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AAOS releases new clinical practice guideline for treatment of hip OA
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The American Academy of Orthopaedic Surgeons released a new clinical practice guideline on the treatment of osteoarthritis of the hip.
According to a press release, the clinical practice guideline (CPG) strongly recommends the use of pre-surgical treatments to ease pain and improve mobility, including corticosteroid injections, physical therapy and non-narcotic medications; however, due to lack of evidence supporting efficacy, the guideline does not recommend the use of hyaluronic acid or glucosamine sulfate to minimize osteoarthritis (OA) symptoms. The guideline also reported no clinically significant differences in patient-oriented outcomes related to the use of an anterior vs. posterior approach during total hip replacement surgery.
The following had strong or moderate evidence and were recommended by the clinical practice guideline:
- use of risk assessment tools to assist in predicting patient complications, assessing surgical risks and educating patients with OA undergoing total hip replacement;
- physical therapy as a conservative treatment to reduce pain in patients with mild to moderate OA of the hip; and
- use of tranexamic acid, injected or administered at the surgical site, for patients undergoing total hip replacement to minimize blood loss.
“These topics were included in the CPG to establish current levels of evidence, and to highlight that future research needs to be conducted in these areas to better determine specifically how preoperative risk modifications may affect the outcome of total hip arthroplasty surgery,” Gregory Polkowski, MD, chair of the CPG Work Group on the Treatment of Osteoarthritis of the Hip, said in the release.
Reference:
www.orthoguidelines.org/topic?id=1021
Perspective
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Dean K. Matsuda, MD
In my practice, patients tend to be younger, more active, and less arthritic than those typically seen in a joint replacement practice. The Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guideline (CPG) for Management of Osteoarthritis of the Hip offers support for several modalities used in the management of younger, more active patients with nonarthritic hip pain. The main indication for arthroscopic hip surgery is chondrolabral pathology, typically from cam and/or pincer femoroacetabular impingement (FAI). Conservative measures include non-narcotic medication (strong evidence in CPG), typically an NSAID. Interestingly, the studies used for this CPG did not investigate Ibuprofen and/or acetaminophen, which is commonly used in many practices and the latter being well-tolerated even in patients with gastrointestinal issues. Intra-articular corticosteroid injection (CSI) (strong evidence in CPG) and physical therapy (PT) (strong evidence in CPG) are sometimes used in my practice, but CSI may unnecessarily delay arthroscopic treatment of chondrolabral and impingement deformities and may potentially increase the small risk of post-arthroscopic surgical infection. No high-quality randomized controlled trials were available comparing the performance of injection of stem cells to placebo; however, I anticipate a future increase in quantity and quality of research on orthobiologics and regenerative therapies.
PT may be temporarily helpful, especially in patients with sagittal plane pelvic tilt that exacerbates pincer FAI, but improper stretching (particularly hip hyperflexion) may be detrimental. I have found activity modification (minimization of impact sports and of repetitive hip flexion activities) to be relatively more effective.
In general, current consensus supports hip arthroscopy in patients with nonarthritic hip pain who have failed a course of conservative treatment and have no or minimal radiographic arthritis. Joint space narrowing less than 2 mm anywhere under the radiographic sourcil and Tonnis 2 and 3 osteoarthritis grades have generally been predictors of poor outcome; however, emerging evidence is challenging Tonnis 2 as a contraindication to hip arthroscopy in select patients.
Unfortunately, some often young patients present with excessive arthritis and I have to counsel them that they are not candidates for hip arthroscopy. Four, albeit low-quality, studies in the CPG showed an increased risk of revision surgeries in younger patients with osteoarthritis undergoing total hip arthroplasty (THA). I advise these patients to exhaust reasonable — and now CPG-supported — conservative measures before proceeding with THA, emphasizing treatment of the patient and not the X-rays.
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