symptoms
  • Presence of flares
  • EQ-5D/EQ VAS
  • WOMAC summary score
  • Any shoulder scores (including the Oxford Shoulder Score, Constant Score, Shoulder Pain and Disability Index and the Disabilities of the Arm, Shoulder and Hand Score)

Limited evidence that the committee concluded was unlikely to provide sufficient evidence was found for the non-response to non-pharmacological interventions prognostic variable.

The committee acknowledged that given the limited evidence and number of indirect outcomes, they concluded that this was an absence of evidence rather than evidence of an absence of effect. Therefore, they considered that, even though evidence may not be present for all prognostic factors, the factors not mentioned may be relevant for decision making.

Non-response to analgesics/intra articular injections

This prognostic variable was investigated in two studies (with one study reporting two surrogate outcomes that were included in the analysis: NSAID intake during the 3 months preceding the evaluation visit and analgesic intake during the previous 3 months preceding the evaluation visit). All outcomes were rated to be of low quality. It should be noted that neither study explicitly discussed the use of intra articular injections before surgery.

While noting the limitations of the evidence given the indirectness of the outcomes, the committee agreed that there was consistent evidence to show that non-response to analgesia lead to more people having a joint replacement procedure. The committee noted that the evidence did not discuss intra articular injections and focussed on oral medication, specifically non-steroidal anti-inflammatory drugs.

On further discussion, the committee agreed that non-response to analgesics may indicate that the symptoms of osteoarthritis are not manageable with other treatments. Non-response to a treatment would be specific to the individual and should be explored with the healthcare professional. In general, the committee discussed that non-response may be seen at 2 to 4 weeks of analgesic treatment. However, people may present after having a flare of disease activity, which may be present throughout this time period and so this evaluation needs to be made taking into account the entire clinical picture of the person. Due to this, using their expert opinion, they made recommendation.

Non-response to non-pharmacological interventions

This prognostic variable was investigated indirectly in one study. This study followed up participants who had been involved in an exercise programme preceding the study. Therefore, the pain at the start of trial was used in this review as a surrogate measure for whether people responded to the exercise programme. The committee agreed that the use of this evidence was limited and was unlikely to give a complete understanding of the effect of this prognostic variable. It was agreed to include this outcome for consideration, but to emphasise the indirectness of the finding.

The outcome showed no difference in people with pain at the start of the study with those who had lower amounts of pain. Based on this evidence and the limitations identified, the committee concluded that further research would be required to investigate the effect of this prognostic variable on predicting whether someone required surgery.

Longer duration of symptoms

This prognostic variable was investigated in three studies (two for people with hip osteoarthritis, and one for people with hip or knee osteoarthritis). Outcomes were rated to be of moderate to low quality evidence. For people with hip osteoarthritis, outcomes showed that a longer duration of symptoms may lead to more joint replacement procedures. For people with hip or knee osteoarthritis, outcomes showed that there was no significant difference in the number of joint replacement surgeries in people with different durations of symptoms.

The committee acknowledged that these findings were contradictory. On examining the quality of the evidence, the committee acknowledged that the outcomes for people with hip osteoarthritis only were downgraded for indirectness as the outcomes used surrogate measures for longer duration of symptoms while the outcome used in people with mixed osteoarthritis was more direct. Furthermore, the committee acknowledged that longer duration of symptoms could be confounded by other risk factors, such as response to analgesics, and so this could influence the results being seen.

Given the evidence and weighing up the benefits and the risks of surgery, the committee agreed that people should receive all appropriate recommended treatments delivered in an appropriate manner before they should be referred to surgery whilst taking into account the duration and rate of progression of the pain and functional deterioration.

Oxford Hip/Knee Score

This prognostic variable was investigated in one study. The outcome was rated to be of low quality. The outcome showed that people with higher Oxford Hip/Knee Scores may be less likely to have joint replacement surgery then people with lower scores.

Due to the limited evidence available, the committee used their expert opinion while making recommendations. The committee discussed that scores such as the Oxford Hip and Knee scores are not designed for preoperative prediction of whether someone requires surgery, and instead clinical judgement based on the experience of the person with osteoarthritis should be the main determinant. Instead, the Oxford Hip and Knee scores are more useful for indicating change in pain and functional outcome after surgery, and so can be used to look at the success of the surgery. Current guidance would indicate that these scores should not be used to determine whether someone should have surgery or not. However, there is inconsistency in how scores are used in current practice. Weighing up the potential benefits and risks, the committee agreed it was inappropriate to use these scores to determine whether someone should have surgery and that the clinical presentation of the person should be of greater emphasis in making this decision.

KOOS/HOOS (summary score)

This prognostic variable was investigated in one study. The outcome was rated to be of low quality. Where reported, only the pain subscale of the KOOS/HOOS scale was used, which limited the interpretation of the evidence. However, the evidence present showed that there was no apparent difference in the number of joint replacement procedures for people with different KOOS/HOOS scores.

As with the Oxford Hip and Knee score, the committee agreed that numerical scales were unlikely to be useful as a main determinant as to whether someone with osteoarthritis should have joint replacement surgery. Furthermore, the evidence showed that KOOS/HOOS scores were not determinants as to whether someone had a joint replacement surgery.

