Clinical Practice Guideline
Total Hip Replacement for Osteoarthritis
Evidence-Based and Patient-Oriented Indications
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Background: Total Hip Replacement (THR) belongs to the most common inpatient operations in Germany, with over 240 000 procedures performed per year. 90% of the artificial joints are still functional at 15 years, and up to 60% at 20 years after surgery. It is essential that the indications for such procedures should be uniform, appropriate, and patient-oriented.
Methods: This review is based on publications retrieved by a systematic literature search for national and international guidelines and systematic reviews on the topic of hip osteoarthritis and THR.
Results: THR should be performed solely with radiologically demonstrated advanced osteoarthritis of the hip (Kellgren and Lawrence grade 3 or 4), after at least three months of conservative treatment, and in the presence of high subjective distress due to symptoms arising from the affected hip joint. Contraindications include refractory infection, acute or chronic accompanying illnesses, and BMI ≥= 40 kg/m2. Patients should stop smoking at least one month before surgery. In patients with diabetes mellitus, preoperative glycemic control to an HbA1c value below 8% is advisable. It is recommended that patients should lower their weight below a BMI of 30 kg/m2.
Conclusion: The decision to perform THR should be taken together by both the physician and the patient when the expected treatment benefit outweighs the risks. Evidence suggests that a worse preoperative condition is associated with a poorer surgical outcome.
Total hip replacement (THR) is among the most common operations conducted in an inpatient setting, with approximately 240 000 procedures performed in Germany in 2019 (1). Along with proximal femoral fractures, hip osteoarthritis (hip OA) is the most common disease of the hip joint, treated by hip replacement surgery.
Depending on the stage of the disease, there are a variety of non-surgical and surgical treatment options available for the management of hip osteoarthritis (2). Apart from pharmacological therapy, patient education and exercise therapy as well as maintaining physical activity, are particularly important during the initial stages of the disease. Evidence suggests that for mild to moderate symptoms it is possible to delay THR surgery for some time (median time 5.4 years) by combining these two types of therapy (3). When symptoms deteriorate in the advanced stage, THR is one of the most successful and effective treatment options (2, 4). Data from the British National Joint Registry (NJR), which has been collecting patient-reported outcomes since 2009, show that 97.5% of patients reported an improvement in hip pain and function (increase of 153% from a median of 17 to 43 points as measured by the Oxford Hip Score) (5).
According to a meta-analysis from 2019, survival of joint replacement constructs of 89.4% can be expected after 15 years, of 70.2% after 20 years, and of 57.9% after 25 years (6). Also, the risk for surgical complications in the inpatient setting (1.51% for general complications and 2.35% for specific complications) and a mortality risk of 0.04% can be regarded as very low (7).
The frequency of THR performed in Germany differs from region to region. It varies in the individual federal states by a factor of 2.8. Higher rates are found in the south and the northwest (8). One possible reason for this variability is the absence of standardized decision criteria as basis for the indication of THR in a transparent and consistent way. (8). Therefore, the guideline project “Evidence-based and consensus-based indication criteria for total hip replacement (EKIT hip)” was initiated under the auspices of the German Society for Orthopedic and Trauma Surgery (DGOU) and the German Society for Endoprosthetics (AE) (9).
The aim was to compile recommendations for indication and contraindication criteria, based on current evidence and agreed by general consensus, and to develop a practical guideline.In order to justify their generally binding character, the agreed recommendations should meet the requirements of the S3 level of clinical-practice guidelines, follow an action-guiding algorithm, and be easy to implement in medical practice.
Twenty-nine representatives from 23 professional societies/organizations participated in the guideline project (eBox). Firstly, a systematic literature search was conducted for national and international guidelines on hip osteoarthritis and THR (last update January 2020). The methodological quality of the related guidelines was assessed using the German guideline assessment tool (DELBI) by two reviewers independently of each other. (10). Secondly, the authors conducted a systematic literature search of systematic reviews and meta-analyses (referred to here as “Overview”) listed in Medline (via Pubmed) and Embase (via Ovid) databases covering the terms “hip joint” and “joint prosthesis” or “hip replacement” (last update August 2020). Screening of the identified hits was performed independently by two reviewers, applying several inclusion criteria for key questions that were prepared according to the PICO model. A structured assessment of the included reviews was conducted using AMSTAR 2 guidelines (11).
The guideline search identified 18 guidelines of which ten were considered methodologically adequate according to DELBI criteria and therefore included (2, 4, 12, 13, 14, 15, 16, 17, 18, 19). A total of 39 relevant systematic reviews (33 with meta-analysis) out of 2175 hits were identified for extraction of the evidence (Figure). According to the AMSTAR criteria, three were of high quality, eight were of adequate quality, and 28 were of lower quality. The level of evidence (LoE) of the included papers varied between 1 + and 2 + (according to the Scottish Intercollegiate Guidelines Network, SIGN), with one meta-analysis (LoE 1 +) (20) and six meta-analyses (LoE 1−) based on randomized controlled trials (RCTs) (21−26) and one meta-analysis based on cohort studies (LoE 2 ++) (27). A further 31 systematic reviews, which included cohort studies, corresponded to evidence level 2 +.
