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American Academy of Orthopaedic SurgeonsOrthopaedic Surgery2023advanced

Management of Osteoarthritis of the Hip

Published by American Academy of Orthopaedic Surgeons · GRADE Evidence-to-Decision Framework

17Recommendations
185References
2Tables
1Figures
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Summary

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Osteoarthritis of the hip has a global prevalence of 7.2% and leads to significant functional impairment, pain, and decreased quality of life. This guideline provides evidence-based recommendations for both non-surgical management and total hip arthroplasty for adult patients.

hip osteoarthritistranexamic acidNSAIDsAAOSorthopaedic surgerytotal hip arthroplastycemented femoral stemguidelines

Key Takeaways

  • 1
    Tranexamic acid (TXA) should be considered to reduce blood loss during total hip arthroplasty.
  • 2
    Formal physical therapy or unsupervised home exercise are both supported post-THA.
  • 3
    Oral NSAIDs should be used for pain and function improvements.
  • 4
    Intraarticular hyaluronic acid is not recommended as it performs no better than placebo.
  • 5
    There is no single preferred surgical approach for total hip arthroplasty; risks and benefits are specific to each.
  • 6
    Older patients may benefit from cemented femoral stems to reduce periprosthetic fracture risk.

What's New in This Version

Replaces the first edition completed in 2017. Adopts the GRADE Evidence-to-Decision Framework to incorporate additional factors into the strength of recommendations rather than relying solely on the rigidity of previous AAOS recommendation language stems.

Key Recommendations

TRANEXAMIC ACID

  • 1

    High quality evidence supports that tranexamic acid (TXA) 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.

    StrongEvidence: HighTreatment

POSTOPERATIVE PHYSICAL THERAPY

  • 2

    High quality evidence supports either formal physical therapy or unsupervised home exercise after total hip arthroplasty for symptomatic osteoarthritis of the hip.

    ModerateEvidence: HighRehabilitation

PHYSICAL THERAPY AS CONSERVATIVE TREATMENT

  • 3

    Physical therapy could be considered as a treatment for patients with mild to moderate symptomatic osteoarthritis of the hip to improve function and reduce pain.

    ModerateEvidence: HighConservative Treatment

INTRAARTICULAR CORTICOSTEROID INJECTION

  • 4

    Intraarticular corticosteroids could be considered to improve function and reduce pain in the short-term for patients with symptomatic osteoarthritis of the hip.

    ModerateEvidence: HighTreatment

INTRAARTICULAR HYALURONIC ACID

  • 5

    Intraarticular hyaluronic acid should not be considered for treatment of symptomatic osteoarthritis of the hip as it does not improve function or reduce pain better than placebo.

    StrongEvidence: HighTreatment

PHARMACOLOGICAL MANAGEMENT: NSAIDs

  • 6

    When not contraindicated, oral nonsteroidal anti-inflammatories (NSAIDs) should be used to reduce pain and improve function in the treatment of symptomatic hip osteoarthritis.

    StrongEvidence: HighTreatment

CEMENTED VS. CEMENTLESS FEMORAL FIXATION

  • 7

    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.

    ModerateEvidence: LowSurgical Intervention

EXPOSURE APPROACH

  • 8

    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.

    ModerateEvidence: HighSurgical Intervention

BMI: ADVERSE EVENTS

  • 9

    Limited evidence suggests that elevated BMI may increase the risk of adverse events in patients undergoing total hip arthroplasty for symptomatic hip osteoarthritis.

    LimitedEvidence: LowRisk Assessment

BMI: CLINICAL OUTCOMES

  • 10

    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.

    LimitedEvidence: LowPrognosis

PRESCRIPTION OPIOID AS CONSERVATIVE TREATMENT

  • 11

    In the absence of sufficient evidence, it is the opinion of the workgroup that oral opioids not be utilized for nonoperative treatment of symptomatic osteoarthritis of the hip.

    ConsensusEvidence: ConsensusTreatment

DIABETES: ADVERSE EVENTS

  • 12

    Limited evidence suggests that patients with symptomatic osteoarthritis of the hip and poorly controlled diabetes may be at a higher risk for adverse events after total hip arthroplasty.

    LimitedEvidence: LowRisk Assessment

SOCIAL DETERMINANTS OF HEALTH

  • 13

    Limited evidence suggests that social determinants of health (e.g., education, income level, food desert, insurance type) may negatively impact length of stay, total cost of care, and mortality after total hip arthroplasty.