Consideration for the evidence for the recommendations

Overall, the committee concluded that, using the limited available evidence combined with their expert opinion and the approaches in current practice, that people with persistent symptoms that are affected their quality of life (such as pain, stiffness, reduced function or progressive joint deformity) and are non-responsive to non-surgical treatments may benefit from surgery. Therefore, they agreed recommendation 1.6.1. In recommending this, the committee extended the evidence of non-response to analgesics to non-pharmacological management, which the committee agreed would also influence decision making even though the evidence for this was not found in this review (this absence of evidence influenced the decision to recommend a research recommendation). Given the evidence and weighing up the benefits and the risks of surgery, the committee agreed that people should receive all appropriate recommended treatments delivered in an appropriate manner before they should be referred to surgery. Through this, the committee made recommendation 1.6.2.

As there was limited evidence, the committee made a research recommendation to investigate the effect of other prognostic variables states in the protocol to investigate if they influence joint replacement surgery rates.

1.1.11.4. Cost effectiveness and resource use

There were no published economic evaluations found specifically about referral for joint replacement. Cost-effectiveness modelling was not feasible since a model would require good evidence of clinical effectiveness, which was not the focus of this review. However, the committee were aware that there is a body of evidence showing that surgery itself is highly effective at improving quality of life and is cost effective in appropriately selected patients.

The committee’s decision to continue to recommend referral for joint surgery for people with osteoarthritis who experience joint symptoms that have a substantial impact on their quality of life and are refractory to medical management. This is unlikely to have an impact on resource use since it reflects current practice and ensures that patients continue to receive current standard of care.

The committee also made a research recommendation to assess whether the presence of night pain, non-response to non-pharmacological interventions, instability symptoms, presence of flares and various summary scores can be suitable indicators for joint replacement surgery. If such indicators were to be recommended as suitable for referral to surgery in future, it would be expected to cause a significant increase in resource use since the surgical procedure itself is costly. However, the additional costs may be justified if there were evidence of improved quality of life post-surgery and/or subsequent reductions in resource use.

1.1.11.5. Other factors the committee took into account

The committee considered health inequalities while making recommendations. The studies mostly included people with a mean age between 60 and 75 years. Older people may be more likely to develop osteoarthritis and so require consideration for surgery. The studies included did not report socioeconomic status. People from lower socioeconomic backgrounds may be more likely to develop osteoarthritis and could be more likely to have other factors that will influence the decision-making regarding surgery (for example: people may be of a higher or lower weight). Ethnicity was not reported in the included studies, though one included study was a sub-study of another trial where non-white women were excluded. Intersectionality may exist with other groups that experience health inequities. The committee agreed that any further research should be representative of the population, including people from different family backgrounds, and socioeconomic backgrounds, disabled people, and people of different ages and genders. Future work should be done to consider the different experiences of people from diverse communities to ensure that the approach taken can be made equitable for everyone. With this in mind the committee included these protected characteristics in the multivariate analysis for their research recommendation where appropriate while suggesting that people from each group should be included in the research to ensure that it is applicable to the entire population.

1.1.12. Recommendations supported by this evidence review

This evidence review supports recommendations 1.6.1 to 1.6.2 and the research recommendation on referral for joint replacement. Other evidence supporting these recommendations can be found in evidence review O.

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Appendices

Appendix B. Literature search strategies

  • What are the indicators for referral for possible primary joint replacement surgery?

The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.63

For more information, please see the Methodology review published as part of the accompanying documents for this guideline.

B.1. Clinical search literature search strategy (PDF, 201K)

B.2. Health Economics literature search strategy (PDF, 224K)

Appendix C. Prognostic evidence study selection

Download PDF (117K)

Appendix D. Prognostic evidence

Download PDF (245K)

Appendix F. GRADE tables

Download PDF (237K)

Appendix G. Economic evidence study selection

Download PDF (205K)

Appendix H. Economic evidence tables

There were no health economic studies found in the review.

Appendix I. Health economic model

No original economic modelling was undertaken.

