AAOS Updates Clinical Practice Guideline for Managing Hip Osteoarthritis

The American Academy of Orthopaedic Surgeons (AAOS) has issued an update to the Clinical Practice Guideline (CPG) for the Management of Osteoarthritis of the Hip, replacing the 2017 edition. This CPG updated 14 of the 23 evidence-based recommendations for the non-operative hip osteoarthritis (OA) treatment in adults, resulting in three strong and five moderate recommendations. In addition to providing guidelines for specific surgical techniques and procedures for hip OA, the CPG also offers options surrounding diabetes, BMI, and prescription opioid treatment.
 
“The incidence and prevalence of osteoarthritis of the hip have risen over time and are expected to continue to do so, particularly as life expectancy and obesity rates continue to rise,” said Charles P. Hannon, M.D., senior associate consultant, Department of Orthopedic Surgery, Mayo Clinic, and co-chair of the CPG workgroup. “This updated clinical practice guideline provides orthopedic surgeons with the most up to date evidence-based practices that they can use to best treat their patients with osteoarthritis of the hip. It outlines both modifiable risk factors as well as surgical techniques and their impact on postoperative outcomes.”
 
Incidence and Prevalence of Hip OA
OA, sometimes called “wear-and-tear arthritis,” is a common condition that many people develop as they age. It can occur in any body joint, but most often develops in weight-bearing joints, such as the hip. Hip OA causes pain and stiffness, which can make it difficult to complete everyday activities like bending over to tie a shoe, rising from a chair, or taking a short walk.
 
The global prevalence of hip OA is estimated at 7.2%.ⁱ The global incidence of hip OA is estimated at 2 million people or 7.8 per 1000 person-years.^ii,iii
 
“Osteoarthritis of the hip leads to significant functional impairment interfering with quality of life,” Hannon added. “It limits patients’ ability to do the activities they love and in more severe cases activities of daily living. In addition to the physical impact, osteoarthritis influences emotional wellbeing and mental health with a reported 19% of patients who are diagnosed experiencing anxiety and depression.”
 
Guideline Recommendations At-A-Glance
Since 2017, there has been an abundance of published literature addressing topics within the CPG. In addition, new important topics, such as social determinants of health and the hip-spine relationship, were added to provide evidence-based recommendations. Highlights include: 

• A strong recommendation showing that tranexamic acid (TXA) should be considered for patients with symptomatic hip OA who are undergoing total hip arthroplasty (THA) to reduce blood loss and the need for blood transfusions.
• A strong recommendation showing that oral nonsteroidal anti-inflammatories (NSAIDs) should be used to reduce pain and improve function in treating symptomatic hip OA.
• A moderate (downgraded) recommendation showing that intraarticular corticosteroids could be considered to improve function and reduce pain in the short-term for patients with symptomatic hip OA.
• A strong recommendation that intraarticular hyaluronic acid should not be considered for treating symptomatic hip OA, as it does not improve function or reduce pain better than a placebo.
• A moderate (downgraded) recommendation for formal postoperative physical therapy or unsupervised home exercise after total hip arthroplasty for symptomatic hip OA. It further notes that physical therapy could be considered as a treatment for patients with mild to moderate symptomatic hip OA to improve function and reduce pain.
• A moderate (upgraded) recommendation for the use of cemented femoral stems in patients at risk for fracture such as patients with osteoporosis or elderly females. 

Additionally, nine options were formulated for the CPG. Options are used when there is little, conflicting, or no evidence on a topic. The new options address the use of oral acetaminophen; adverse events and patient reported outcomes in patients with an elevated BMI or with poorly controlled diabetes undergoing THA; and oral opioid use for nonoperatively treating symptomatic hip OA; among others.
 
Clinical Practice Guidelines in Practice
The scope of this CPG includes non-surgical treatment and surgical treatment with total hip arthroplasty of symptomatic hip OA. It does not provide recommendations for patients diagnosed with rheumatoid arthritis, OA of other joints, hip dysplasia, or other inflammatory arthropathies. ANd it does not provide recommendations for surgical interventions less invasive than total hip arthroplasty.
 
CPGs are not meant to be stand-alone documents, but rather serve as a point of reference and educational tool for both healthcare professionals managing patients hip OA and orthopedic surgeons. CPGs recommend accepted approaches to treatment and/or diagnosis and are not intended to be a fixed protocol for treatment or diagnosis. Patient care and treatment should always be based on a clinician’s independent medical judgment, giving the individual patient’s specific clinical circumstances. The guideline is not intended for use as a benefits determination document.
 
The full Clinical Practice Guideline for the Management of Osteoarthritis of the Hip is intended for reference by orthopedic surgeons and other physicians, and available through AAOS’ OrthoGuidelines website and free mobile app. 
 
With more than 39,000 members, AAOS is the world’s largest medical association of musculoskeletal specialists. It provides comprehensive education to help orthopedic surgeons and allied health professionals best treat patients in their daily practices. The AAOS is the source for information on bone and joint conditions, treatments and related musculoskeletal health care issues; and it leads the health care discussion on advancing quality.

References 
ⁱ Fan, Zijuan, et al. “The prevalence of hip osteoarthritis: a systematic review and meta-analysis.” Arthritis Research & Therapy 25.1 (2023): 51.
ⁱⁱ James, Spencer L., et al. “Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.” The Lancet 392.10159 (2018): 1789-1858
ⁱⁱⁱ Arslan, Ilgin G., et al. “Estimating incidence and prevalence of hip osteoarthritis using electronic health records: a population-based cohort study.” Osteoarthritis and Cartilage 30.6 (2022): 843-851.