    LimitedEvidence: LowRisk Assessment

PHARMACOLOGICAL MANAGEMENT: ACETAMINOPHEN

  • 14

    In the absence of sufficient evidence, it is the opinion of the workgroup that when not contraindicated, oral acetaminophen may be considered to improve pain and function in the treatment of symptomatic osteoarthritis of the hip.

    ConsensusEvidence: ConsensusTreatment

HIP-SPINE RELATIONSHIP

  • 15

    In the absence of sufficient evidence, it is the opinion of the workgroup that 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.

    ConsensusEvidence: LowRisk Assessment

NEURAXIAL VS. GENERAL ANESTHESIA

  • 16

    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.

    LimitedEvidence: LowSurgical Intervention

TOBACCO

  • 17

    Limited evidence suggests that patients with symptomatic osteoarthritis of the hip who use tobacco products may be at an increased risk for adverse events after total hip arthroplasty.

    LimitedEvidence: LowRisk Assessment

Scope & Objectives

Clinical Topic

Osteoarthritis of the Hip

Objectives

To evaluate the current best evidence associated with treatment of symptomatic osteoarthritis of the hip in adults to help practitioners integrate evidence and clinical practice.

Target Patient Population

Adult patients (ages 18 years and older) who have been diagnosed by a trained healthcare provider with OA of the hip and are undergoing treatment.

Target Providers

Orthopaedic surgeonsTrained physiciansCliniciansHealthcare providersPhysical therapists

Patient Criteria & Setting

Therapeutic Area

Orthopaedics

Guideline Scope

Non-surgical treatmentSurgical treatment

Inclusion Criteria

  • OAH or prevention thereof
  • Published in or after 1966
  • 10 or more patients per group
  • Minimum of 3 months follow up duration for surgical treatment
  • Minimum of 1 month for non-operative treatment
  • Full article report of a clinical study
  • Study of humans
  • Published in English
  • Quantitatively presented results

Exclusion Criteria

  • Rheumatoid arthritis
  • OA of other joints
  • Hip dysplasia
  • Other inflammatory arthropathies
  • Surgical interventions less invasive than total hip arthroplasty
  • Retrospective non-comparative case series
  • Medical records review
  • Meeting abstracts
  • Historical articles
  • Editorials
  • Letters
  • Commentaries
  • Confounded studies
  • Case series with non-consecutive enrollment
  • Very Low Quality evidence
  • In vitro studies
  • Biomechanical studies
  • Performed on cadavers

Care Settings

Ambulatory careHospitalPhysician office

Special Populations

Patients with elevated BMIPatients with poorly controlled diabetesOlder adult patientsPatients with stiff spine syndrome

Evidence Grading

System: GRADE Evidence-to-Decision Framework

Evidence Distribution

179articles_included
5699abstracts_reviewed
587articles_excluded_full_text
766articles_recalled_full_text
4933articles_excluded_title_abstract

Evidence Levels

LowEvidence from two or more 'Low' quality studies with consistent findings or evidence from a single 'Moderate' quality study recommending for or against the intervention. Or Rec is downgraded using the EtD framework.
HighEvidence from two or more 'High' quality studies with consistent findings recommending for or against the intervention. Or Rec is upgraded using the EtD framework.
ModerateEvidence from two or more 'Moderate' quality studies with consistent findings or evidence from a single 'High' quality study recommending for or against the intervention. Or Rec is upgraded or downgraded using the EtD framework.
Very Low / ConsensusEvidence from one 'Low' quality study, no supporting evidence, or Rec is downgraded using the EtD framework. Statement based on clinical opinion.

Recommendation Strength

StrongEvidence from two or more 'High' quality studies with consistent findings. Not likely to change.
LimitedEvidence from two or more 'Low' quality studies with consistent findings or evidence from a single 'Moderate' quality study. Change possible/anticipated.
ModerateEvidence from two or more 'Moderate' quality studies with consistent findings or evidence from a single 'High' quality study. Less likely to change.
ConsensusThere is no supporting evidence, or limited level evidence was downgraded due to major concerns addressed in the EtD framework. Impact unknown.

Safety & Contraindications

Contraindications

  • Chronic kidney disease
  • Significant cardiac conditions
  • Preexisting liver disease

Authors & Contributors

American Association of Hip and Knee Surgeons

Guideline Features

Dosing informationFlowcharts includedBased on systematic reviewMultidisciplinary

Learning Context

Difficulty

advanced

Learning Paths

OsteoarthritisHip ArthroplastyOrthopaedicsPain ManagementSurgical ApproachesClinical Practice Guideline