Management of Osteoarthritis of the Hip
Endorsed by: POSNA, APTA, ACR, ASA
Risk Assessment Tools
Moderate strength evidence supports that the practitioner could use risk assessment tools to assist in predicting adverse events, assessing surgical risks and educating patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty.
Moderate Evidence Moderate Evidence

One high quality study (Gordon, Frumento, et al) employed the Charnley comorbidity classification and the EQ5D generic health outcome questionnaire in the Swedish Hip Registry of over 28,500 THA patients.  Inferior THA results were demonstrated in a specific subset of patients:  women with  Charnley class C.  Five moderate quality and five low quality studies further support the use of various risk assessment tools to predict outcomes and adverse events after THA.  These include the EQ5D, SF-36, WOMAC, ASA classification, Charlson comorbidity index, and the Elixhauser score.  Rolfson and Dahlberg, et al analyzed 6,158 Swedish Registry patients  to determine that the EQ-5D  anxiety/depression domain was highly predictive for pain relief and patient satisfaction after THA.  Using the WOMAC and SF-36 Short Form, Gandhi, et al demonstrated that older age, year of followup, and greater comorbidity were negative prognostic indicators for THA function, and proposed that risk assessment data may be effectively utilized to set realistic patient expectations after THA.  In another moderate quality study, Gordon and Frumento, et al studied over 134,000 patients from the Swedish registry.  The Elixhauser comorbidity score was directly related to risk of re-operation within two years after THA.  Martinez-Huedo, et al examined the effect of  diabetes mellitus (DM) on 122,926 THA patients in the Spanish National Hospital Database.  Immediate postoperative outcomes were worse among patients with DM, including increased length of hospital stay and in-hospital mortality.  With respect to patients’ preoperative expectations, Judge, et al investigated the use of  ASA status, WOMAC score, and EQ-5D, to show that risk assessment tools can be effectively utilized for informed patient-clinician decision-making.

BMI and THA- Association with Patient Satisfaction and Pain and Function
Moderate strength evidence supports that obese patients with symptomatic osteoarthritis of the hip, when compared to non-obese patients, may achieve lower absolute outcome scores but a similar level of patient satisfaction and relative improvement in pain and function after total hip arthroplasty.
Moderate Evidence Moderate Evidence

There are four moderate quality studies that support the existence of lower clinical scores in obese patients with mild variation in the cutoff points that define obesity (Yeung et al; BMI>30, Stevens et al; BMI>30, Davis et al; BMI >35, Judge et al; BMI >30).  These results are supported by two low quality studies (McCalden et al; BMI>30, Jackson et al; BMI>30).  Similar improvements in clinical scores between obese and non-obese patients are supported by one moderate quality study (Judge et al) and two low quality studies (Bennett et al; BMI>40, McCalden et al). 

Similarities between obese and non-obese patient satisfaction with total hip replacement are supported by one moderate quality study (Yeung et al) and one low quality study (Villalobos et al; BMI>28). 

One moderate quality study identifies a higher incidence of post-operative dislocation and superficial wound infection in obese patients (Davis et al; BMI>35).  A low quality study reported a higher operative blood loss in obese patients (Bowditch et al; BMI>30). 

Most of the included studies used a BMI level >30 to define obesity and for use as a comparison with lower ranges.  This relatively low cutoff may mask some more dramatic differences in complications and outcomes at the higher levels, such as 40-50 and >50.  In addition, BMI may not be a specific enough index to define the proportionality and distribution of adipose tissue at surgical sites. 

BMI and THA- Risk Factor for Adverse Events
Limited strength evidence supports that obese patients with symptomatic osteoarthritis of the hip, when compared to non-obese patients, have increased incidence of postoperative dislocation, superficial wound infection, and blood loss after total hip arthroplasty.
Limited Evidence Limited Evidence

There are four moderate quality studies that support the existence of lower clinical scores in obese patients with mild variation in the cutoff points that define obesity (Yeung et al; BMI>30, Stevens et al; BMI>30, Davis et al; BMI >35, Judge et al; BMI >30).  These results are supported by two low quality studies (McCalden et al; BMI>30, Jackson et al; BMI>30).  Similar improvements in clinical scores between obese and non-obese patients are supported by one moderate quality study (Judge et al) and two low quality studies (Bennett et al; BMI>40, McCalden et al). 