The recommendations were structured according to six subject complexes, the sequence of which can serve as a practical decision-making aid (Box).
The recommendations were defined from the search results as follows:
a) evidence-based (the literature used is based on the results of the overview) or
b) based on guideline adaptation or taking guideline(s) into account, i.e. one or more recommendations from the included guidelines were used as a recommendation basis.
The strength of recommendation is marked in the text with “↑↑” (strong recommendation, level A) or “↑” (weak recommendation, level B). Where evidence is lacking or incomplete, recommendations are identified as “EC” (expert consensus).
Diagnosis confirmation (objective requirement)
If typical symptoms of hip osteoarthritis are present, the diagnosis should be established sequentially, first by taking a targeted history (hip pain, morning stiffness less than 60 minutes) and then by a physical examination of the hip joint (painful internal rotation, limited flexion) (EC) (2). Relevant differential diagnoses should be considered and ruled out. This is particularly indicated in younger age groups to clarify the possibility of joint-preserving surgery (↑↑, guideline adaptation) (15). Otherwise, conventional radiographs (standard anterior-posterior pelvic view and a second projection of the hip joint) should be obtained, at the latest when hip symptoms persist despite non-surgical therapy (EC).
This expert consensus takes into account the consensus-based recommendations of the European League Against Rheumatism (EULAR) (18), which found no evidence of additional value or superiority of imaging as compared with clinical examination alone in osteoarthritis of the hip. Nevertheless, the indication for THR should only be established after radiological confirmation of osteoarthritis. The irreversibility of the procedure and the potential risks mean that surgery is usually only indicated for advanced osteoarthritis of the hip (Kellgren-Lawrence [KL] grade 3 or 4, Figure) (↑↑, evidence-based). This recommendation is based on two systematic reviews, which reported evidence for a poorer postoperative outcome in lower-grade osteoarthritis, although the included studies were heterogeneous (28, 29).
However, there are also borderline cases (e.g. dysplasia, femoroacetabular impingement) which are only detectable on MRI and represent an indication for THR despite radiographically lower grade osteoarthritis. Therefore, additional imaging using MRI and/or CT should only be obtained if there is a discrepancy between clinical and radiographic findings (EC, guideline adaptation) (18). The same applies to avascular necrosis of the femoral head, for which, according to the S3 guidelines “Non-traumatic avascular necrosis of the femoral head” (13), THR may be indicated from at least stage IIIc of the International Association for Bone Necrosis (ARCO), even without advanced signs of osteoarthritis (↑, guideline adaptation).
Patient’s subjective distress (personal need)
Apart from clinical and radiographic evaluation of hip osteoarthritis severity, an assessment of the patient’s subjective distress and hip osteoarthritis-related symptoms is also needed:
- Limitations of function and activities of daily living
- Restrictions of health-related quality of life (↑↑, guideline adaptation) (14, 15).
These evaluations are not only relevant for the assessment of treatment outcomes (non-surgical and/or surgical), but also for the process of shared-decision-making for or against surgery. Validated patient-reported outcome measurement (PROM) instruments should be used wherever possible (↑↑, evidence-based). The AE has published consensus-based recommendations for outcome measurements in artificial hip and knee replacement (30). The recommendation of the Oxford Hip Score (OHS) or alternative measurement tools (WOMAC, HOOS or HOOS-PS) as well as a generic score (e.g. EQ-5D, SF-12, SF-36) applies primarily when conducting clinical trials but can also be extended to cover general use. German translations are available for the PROMs mentioned; these are partly subject to a license fee for their commercial use (30).
The question for the appropriate time for surgery is important, both for patients and physicians. There are a number of studies looking at the impact of the degree of preoperative complaints on the likely postoperative treatment outcome (15, 28, 29, 31).
The study evidence does not allow any clear statement as to whether a poor preoperative condition produces a less favorable outcome after THR. But there are clear trends showing that patients in a worse condition before surgery (pain, function, comorbidities and quality of life) do not achieve the same good level after surgery as patients who undergo THR earlier in the disease process (32).A delay of THR must therefore be considered just as thoroughly as an early indication without adequately meeting the indication criteria (for example, low radiological grade and/or insufficiently conducted non-surgical therapy). This should be well considered during the informed consent discussion, taking into account the individual symptom severity (↑↑, evidence-based).
Ultimately, a high level of subjective distress from hip-related complaints (pain, limitations in function and activities of daily living) and restrictions in health-related quality of life and the presence of the other indication criteria (radiographic evidence of hip osteoarthritis KL grade 3, prior non-surgical therapy with a combination of pharmacological therapy and non- pharmacological therapy for three months) is a strong justification for THR (↑↑, guideline adaptation) (15).
