First Guidelines on Hip Osteoarthritis From AAOS

Veronica Hackethal, MD

April 13, 2017

New guidelines from the American Academy of Orthopedic Surgeons (AAOS) place an emphasis on presurgical treatments to reduce pain and increase mobility, including corticosteroid injections and nonnarcotic pain medication. The recommendations also highlight patient populations who may have greater risk associated with hip replacement surgery.

The document, published on the Academy's website on April 5, represents the first time the AAOS has issued guidelines for hip osteoarthritis and is part of a wider effort to systematically evaluate the evidence and provide recommendations on clinically relevant topics for practicing orthopedic surgeons.

The guidelines are endorsed by the Pediatric Orthopedic Society of North America, the American Physical Therapy Association, and the American College of Radiology.

Hip osteoarthritis is a common cause of disability in US adults, and the leading cause for joint replacement surgery. Increasing life expectancy means that the prevalence of hip osteoarthritis will likely continue to rise.

The AAOS guideline gives strong recommendations for corticosteroid injections, physical therapy, and nonnarcotic medication to improve pain and mobility in the preoperative period.

"Corticosteroid injections, physical therapy, and nonnarcotic anti-inflammatory medications like ibuprofen and naproxen were all treatment modalities that had the highest levels of evidence to support their use prior to hip replacement surgery," Gregory Polkowski, MD, from Vanderbilt University, Nashville, Tennessee, told Medscape Medical News. Dr Polkowski chaired the work group that drew up the clinical practice guidelines.

In contrast, the group does not recommend use of hyaluronic acid injections and glucosamine sulfate for the nonsurgical treatment of hip osteoarthritis, as the literature review showed they were not effective.

The guideline authors also looked at factors that contribute to complications associated with hip replacement surgery, such as infection, blood clots, dislocation, pain, and the need for reoperation. They found that obesity, smoking, age, and type 2 diabetes were all associated with higher complication rates after surgery. The risk was particularly exaggerated for patients who had poorly controlled diabetes.

Dr Polkowski emphasized that the intent of identifying higher-risk groups was not to discourage surgery in these groups.

"That's not to say that patients with those conditions don't benefit from hip replacement surgery. They benefit tremendously. However, the complication rates are higher. We think it's important for surgeons to counsel their patients to that effect and, if possible, try to modify those risk factors with their patients on an individual basis," he said.

In particular, weight reduction is important for any patient with lower extremity arthritis to help control symptoms and potentially slow down progression, he added.

Strong and Moderate Evidence Available

To draw up the guidelines, the group searched four databases for articles about the surgical treatment of hip osteoarthritis in adults, published between January 1990 and April 2016. They also manually searched bibliographies of selected articles. After peer review and public comments, the draft guidelines were edited and approved by the AAOS Committee on Evidence-Based Quality and Value, AAOS Council on Research and Quality, and AAOS Board of Directors.

The group found moderate strength evidence for the following risk issues:

  • Practitioners may use risk assessment tools for predicting complications, assessing surgical risks, and educating patients about receiving total hip arthroplasty.

  • Obese patients may have lower absolute outcome scores, but similar levels of satisfaction and improvement in pain and function after total hip replacement compared with nonobese patients.

  • Increased age is associated with lower functional and quality-of-life outcomes after total hip replacement.

  • Mental health disorders, including depression, anxiety, and psychosis, are associated with decreased function, pain relief, and quality of life after total hip replacement.

Dr Polkowski and colleagues found limited-strength evidence suggesting that tobacco use and obesity are associated with increased risk for surgical complications. Limited evidence also suggested that younger age may be associated with a higher risk for surgical revision, and increased age may be associated with a higher risk for mortality after surgery.

They found strong evidence regarding the following management approaches:

  • Nonnarcotic medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) improve short-term pain, function, or both.

  • Corticosteroid injections provide short-term improvements in function and pain.

  • Hyaluronic acid injections are no better than placebo for improving function, stiffness, and pain.

  • Physical therapy improves function and decreases pain in mild to moderate hip osteoarthritis.

And moderate strength evidence for the following:

  • Postoperative physical therapy improves early function more than no physical therapy.

  • Glucosamine sulfate is no better than placebo for improving function, reducing stiffness, and decreasing pain.

  • Practitioners may use intravenous or topical tranexamic acid to reduce blood loss associated with total hip replacement surgery.

  • No clinically significant differences in patient-oriented outcomes for anterior vs posterior approaches in total hip replacement.

The guidelines were funded by the American Academy of Orthopaedic Surgeons. The authors have disclosed no relevant financial relationships.

"Management of osteoarthritis of the hip: Evidence-based guidelines." American Academy of Orthopedic Surgeons. April 5, 2017. Full text

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