Similarities between obese and non-obese patient satisfaction with total hip replacement are supported by one moderate quality study (Yeung et al) and one low quality study (Villalobos et al; BMI>28). 

One moderate quality study identifies a higher incidence of post-operative dislocation and superficial wound infection in obese patients (Davis et al; BMI>35).  A low quality study reported a higher operative blood loss in obese patients (Bowditch et al; BMI>30). 

Most of the included studies used a BMI level >30 to define obesity and for use as a comparison with lower ranges.  This relatively low cutoff may mask some more dramatic differences in complications and outcomes at the higher levels, such as 40-50 and >50.  In addition, BMI may not be a specific enough index to define the proportionality and distribution of adipose tissue at surgical sites. 

Age and THA- Associated Risk of Lower Functional and QoL Outcomes
Moderate strength evidence supports that increased age is associated with lower functional and quality of life outcomes in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty.
Moderate Evidence Moderate Evidence

There are four moderate and two low quality articles that support increased age is associated with lower functional and quality of life outcomes in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty.  Specifically, older age is associated with lower mental and physical component SF-36, EQ-5D, and WOMAC scores (Badure-Brzoza 2008, Fujita 2016 & Stevens 2012). Older age is also associated with less sustained improvement in SF-36 and WOMAC scores (Gandhi 2010).  There is a non-linear association of age and EQ-5D scores with peak of improvement at age 65 then steeply declining around age 70 (Gordon 2014). Additionally, there is worsening of Oxford hip scores in patients older than 70 (Judge 2013), and patients older than 80 had an average Oxford hip score 3.81 points lower than patients in the 60-70 years cohort. Nonetheless, the change in functional status between younger and older patients was similar (Judge et al 2011; Aranda,Villalobos; Jones et al 2012; McHugh 2013; Quintana et al 2009).

In regard to mortality, there was one moderate and one low quality article demonstrating increased mortality with increasing age in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty. Whittle 1993 showed a proportional increase of a hazard ratio of 2.4 per 10 year increase in age, which corresponds to a 3.75% 90 day mortality among patients 85 years of age or older.  McMinn 2012 demonstrated a similar trend of increasing mortality with increasing age. 

Four low quality studies showed an increased risk of revision surgeries in younger patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty. For selected studies, age under 65 was associated with increased risk of revision for aseptic loosening with uncemented prostheses with hazard ratios of 3.21 (Corten 2011) and 2.29 (Visuri 2002). Conversely, Katz 2012 reported a 2% risk of revision in the first 18 months followed by 1% for every year thereafter.  Similarly, McMinn 2012 showed that revision risk decreases with increasing age. 

Age and THA- Associated Risk of Mortality
Limited strength evidence supports that increased age may be associated with a higher risk of mortality in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty.
Limited Evidence Limited Evidence

There are four moderate and two low quality articles that support increased age is associated with lower functional and quality of life outcomes in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty.  Specifically, older age is associated with lower mental and physical component SF-36, EQ-5D, and WOMAC scores (Badure-Brzoza 2008, Fujita 2016 & Stevens 2012). Older age is also associated with less sustained improvement in SF-36 and WOMAC scores (Gandhi 2010).  There is a non-linear association of age and EQ-5D scores with peak of improvement at age 65 then steeply declining around age 70 (Gordon 2014). Additionally, there is worsening of Oxford hip scores in patients older than 70 (Judge 2013), and patients older than 80 had an average Oxford hip score 3.81 points lower than patients in the 60-70 years cohort. Nonetheless, the change in functional status between younger and older patients was similar (Judge et al 2011; Aranda,Villalobos; Jones et al 2012; McHugh 2013; Quintana et al 2009).

In regard to mortality, there was one moderate and one low quality article demonstrating increased mortality with increasing age in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty. Whittle 1993 showed a proportional increase of a hazard ratio of 2.4 per 10 year increase in age, which corresponds to a 3.75% 90 day mortality among patients 85 years of age or older.  McMinn 2012 demonstrated a similar trend of increasing mortality with increasing age. 

Four low quality studies showed an increased risk of revision surgeries in younger patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty. For selected studies, age under 65 was associated with increased risk of revision for aseptic loosening with uncemented prostheses with hazard ratios of 3.21 (Corten 2011) and 2.29 (Visuri 2002). Conversely, Katz 2012 reported a 2% risk of revision in the first 18 months followed by 1% for every year thereafter.  Similarly, McMinn 2012 showed that revision risk decreases with increasing age. 

