Participant characteristics
Fifteen medical professionals (6 orthopaedic surgeons, 4 rheumatologists and 5 general practitioners) were interviewed. The average length of the whole interview was 20 minutes (range 14 to 30 minutes). Participants had an average age of 52 years (SD 12) and 25 years of clinical experience (SD 15). Table 1 reports the demographic and employment characteristics of the participants.
Table 1
Variable | n = 15 |
Profession, n (%) GP Rheumatologist Orthopaedic surgeon | 5 (33) 4 (27) 6 (40) |
Age (years), mean (SD) | 52 (12) |
Female, n (%) | 1 (7) |
Years practicing, mean (SD) | 25 (15) |
GP Rheumatologist Orthopaedic surgeon | 32 (15) 22 (14) 15 (10) |
Current volume of management of hip and knee OA, mean (SD) | |
High volumea Low volume | 13 (87) 2 (13) |
Work setting for orthopaedic surgeons and rheumatologists, n % Both private and public Private only Public only | 8 (80) 2 (20) 0 (0) |
OA = osteoarthritis; GP = general practitioner; ahigh volume included following examples of responses – ‘all or majority of practice’, ‘a lot’, ‘daily’, ‘75 to 90%’, ‘at least 30–40 patients per week’ |
Themes
Three main themes were identified: (i) recognition of the importance of non-surgical management of hip and knee OA, focussed on exercise-therapy, weight management, and analgesia; (ii) joint replacement being considered the ‘last resort’ for end stage disease not responding to non-surgical management; and (iii) determination of management ‘success’ through patient perceptions rather than the use of validated instruments.
(i) Recognition of the importance of non-surgical management of hip and knee OA, focussed on exercise-therapy, weight management, and analgesia
All participants considered that non-surgical management, particularly exercise-therapy and analgesia, was important for patients with hip and knee OA and should be provided before considering surgery. The perceived value was summed up by one rheumatologist:
“Critical, critical. And by that, I don’t mean just medications and injection. I think strength training in particular is something that’s very underutilised.”
Rheumatologist (P2)
Non-surgical management was broadly interpreted to incorporate tailored treatment options, guided by both clinical symptoms and radiological features. Treatments considered to be important included encouragement to self-manage, improve lifestyle and keep mobile, activity modification (commonly reported by orthopaedic surgeons), physiotherapy, exercise-therapy, weight management, analgesia (including injections), heat/ice/compression (for acute exacerbations), glucosamine despite acknowledging no evidence of efficacy, manual therapy, use of gait aids and braces, and management of mental health.
“I usually like people to modify their activities, I like them to lose weight, I like them to stop running, jogging, and doing activities that stir things up.”
Orthopaedic surgeon (participant 4)
The most valuable components of non-surgical management were perceived to be exercise-therapy, weight management and analgesia. Exercise-therapy was considered important for varying reasons, including providing more muscular support for joints, improving confidence about activities and mobility, and the potential to facilitate positive surgical outcomes. Weight management was considered important by all medical professionals interviewed, yet challenges in achieving weight loss were acknowledged. Most medical professionals discussed the regular provision of patient education, with a few medical professionals discussing the role of education as an important component of management. Several medical professionals also recognised that education can be challenging to deliver effectively due to time constraints (e.g. general practice consultations) and patient language barriers.
“I’ll probably do education as part of an ongoing thing from visit to visit without actually focusing on it.” General practitioner (participant 12)
Simple analgesia was considered important to control pain and keep people mobile. Paracetamol was preferred over anti-inflammatories due to being safer, but anti-inflammatories were suggested to produce better results. Medical professionals typically recommended avoiding opioids where possible. Cortisone injections played a common role in management, particularly if surgery was not considered appropriate, to achieve short term improvement in symptoms (e.g. before travelling), for the treatment of acute exacerbations and based on patient preference. Other injectables such as hyaluronic acid and platelet rich plasma were commonly used or trialled despite participants being aware that these treatments lacked evidence of effectiveness.
“Steroid injection of knees, I occasionally do. It’s just analgesia of various kinds. Sometimes if they request platelet-rich plasma or Synvisc or – what's the other one? Stem cells, etcetera. I generally discourage them and left it up to the patient.” Rheumatologist (participant 15)
(ii) Joint replacement being considered the ‘last resort’ for end stage disease not responding to non-surgical management
Joint replacement was perceived by participants to be important for people with severe, end stage OA. It was a common view that joint replacement should be offered to address severe pain and/or disability for people who were not responding to appropriate non-surgical management.
When considering the appropriateness of joint replacement surgery, surgeons considered a range of factors including age and fitness for surgery, patient willingness to undergo surgery, expectations about the outcome from surgery, and likelihood of post-operative complications. For example, one orthopaedic surgeon’s view was that younger patients with higher function were less likely to be satisfied with a joint replacement and consequently emphasised the importance of ensuring appropriate non-surgical options were appropriately trialled before surgery was offered.
“So the younger you are when you have a knee replacement and the more function you’ve got when you have a knee replacement, the less likely you are to love the knee replacement ‘cause it’s an artificial knee.”Orthopaedic surgeon (participant 6)
Divergent opinions between rheumatologists and orthopaedic surgeons regarding the role of joint replacement surgery were evident. Two rheumatologists referred to joint replacement surgery as an ‘adjunct’ treatment, with a role in the overall management of OA, while two orthopaedic surgeons considered that joint replacement was the ‘ultimate surgery’ and a ‘definitive cure’ in cases of severe disease. Surgeons also discussed the appropriateness of other surgical procedures for knee OA including osteotomies, patellofemoral joint replacements and arthroscopy. It was the view of some orthopaedic surgeons that osteotomies may have a role in knee OA management for younger patients to help prevent OA progression, that patellofemoral surgery was a difficult procedure and may not help, and knee arthroscopy was not a useful procedure for OA.
(iii) Determination of management ‘success’ through patient perceptions rather than use of validated instruments
Most participants relied on the patient’s overall perception of improvement in symptoms, function, physical activity and satisfaction to determine treatment success, rather than the use of validated, disease specific outcome instruments. Only one orthopaedic surgeon and one rheumatologist reported using patient-reported outcome measures to assist in decision making about surgery and to judge treatment success.
“Happy patients, pretty simple.” Orthopaedic surgeon (participant 4)
“Oh, they’ll tell me if they’re better or not.” General practitioner (participant 7)
Common considerations for treatment success included pain levels, activity, subjectively reported quality of life, individual goals or overall satisfaction with care. Activity examples included walking distance, ease of using stairs, work, travel, the ability to provide care to others and to look after themselves.