Newly Revised CPG Provides Guidance on Osteoarthritis of the Hip

In December 2023, the AAOS Board of Directors approved a revamped Clinical Practice Guideline (CPG) for the Management of Osteoarthritis (OA) of the Hip. The new CPG, a revision of the guideline issued in 2017, is based on a systematic review of published studies examining the treatment of hip OA.

Charles Hannon, MD, MBA, FAAOS, co-chair (representing AAOS) of the CPG Development Group along with Ronald Delanois, MD, FAAOS (representing the Hip Society), noted that the new CPG includes several new topics since the 2017 edition, including cemented versus cementless femoral fixation, social determinants of health, hip–spine relationship, and diabetes as a risk factor.

The guideline provides three strong and five moderate recommendations. The “strong” entries cite high-quality evidence in support of two treatment options or adjuncts:

• Tranexamic acid should be considered for patients with symptomatic osteoarthritis of the hip who are undergoing total hip arthroplasty (THA) to reduce blood loss and the need for blood transfusions.
• When not contraindicated, oral nonsteroidal anti-inflammatories should be used to reduce pain and improve function in the treatment of symptomatic hip osteoarthritis.

The other strong recommendation advises against the use of intraarticular hyaluronic acid, “as it does not improve function or reduce pain better than placebo.”

The recommendation on cemented versus cementless fixation, among the moderate-strength options, states, “Low-quality evidence suggests in older adult patients undergoing total hip arthroplasty for symptomatic osteoarthritis, cemented femoral stems could be considered as they are associated with a lower risk of periprosthetic fracture.” Dr. Hannon said this item “piqued the most discussion among the workgroup.” He explained: “In a CPG, registry data are not included. Thus, the data on cemented versus cementless stems included in the guideline were limited to low-quality studies. The recommendation to consider cemented fixation in older patients undergoing THA was upgraded due to the risks of periprosthetic fracture, risks to acceptability as the vast majority of femoral stems implanted are cementless, as well as the importance of training surgeons on cement technique. The workgroup felt that as a result of these factors, a greater strength of recommendation was deserved.”

The guideline makes two recommendations regarding physical therapy for hip OA, one in regard to conservative treatment and one in regard to therapy after surgical treatment. Although both indications are endorsed, the recommendations were downgraded to moderate. Dr. Hannon explained: “For mild to moderate OA of the hip, physical therapy could be considered as a treatment. While there were 13 high-quality studies, the workgroup downgraded this recommendation due to the significant heterogeneity in the studies published. The data on physical therapy for conservative treatment are extremely variable on the type of therapy, frequency, as well as duration. This also applies to physical therapy after THA. After THA, formal physical therapy or unsupervised home exercises are equally effective.”

On the question of exposure approach—often a topic of robust discussion in regard to hip arthroplasty—the CPG’s moderate recommendation states: “High-quality evidence supports that there are specific risks and benefits to each surgical approach and that there is not a preferred surgical approach for patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty.”

Dr. Hannon elaborated: “There has been an abundance of high-quality literature on the impact of approach to THA on postoperative outcomes. The data clearly support that there is not a single approach that is better than the others. Each surgical approach in THA is associated with specific risks and benefits. Certain risks or benefits may be more associated with one approach over another. For example, a posterior approach is associated with an increased risk of dislocation and an anterior approach associated with an increased risk of wound complications. The decision to use a specific approach should be based on a surgeon’s training and experience with the approach and should be individualized to each patient.”

Although the guideline firmly advises against use of hyaluronic acid, it offers a moderate recommendation in favor of intra-articular corticosteroid injection, which, it states, “could be considered to improve function and reduce pain in the short term for patients with symptomatic osteoarthritis of the hip.”

In addition to the recommendations characterized as strong or moderate, the new CPG offers eight “options”—which are formed “when there is little, conflicting, or no evidence on a topic.” These included an opinion that oral acetaminophen, when not contraindicated, “may be considered to improve pain and function” in treatment of symptomatic hip OA. In regard to prescription oral opioids as conservative treatment, the CPG advises against their use in nonoperative management.

Another option, addressing neuraxial versus general anesthesia, states, “Limited evidence suggests that neuraxial anesthesia may be used to reduce adverse events in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty.”

Two options cover current thinking about the role and effect of BMI in hip OA and its management. One states that elevated BMI may increase the risk of adverse events in patients undergoing THA, and the other states that “limited evidence supports that patients with elevated BMI and symptomatic osteoarthritis of the hip may achieve lower absolute patient-reported outcome scores but a similar degree of improvement in patient satisfaction, pain, function, and quality of life after total hip arthroplasty.”

New to this revised CPG is guidance on the hip–spine relationship: “Patients with osteoarthritis of the hip and stiff spine syndrome may be at increased risk of dislocation after total hip arthroplasty compared to patients without stiff spine syndrome.” Another new topic is social determinants of health, with an option suggesting that such determinants, including education, income level, food desert, and insurance type, “may negatively impact length of stay, total cost of care, and mortality after total hip arthroplasty.”

The option on diabetes states that patients with poorly controlled diabetes may be at higher risk for adverse effects after hip arthroplasty. Finally, an option notes that patients with symptomatic hip OA who use tobacco products may be at an increased risk for adverse events after THA.

Dr. Hannon said the revised CPG is timely and appropriate. “There has been an abundance of literature published on many of the topics in the guideline since 2017. This guideline provides AAOS members with the most up-to-date evidence-based practices that they can use to best treat their patients with osteoarthritis of the hip.”

Representatives from the Hip Society, American Physical Therapy Association, American Association of Hip and Knee Surgeons, and American College of Radiation participated in the development of this guideline.

The CPG on Management of Osteoarthritis of the Hip can be accessed on the OrthoGuidelines app and at OrthoGuidelines.org.

Terry Stanton is the former senior medical writer for AAOS Now.