Age and THA- Associated Risk of Revision
Limited strength evidence supports that younger age may be associated with a higher risk of revision in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty.
Limited Evidence Limited Evidence

There are four moderate and two low quality articles that support increased age is associated with lower functional and quality of life outcomes in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty.  Specifically, older age is associated with lower mental and physical component SF-36, EQ-5D, and WOMAC scores (Badure-Brzoza 2008, Fujita 2016 & Stevens 2012). Older age is also associated with less sustained improvement in SF-36 and WOMAC scores (Gandhi 2010).  There is a non-linear association of age and EQ-5D scores with peak of improvement at age 65 then steeply declining around age 70 (Gordon 2014). Additionally, there is worsening of Oxford hip scores in patients older than 70 (Judge 2013), and patients older than 80 had an average Oxford hip score 3.81 points lower than patients in the 60-70 years cohort. Nonetheless, the change in functional status between younger and older patients was similar (Judge et al 2011; Aranda,Villalobos; Jones et al 2012; McHugh 2013; Quintana et al 2009).

In regard to mortality, there was one moderate and one low quality article demonstrating increased mortality with increasing age in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty. Whittle 1993 showed a proportional increase of a hazard ratio of 2.4 per 10 year increase in age, which corresponds to a 3.75% 90 day mortality among patients 85 years of age or older.  McMinn 2012 demonstrated a similar trend of increasing mortality with increasing age. 

Four low quality studies showed an increased risk of revision surgeries in younger patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty. For selected studies, age under 65 was associated with increased risk of revision for aseptic loosening with uncemented prostheses with hazard ratios of 3.21 (Corten 2011) and 2.29 (Visuri 2002). Conversely, Katz 2012 reported a 2% risk of revision in the first 18 months followed by 1% for every year thereafter.  Similarly, McMinn 2012 showed that revision risk decreases with increasing age. 

Mental health disorder
Moderate strength evidence supports that mental health disorders, such as depression, anxiety, and psychosis, are associated with decreased function, pain relief, and quality of life outcomes in patients with symptomatic osteoarthritis of the hip who undergo total hip arthroplasty (THA).
Moderate Evidence Moderate Evidence

Six moderate quality studies (Davis, 2006; Duivenvoorden, 2013; Gandhi, 2010; Jamsen, 2013; Judge, 2013; Rolfson, 2009) support this recommendation.  Mental health disorders were assessed using a variety of validated tools including the SF36 Mental Component Score (Judge, 2013; Gandhi, 2010), the depression/anxiety question on the EQ-5D (Rolfson, 2009) and the HADS (Duivenvoorden, 2013).  Functional outcomes were assessed utilizing the Oxford Hip Score, WOMAC or HOOS.  The presence of depression preoperatively predicted a lower functional outcome and/or less improvement between pre-operative and post-operative function.  In one long-term study (Jamsen, 2013), patients with depression were found to exceed 10% revision rate at ten years; pre-operative psychosis increased the risk of implant failure with Kaplan Meier Survivorship analysis by 40%.

Tobacco use
Limited strength evidence supports that patients who use tobacco products are at an increased risk for complications after total hip arthroplasty.
Limited Evidence Limited Evidence

Two low-quality studies (Sadr et al and Huddleston et al) examined the complication rates of THA patients who smoked tobacco compared with those who did not. One of the studies (Sadr) found a significant increase in perioperative complications in heavy tobacco users, and a 43% increase in complications in those who previously used tobacco, which rose to 56% for current tobacco users. However, Huddleston et al showed no increase in complications among THA patients who smoked tobacco when compared with those who did not.

The detrimental effects of smoking on wound healing, pulmonary function, and the immune system are well accepted.  While the evidence to require patients to cease smoking prior to THA consisted of low-quality studies, educating and engaging patients in the health benefits of smoking cessation remains a priority.

Non-narcotic management
Strong evidence supports that NSAIDs improve short-term pain, function, or both in patients with symptomatic osteoarthritis of the hip.
Strong Evidence Strong Evidence

All efficacy studies included are high quality placebo controlled trials (Schnitzer, et.al., Baerwald, et.al. , Svensson, et.al., Klein, et.al., Makarowski, et.al. , Kivitz et.al ). Some studies also included comparisons to unavailable, experimental and nutriceutical agents (insert references); these agents were not considered for this review.

