Determining who should be referred for total hip and knee replacements

Total hip and total knee replacements (THR and TKR respectively), the definitive treatments for end-stage arthritis, are both safe and extremely successful in relieving pain and improving function. However, physicians who care for patients with chronic hip and knee arthritis are often the 'gatekeepers' to total joint replacement (TJR) procedures as they select patients for referral to an orthopaedic surgeon to be considered for arthroplasty. Currently, no evidence-based criteria exist to guide physicians in this decision-making process, and this situation raises the possibility that conscious or unconscious biases may influence referral patterns, potentially leading to systematic inequities regarding which patients are eventually offered TJR. This article reviews why TJRs are particularly important procedures, and highlights common misperceptions among physicians regarding TJR risk assessment. This article also underscores the benefits of ongoing discussion regarding TJR with all patients with moderate-to-severe chronic hip or knee pain and disability.