The Grand Challenge – Managing End-Staged Joint Osteoarthritis

What is the problem? Musculoskeletal disease is a common condition that affects up to one quarter the population over 65 years in many developed countries. Over 6 million Australians (1) and 27 million Americans (2) are affected by some type of musculoskeletal disorder of which osteoarthritis (OA) is the most common. Musculoskeletal disorders account for one fifth of all consultations with general practitioners (3) in Australia. The total cost of OA and other musculoskeletal conditions in Australia was estimated as $55.1 billion in 2012, and the burden of disease cost was estimated to be $34.2 billion, based on a loss of 182,135 disability adjusted life years (DALYs) (4). In the United States, the personal and community cost of musculoskeletal diseases including those through lost wages now approaches $950 billion (5). The 2010 Global Burden of Disease Study demonstrates the worldwide scale of this problem, identifying musculoskeletal disorders as the second largest contributor to life lost through disability after Cancer (6). OA has the highest trajectory of increasing prevalence across all musculoskeletal conditions (4) and in Australia is forecast to become the leading cause of disability (7). Total joint replacement (TJR), which is not only effective for improving the quality of life of people with end stage OA (8) is also a cost effective solution (9). What is the challenge? What is required is system-wide reform of the management of end-stage OA beginning with how patients with OA are assessed for referral to orthopaedic surgeons for TJR, how the appropriateness for referral is decided, how patients who are being considered for TJR are re-evaluated while co-morbidities are addressed and finally how patients who are not suitable for TJR are identified and referred for alternate care. The central theme that unites these processes and which is the essence of this grand challenge is improving outcomes after TJR by determining Appropriate Patient Selection – The right treatment for the right patient at the right time. What are the dilemmas when considering TJR? TJR can be the treatment of choice for OA, but there is little evidence to guide decision-making about who is most likely to benefit from TJR, nor the best timing of when surgery should be performed (10). There are many factors complicating the decision-making process. (i) High volume Referral guidelines for TJR have been promulgated by many learned colleges and consumer advocacy groups (11). However, referrals for TJR are becoming so prolific that the numbers on surgical waiting lists may rise