 

All studies reported clinical improvements employing standard clinical measuring instruments, including Womac, SF-36, VAS, OARSI and Lequensne scoring; at least two were used in each study. Study duration never exceeded 13 weeks and was the maximum duration considered when “short-term” was referenced in the work group recommendation. The clinically relevant drugs reviewed included Naproxen, Celecoxib, and Diclofenac. No recommendation can thus be made regarding the use of other agents possibly studied prior to the cutoff date of the systematic literature review inclusion criteria (1990). The “percent responders” ranged widely in studies that made specific note. Likely the values of 67%(Schnitzer), 50% Baerwald, 50% Klein, and 30% Kivitz, can be considered prognostic.

Glucosamine sulfate
Moderate strength evidence does not support the use of glucosamine sulfate because it did not perform better than placebo for improving function, reducing stiffness and decreasing pain for patients with symptomatic osteoarthritis of the hip.
Moderate Evidence Moderate Evidence
A literature search for studies investigating the treatment of symptomatic hip OA with glucosamine, chondroitin, and other nutraceuticals yielded 85 studies. Only one high quality study met our inclusion criteria (Rozendaal et al). In this placebo randomized control trial study, 222 patients were given oral glucosamine or placebo and evaluated for 2 years. Glucosamine sulfate did not perform better than placebo for improving function, or reducing stiffness and pain.
Intraarticular corticosteroids: supported
Strong evidence supports the use of intraarticular corticosteroids to improve function and reduce pain in the short-term for patients with symptomatic osteoarthritis of the hip.
Strong Evidence Strong Evidence

Three high quality studies (Lambert et al, Atchia et al , Qvistgaard et al ) compared IA injection of corticosteroids with placebo and showed statistically significant improvement in pain and function scores. Significant benefits from IA corticosteroid injection were present 3 months (Lambert et al ) and 8 weeks (Atchia et al ) after treatment compared to placebo.

Atchia et al and Qvistgaard et al also compared IA injection of hyaluronic acid (HA) to corticosteroid and placebo in the same aforementioned studies. While these studies demonstrated improved pain and function with IA corticosteroid, they both failed to show significant difference between the performance of HA and placebo. In addition, single IA injection of HA for the treatment of symptomatic (VAS pain score >40mm) moderate hip OA (Kellgren Lawrence grades 2 and 3) failed to demonstrate significant improvement compared to placebo in another high quality study (Richette et al for function, stiffness and pain at 3 months. Other high quality studies investigating HA for the treatment of symptomatic hip OA discovered in this search compared the performance of IA injections of different formulations of HA (Bekerom 2008, Tikiz et al , IA injection of corticosteroids (Spitzer et al), and IA injection of anesthetic (Migliore et al), but did not test against a placebo.

No high quality randomized controlled trials were available comparing the performance of IA injection of stem cells or prolotherapy to placebo. Three studies (Battaglia et al , Dallari et al) compared IA injections of platelet-rich plasma (PRP) versus HA or a combination of PRP and HA. However, no high quality studies comparing PRP with placebo were available for inclusion in our analysis.

Intraarticular hyaluronic acid: not supported
Strong evidence does not support the use of intraarticular hyaluronic acid because it does not perform better than placebo for function, stiffness, and pain in patients with symptomatic osteoarthritis of the hip.
Strong Evidence Strong Evidence

Three high quality studies (Lambert et al, Atchia et al , Qvistgaard et al ) compared IA injection of corticosteroids with placebo and showed statistically significant improvement in pain and function scores. Significant benefits from IA corticosteroid injection were present 3 months (Lambert et al ) and 8 weeks (Atchia et al ) after treatment compared to placebo.

Atchia et al and Qvistgaard et al also compared IA injection of hyaluronic acid (HA) to corticosteroid and placebo in the same aforementioned studies. While these studies demonstrated improved pain and function with IA corticosteroid, they both failed to show significant difference between the performance of HA and placebo. In addition, single IA injection of HA for the treatment of symptomatic (VAS pain score >40mm) moderate hip OA (Kellgren Lawrence grades 2 and 3) failed to demonstrate significant improvement compared to placebo in another high quality study (Richette et al for function, stiffness and pain at 3 months. Other high quality studies investigating HA for the treatment of symptomatic hip OA discovered in this search compared the performance of IA injections of different formulations of HA (Bekerom 2008, Tikiz et al , IA injection of corticosteroids (Spitzer et al), and IA injection of anesthetic (Migliore et al), but did not test against a placebo.