Appendix J. Excluded studies

Clinical studies

Table 18Studies excluded from the clinical review

StudyExclusion reason
Agricola 20131Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Agricola 20132Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Barr 20123Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Bastick 20155Systematic review; references checked
Bastick 20174Does not adjust for BMI in multivariate analysis
Betancourt 20096Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Bevers 20157Wrong prognostic factor (radiographic or clinical factors that were not included in the protocol), Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Bihlet 20208Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Birch 20199Wrong study type (cross-sectional study)
Birrell 200310Does not adjust for variable in a multivariate analysis
Bouyer 201611Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Bruyere 201312Outcomes not adjusted for in a multivariate analysis
Chan 201013Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Collins 201415Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Collins 202116Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Conaghan 201017Multivariate analysis does not adjust for age and BMI
Costa 202118Conference abstract
Costello 202119Does not adjust for age and BMI in a multivariate analysis
Davis 201822Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Dieppe 200023Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Dieppe 201124Narrative review
Dougados 199925Does not adjust for age and BMI in a multivariate analysis
Dreinhofer 200626Wrong study type (survey)
Driban 201628People with osteoarthritis or at risk of osteoarthritis
Driban 202027Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Faschingbauer 201729Does not adjust for age and BMI in a multivariate analysis
Fox 199631Does not adjust for age and BMI in a multivariate analysis
Ferguson 202130Wrong prognostic variable (comorbidity scores)
Gillam 201332Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Gossec 201133Wrong study type (cross-sectional study)
Hafezi-Nejad 201636Does not adjust for age and BMI in a multivariate analysis
Harms 200737Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Hawker 201338Wrong population (people with rheumatoid arthritis and osteoarthritis, all people had surgery), Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Hirschmann 201339Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Huynh 201840Wrong study type (cross-sectional study)
Kanthawang 202141Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Kany 202142Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Kastelein 201143Wrong population (only 50% of the population had osteoarthritis)
Kwoh 202044Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Ledingham 202046Does not adjust for risk factors in a multivariable analysis
Leung 201547Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Levine 201348Systematic review not relevant to our review (looks at interventions)
Leyland 201649Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Lievense 200750Does not adjust for risk factors in a multivariable analysis
MacIntyre 201551Does not adjust for BMI in multivariate analysis
Maillefert 200853Factors not investigated in a multivariate analysis (examined other factors, such as comorbidity, joint space narrowing and SF-12)
Mancuso 199654Wrong study type (surveys)
Mandl 201355Wrong study type (narrative review)
McHugh 201157Does not adjust for weight and BMI in a multivariate analysis for the outcomes of interest
Mezhov 202159Does not adjust for age and BMI in a multivariate analysis
Miura 202160Wrong study type (cross-sectional study), wrong population (mixture of osteoarthritis and degenerative dysplasia of the hip)
Neufeld 201964Does not adjust for age and BMI in a multivariate analysis
Peer 201365Systematic review not relevant to our review (validity and reliability review)
Pelletier 201366Narrative review
Perry 202067Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Ponzio 202168Wrong population (all people had surgery)
Pope 200869Wrong study type (case control study)
Price 202070Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Quintana 200571Wrong study type (cross-sectional study)
Rahman 201172Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Rajamaki 202173Wrong population (all people had surgery)
Reijman 200574Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Riddle 201278Does not adjust for BMI in multivariate analysis
Riddle 201379Reports outcomes as growth curve parameters, no mention of a multivariate analyses
Riddle 201376Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Riddle 201577Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Riddle 202075Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Schiphof 201980Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Tambascia 201681Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Teirlinck 201982Systematic review; references checked
Teng 201783Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Tolpadi 202084Wrong study type (case control study)
Turcotte 202185Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
van de Sande 200686Systematic review; not relevant PICO
Vinciguerra 199587Not available
Wang 200988Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)
Wang 202089Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Weigl 202190Does not adjust for age and BMI in a multivariate analysis
Wijn 202091Does not adjust for age and BMI in a multivariate analysis
Zeng 201992Wrong comparator (comparing to something other than whether the person goes on to need joint replacement surgery)
Zeni 201093Wrong prognostic variable (radiographic or clinical factors that were not included in the protocol)

Health Economic studies

Published health economic studies that met the inclusion criteria (relevant population, comparators, economic study design, published 2005 or later and not from non-OECD country or USA) but that were excluded following appraisal of applicability and methodological quality are listed below. See the health economic protocol for more details.

Table 19Studies excluded from the health economic review

ReferenceReason for exclusion
Dakin 201221Excluded as rated not applicable. Study is not relevant to the review question as it assesses the cost effectiveness of joint replacement surgery.
Mari 201656Excluded as rated not applicable. Study is not relevant to the review question as it assesses the cost effectiveness of joint replacement surgery.
Medical Advisory Secretariat 200558Excluded as rated not applicable. Study is not relevant to the review question as it assesses the cost effectiveness of joint replacement surgery.
Mujica Mota 201362Excluded as rated not applicable. Study is not relevant to the review question as it assesses the cost effectiveness of joint replacement surgery.
Mujica Mota 201761Excluded as rated not applicable. Study is not relevant to the review question as it assesses the cost effectiveness of joint replacement surgery.

Appendix K. Research recommendations – full details

K.1. Research recommendation

What are the most important indicators that someone with osteoarthritis (including shoulder osteoarthritis) would benefit from joint replacement? For example:

  • presence of night pain
  • non-response to non-pharmacological interventions
  • joint instability symptoms
  • presence of flares
  • numerical summary scores.

K.1.1. Why this is important

Although joint replacement is demonstrated to be an effective treatment for end-stage osteoarthritis, there are few data on the relative importance of the various clinical features of the disease as indications for referral for surgery. It is important to understand which of these features should action a referral for surgery.

K.1.2. Rationale for research recommendation

Download PDF (163K)

K.1.3. Modified PICO table

Download PDF (156K)

Final version

Evidence reviews underpinning recommendations 1.6.1 to 1.6.2 and research recommendations in the NICE guideline

Disclaimer The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Copyright © NICE 2022.
Bookshelf ID: NBK589221PMID: 36791242

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