Are Radiographs Necessary at 1 Year After Routine, Uncomplicated TJA?
Dr. Nicolas Noiseux answers ICJR’s questions about his study that examined whether routine radiographs obtained 1 year postoperatively are necessary for clinical management of total hip and total knee arthroplasty patients and whether these patients are even showing up for their follow-up visits.
ICJR: What question did you and your co-authors want to answer with this study?
Nicolas O. Noiseux, MD, MS, FRCSC: The need to continue the practice of routinely ordering radiographs following total joint arthroplasty (TJA) is questionable given improvements in techniques and implants and the growing emphasis on cost efficiency. In the case of virtual clinic visits – which have become more common since the early days of the COVID-19 pandemic – obtaining radiographs is impossible.
Our study examined whether routine postoperative radiographs, ordered “per protocol” in the course of uncomplicated TJA follow-up, contribute to changes in clinical management, especially by 1 year postoperatively. As a secondary question, we sought to assess how often patients are attending surveillance follow-up appointments in the short term (6 to 12 weeks) and 1 year after surgery.
ICJR: What did you conclude about routine radiographs post-TJA?
Dr. Noiseux: We concluded that repeated radiographs obtained during follow-up of an otherwise uncomplicated primary TJA are unlikely to provide novel information leading to changes in clinical management. Although it is essential to obtain 1 set of high-quality films for future long-term follow-up comparisons, we felt that we could order radiographs less frequently in patients who were recovering as anticipated. Thus, if satisfactory films are taken at 6 to 12 weeks postoperatively, the 1-year asymptomatic surveillance assessment/visit does not require further films.
ICJR: How did you reach your conclusions? What was your study cohort and what did you find with your analysis?
Dr. Noiseux: Our study included 978 patients who underwent primary total hip (n=481) or total knee arthroplasty (n=497) in 2018 at our institution, which is the largest tertiary referral center in the state. We excluded patients who had a significant event, such as a fall leading to periprosthetic fracture or instability requiring revision, as these problems would change the patient’s clinical management and their need for additional radiographs. We also excluded patients who underwent TJA as a result of a tumor or trauma.
Of the more than 800 radiographs obtained during follow-up visits, the radiologist noted only 1 radiographic abnormality, which the surgeon interpreted as artifact. Routine follow-up radiographs, therefore, did not contribute to any change in the management of patients with an uncomplicated clinical course.
Nearly all patients attended a 6- and/or 12-week follow-up visit, but only about two thirds attended their 1-year follow-up visit. We believe, based on these finding, that the 6- or 12-week visit may be the ideal time point to obtain baseline implant radiographs for long-term follow-up.
ICJR: Why are these findings significant for clinical practice?
Dr. Noiseux: Our findings are significant in light of the continued expansion of virtual clinic visits. Surgeons may struggle with the decision to repeatedly bring asymptomatic patients into the office just to obtain routine radiographs. Findings from our study suggest that repeated radiographs are unlikely to provide new information or alter clinical management. Therefore, it may be unnecessary to bring a patient to clinic just for radiographs, particularly if they are doing well clinically.
Thus, the use of virtual surveillance follow-up visits to obtain patient-reported outcomes or other information on how patients are doing can be a paradigm shift that improves safety (in a pandemic setting, for example) and efficiency in total joint practices. There is minimal risk of missing radiographic findings as a result of forgoing further radiographs.
Hart AA, DeMik D, Noiseux NO. Routine radiographs after total joint arthroplasty: is there clinical value? (Paper 729). Presented at the 2021 Annual Meeting of the American Academy of Orthopaedic Surgeons, August 31-September 3, San Diego, California.
Hart AA, DeMik DE, Brown TS, Noiseux NO. Routine radiographs after total joint arthroplasty: is there clinical value? J Arthroplasty. 2021 Jul;36(7):2431-2434. doi: 10.1016/j.arth.2021.02.050. Epub 2021 Feb 24.
About the Expert
Nicolas O. Noiseux, MD, MS, FRCSC, is an Associate Professor and the Vice Chair for Clinical Affairs in the Department of Orthopedics and Rehabilitation at The University of Iowa Hospitals and Clinics in Iowa City.
Disclosures: Dr. Noiseux has disclosed that he receives royalties from Link Orthopaedics and that he receives research support from DePuy Synthes, MicroPort, and Smith & Nephew.