No high quality randomized controlled trials were available comparing the performance of IA injection of stem cells or prolotherapy to placebo. Three studies (Battaglia et al , Dallari et al) compared IA injections of platelet-rich plasma (PRP) versus HA or a combination of PRP and HA. However, no high quality studies comparing PRP with placebo were available for inclusion in our analysis.

Physical Therapy as a Conservative Treatment
Strong evidence supports the use of physical therapy as a treatment to improve function and reduce pain for patients with osteoarthritis of the hip and mild to moderate symptoms.
Strong Evidence Strong Evidence

There were 9 high quality studies (Bennell et al, Beselga et al, Fernandes et al, French et al, Hoesksma et al, Koybasi et al, Pister et al, Poulsen et al, Svege, et al) and 3 moderate quality studies (Nguyen et al, Svege et al, Tak et al) that were initially identified as evaluating the effect of physical therapy for individuals with hip osteoarthritis. One of the moderate quality studies (Nguyen et al) was excluded from this recommendation because it did not include interventions that are typical of physical therapy.

Patients included in the majority of these studies had mild or moderate symptoms, although this was defined differently between studies. Mild to moderate OA was qualified as being hip pain of at least 40 out of 100, but not being scheduled for hip surgery (Bennell et al), having a Harris Hip Score between 60 and 95 (Fernandes et al), not requiring a walking aid during ambulation (Beselga et al), or other similar criteria.

There was conflicting evidence pertaining to the effectiveness of physical therapy on pain and function in individuals with symptomatic hip osteoarthritis. In a high quality sham-controlled study, Beselga et al. found an immediate effect of joint mobilization on patient symptoms. In two other high quality studies, patients had greater improvements in pain with physical therapy compared to either a control group (Poulson et al) or a group that did not receive joint mobilization in addition to exercise (French et al). In one moderate quality study, physical therapy reduced pain and improved function compared to a non-active control group. In another moderate quality study an exercise intervention improved pain and function to a greater extent than a control group, sham ultrasound group, and active ultrasound group. Despite evidence to support physical therapy, two high quality studies found no benefit of physical therapy compared to a placebo group (Bennell et al) or a group that received only patient education (Fernandes et al).

To address this conflicting evidence, we performed a meta-analysis to determine the potential effect of physical therapy on pain and function at different follow-up periods. This analysis revealed that there was a net positive benefit of physical therapy on functional outcomes at 6 to 12 month follow-up. The analysis also revealed a positive effect of physical therapy on reducing pain at up to a 9-month follow-up. Given the cumulative positive effect of physical therapy on functional and pain, there is strong evidence to support physical therapy on improving outcomes at up to 9 months after treatment.

Preoperative Physical Therapy
Limited evidence supports the use of pre-operative physical therapy to improve early function in patients with symptomatic osteoarthritis of the hip following total hip arthroplasty.
Limited Evidence Limited Evidence

There were 2 high quality and 2 moderate quality studies that evaluated the effect of pre-operative physical therapy on post-operative outcomes with conflicting results causing this recommendation to be of limited strength (Villadsen et al, Rooks et al, Ferrara et al, Vukomanovik et al). There was a trend that pre-operative physical therapy improved short term post-operative outcomes. One moderate study demonstrated a reduced risk of needing inpatient rehabilitation after THA (Rooks et al) and another high quality study found improved early recovery (less than 3 months) after THA in the group that received pre-operative physical therapy (Villadsen et al). One high quality study found no benefit of pre-operative physical therapy on most post-operative outcomes with the exception of range of motion and pain at 3 months (Ferrara), while another high quality study found no functional benefit of pre-operative rehabilitation on outcomes 3 months after THA (Vukomanovik et al).

Five studies evaluated the effect of post-operative physical therapy on outcomes. Three of the high quality studies revealed a benefit of post-operative physical therapy (Mikkelson et al, Heiberg et al, Umpierres et al), although one of these studies only found a significant benefit for secondary outcomes of walking speed and stair performance, while the primary outcome of leg strength was not different between groups. One of these studies demonstrated only a short term benefit at 15 days after THA (Umpierres et al), while another found a persistent benefit at one year for one of the functional measures (Heiberg et al). Two studies showed no benefit to post-operative physical therapy (Galea et al, Heiberg et al), although one of these studies was a 5-year follow-up of the original clinical trial (Heiberg et al).

While there were 13 high quality studies and 4 moderate quality studies that were initially identified in the search, several were excluded. Studies were excluded because they were feasibility studies (Hoogenboom et al, Jepson et al), did not include a passive or unsupervised control group to which physical therapy was compared (Hesse et al, Husby et al, Husby et al, Liebs et al, Giaquinto et al, Monticone et al) or did not include a post-operative assessment (Villadsen et al).

Postoperative Physical Therapy
Moderate evidence supports the use of post-operative physical therapy because it could improve early function to a greater extent than no physical therapy management for patients with symptomatic osteoarthritis of the hip who have undergone total hip arthroplasty.
Moderate Evidence Moderate Evidence

There were 2 high quality and 2 moderate quality studies that evaluated the effect of pre-operative physical therapy on post-operative outcomes with conflicting results causing this recommendation to be of limited strength (Villadsen et al, Rooks et al, Ferrara et al, Vukomanovik et al). There was a trend that pre-operative physical therapy improved short term post-operative outcomes. One moderate study demonstrated a reduced risk of needing inpatient rehabilitation after THA (Rooks et al) and another high quality study found improved early recovery (less than 3 months) after THA in the group that received pre-operative physical therapy (Villadsen et al). One high quality study found no benefit of pre-operative physical therapy on most post-operative outcomes with the exception of range of motion and pain at 3 months (Ferrara), while another high quality study found no functional benefit of pre-operative rehabilitation on outcomes 3 months after THA (Vukomanovik et al).

Five studies evaluated the effect of post-operative physical therapy on outcomes. Three of the high quality studies revealed a benefit of post-operative physical therapy (Mikkelson et al, Heiberg et al, Umpierres et al), although one of these studies only found a significant benefit for secondary outcomes of walking speed and stair performance, while the primary outcome of leg strength was not different between groups. One of these studies demonstrated only a short term benefit at 15 days after THA (Umpierres et al), while another found a persistent benefit at one year for one of the functional measures (Heiberg et al). Two studies showed no benefit to post-operative physical therapy (Galea et al, Heiberg et al), although one of these studies was a 5-year follow-up of the original clinical trial (Heiberg et al).

While there were 13 high quality studies and 4 moderate quality studies that were initially identified in the search, several were excluded. Studies were excluded because they were feasibility studies (Hoogenboom et al, Jepson et al), did not include a passive or unsupervised control group to which physical therapy was compared (Hesse et al, Husby et al, Husby et al, Liebs et al, Giaquinto et al, Monticone et al) or did not include a post-operative assessment (Villadsen et al).

Anesthetic Types
Limited evidence supports the use of neuraxial anesthesia compared to general anesthesia to reduce complications in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty.
Limited Evidence Limited Evidence

Two studies (Hunt et al and Basques et al) examined the use of spinal compared with general anesthesia in total hip arthroplasty and met the criteria for the guideline. Both were retrospective analyses of large cohort databases, and both noted fewer adverse events when spinal anesthesia was used when compared with general anesthesia. Hunt et al examined outcomes of 409,096 total hip arthroplasties recorded in the National Joint Registry for England and Wales, and reported a 0.85 hazard ratio of death within 90 days when spinal anesthesia was used instead of general. Basques et al examined 20,936 total hip arthroplasty patients in the National Surgical Quality Improvement Program (NSQIP) database, of which 12,752 had general and 8184 had spinal anesthesia. General anesthesia was associated with a 1.31 odds ratio of having any adverse event, 5.81 odds ratio of prolonged ventilator use, 2.17 odds ratio of unplanned intubation, 2.51 odds ratio of stroke, 5.04 odds ratio of cardiac arrest, 1.34 odds ratio of blood transfusion, and 1.35 odds ratio of a minor adverse event after surgery.

Tranexamic Acid
Moderate strength evidence supports that the practitioner could use intravenous or topical tranexamic acid for patients with symptomatic osteoarthritis of the hip who are undergoing total hip arthroplasty (THA) as a part of the effort to reduce blood loss.
Moderate Evidence Moderate Evidence
Two high quality (Martin et al, Niskanen et al) and two moderate strength (Imai et al, Benoni et al) studies evaluated the perioperative use of tranexamic acid (TXA) for total hip arthroplasty (THA). Martin, et al conducted a prospective, stratified, randomized, double-blind, placebo-controlled trial that demonstrated that the use of topical TXA in THA resulted in a smaller reduction in postoperative hemoglobin. There was a trend toward lower transfusion rates that was not statistically significant. Niskanen at el and Korkala et al conducted a randomized, double-blind study of 39 THA patients that demonstrated smaller total blood loss in cemented THA for patients who received perioperative intravenous TXA. Imai, et al evaluated 107 THA patients who were randomly divided into 1 control group and 4 treatment groups based on the timing of TXA administration. All groups who received TXA, irrespective of the dose timing, experienced lower intraoperative and perioperative total blood loss. Benoni et al, performed a prospective, randomized, double-blind study on the effect of intravenous TXA at the beginning of THA which also demonstrated significantly lower postoperative blood loss compared to placebo. Since indications for allogenic blood transfusions differed among studies, there was no consistent evidence that TXA reduced perioperative transfusion rates.
Approach Exposure
Moderate strength evidence supports that there were no clinically significant differences in patient oriented outcomes related to the surgical approach for patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty.
Moderate Evidence Moderate Evidence

Three high quality studies (Goosen et al 2011, Repantis et al 2015, and Taunton et al 2014) examined the three most common total hip approaches. Though well designed individually, they did not compare all of the common approaches in each paper. Therefore, the strength of the recommendation was downgraded to moderate.

Weight Loss as a Conservative Statement
In the absence of reliable evidence, it is the opinion of the guideline development group that weight loss may be beneficial in the non-operative management of pain, function, and quality of life in patients with osteoarthritis of the hip.
Consensus Consensus

N/A

Diabetes as a Risk Factor for Total Hip Arthroplasty (THA)
In the absence of reliable evidence, it is the opinion of the guideline development group that patients with poorly controlled diabetes may be at a higher risk for short-term adverse events after total hip arthroplasty.
Consensus Consensus
N/A
Social Comorbidities as a Risk Factor for Total Hip Arthroplasty (THA)
In the absence of reliable evidence, it is the opinion of the guideline development group that while total hip arthroplasty for patients with lower socioeconomic status and educational levels with symptomatic osteoarthritis of the hip remains beneficial, risk adjustment may be appropriate as inferior outcomes and increased complication rates may occur in this population.
Consensus Consensus

N/A

Intraarticular Imaging
In the absence of reliable evidence, it is the opinion of the guideline development group that in patients with normal x-rays but a history and physical exam consistent with IA hip pathology, advanced imaging and/or diagnostic IA injection may be indicated.
Consensus Consensus

N/A

Prescription Opioids
In the absence of reliable evidence, it is the opinion of the guideline development workgroup that long-term prescription opioids are not recommended in the treatment of symptomatic osteoarthritis of the hip.
Consensus Consensus

N/A 


ACKNOWLEDGEMENTS

Guideline Work Group:
Greg Polkowski, MD, Co-Chair
Norman Johanson, MD, Co-Chair
Mark Barba, MD
John C. Grady-Benson, MD
Theodore Toan Le, MD

Harold Rees, MD
Ralph T. Salvagno, MD
Richard Schultz, MD
James Browne, MD
Courtland G. Lewis, MD
Albert Song, MD
Joseph A. Zeni, PT, PhD
David Podeszwa, MD
Ira Zaltz, MD

Additional Contributing Members

Atul F. Kamath, MD
Greg McComis, MD

Guidelines Oversight Chair
Robert Quinn, MD; AUC Section Leader of the AAOS Evidence-Based Quality and Value Committee

AAOS Clinical Practice Guideline Section Leader
Gregory Brown, MD, PhD

AAOS Committee on Evidence-Based Quality and Value Chair
Kevin Shea, MD

AAOS Council on Research and Quality Chair
David Jevsevar, MD, MBA

AAOS Staff:
William O. Shaffer, MD,
AAOS Medical Director
Deborah Cummins, PhD, Director of Research & Scientific Affairs
Jayson Murray, MA, Manager, Evidence-Based Medicine Unit
Nilay Patel, MA, Research Analyst
Patrick Donnelly, MA, Research Analyst
Nicole Nelson, MPH, Research Analyst
Mary DeMars, Administrative Assistant
Yasseline Martinez, Administrative Coordinator
Kaitlyn Sevarino, MBA, Evidence-Based Quality and Value Specialist
Peter Shores, MPH, Statistician
Anne Woznica, MLIS, AHIP, Medical Research Librarian

Additional Contributors:
Yupei Chen,
AAOS Research Intern