Assessment of alternative treatment options (assessment of appropriateness)
The recommendation of combining pharmocological and non-pharmacological therapy for non-surgical management of patients with hip osteoarthritis (↑↑, guideline adaptation) is supported by a total of six of the included guidelines (2, 4, 12, 14, 15, 16). Patients should have at least carried out, or should have been recommended, the following core elements of conservative non-pharmacological therapy:
- Patient education (information, education and counseling about the disease)
- Exercise therapy and enhancement of physical activity
- Weight reduction in patients with overweight and obesity (↑↑, guideline adaptation).
The evidence base for the first two core elements is comprehensive and of high quality. The UK guideline cites the significant effect of providing disease-specific information (treatment programs, self-management programs, training, leaflets) on pain relief, reduction of pain medication, improved quality of life, and self-help – including two meta-analyses and six randomized controlled trials (RCTs) (15).
The most recent guidelines of the Osteoarthritis Research Society International (OARSI) report eight RCTs showing significant effects of exercise therapy on pain relief, improvements of function and activity (4).
THR should be indicated when a high subjective level of distress persists for at least three months, despite guideline-based non-surgical therapy (↑, evidence-based). This recommendation is based on two high-quality meta-analyses (20, 22). In a Cochrane review, Fransen et al. (20) examined ten RCTs that compared exercise therapy (strengthening and stretching exercises, cardiovascular training) with a control group without exercise therapy . A significant treatment effect was demonstrated for pain relief (9 RCTs, n = 549, standardized mean difference [SMD] –0.38, 95% confidence interval [–0.55; –0.20]) and functional gain (9 RCTs, n = 521, SMD –0.38, [–0.54; –0.05]) immediately after treatment.
Analysis of five RCTs on the sustainability of the effects over three to six months also found significant results (pain relief n = 391, SMD –0.38 [–0.58; –0.18] and functional gain n = 365, SMD –0.37 [–0.57; –0.16]). In their analysis of 77 RCTs on hip and knee osteoarthritis (comparison of intervention groups with additional therapeutic exercise with control groups without additional therapy), Goh et al. (22) found that the positive effects in terms of pain, improvement in function and activity, and increase in quality of life through additional exercise peaked after eight weeks and decreased afterwards. There was no difference from the control group after about 9 to 18 months.
The proportion of patients with an absolute contraindication for THR surgery is comparatively low. Given the increased risk of infection, revision and mortality, the indication for THR should not be made, or should be delayed, and should be reviewed particularly critically in the presence of the following factors:
- previous, not eradicated infection of the hip joint
- acute or chronic comorbidities and
- morbid obesity (body mass index [BMI] ≥40 kg/m2).
Before performing a THR, an active infection of the affected hip joint as well as of the surrounding soft tissues must be ruled out (↑↑, guideline adaptation). The Second International Consensus Meeting on Orthopedic Infections (2nd ICM) (17) justifies this recommendation with the data of Pugely et al., who reported a 5-fold increased probability of periprosthetic joint infection within 30 days after surgery following a previous wound infection (n = 23 128 total hip and knee replacement, OR 5.0 [2.3; 10.9]) (33).
Active infections at other sites (hematogenous spread, local tissues, joints) should have healed before THR is performed (↑↑, guideline adaptation) (17). There is strong evidence for this recommendation (17 observational studies), which consistently showed a significantly increased risk of infection after surgery. A thorough medical history (infectious diseases, immunosuppressant medication usage, alcohol and nicotine addiction) and physical examination (dental, venous, skin status) as well as blood tests (CRP, white blood cell count, blood glucose, HbA1c) or, if necessary, joint aspiration are used to confirm absence of infection.
The association between a BMI ≥40 kg/m2 and a strongly increased risk of periprosthetic joint infections may be considered confirmed (three meta-analyses):
- for septic revisions (n = 10 325, relative risk 9.8 [3.6; 26.6]) (34)
- for periprosthetic infections (n = 8253, RR 8.5 [3.5; 20.7]) (35) and (n = 24 134, RR 3.7 [2.3; 6.0]) (27).
The 2nd ICM also rates the evidence for an increased risk of wound and periprosthetic infection with increasing BMI as reliable (17). Patients with a BMI ≥40 kg/m² should undergo a particularly critical risk-benefit analysis of the intervention (↑↑, evidence-based and guideline adaptation).
Optimization of modifiable risk factors
Patients have their own individual risk-factor profile that can have a negative impact on perioperative and postoperative complication rates, as well as treatment outcomes and implant survival (36). When planning treatment, it is important to consider whether existing risk factors are modifiable and the individual potential for complications can be reduced. Modifiable risk factors include nicotine addiction, poorly controlled diabetes mellitus, obesity (BMI ≥30 kg/m2), asymptomatic bacteriuria, mental disorders, anemia, and preoperative intra-articular corticosteroid injections. Systematic reviews that show evidence of these risk factors and their impact on postoperative outcomes are presented in eTable 1.
- Smokers should be encouraged to abstain from nicotine at least 1 month prior to scheduled THA (↑↑, evidence-based).
- Blood sugar levels of patients with diabetes mellitus should be optimized prior to THR surgery (↑↑, evidence-based). An HbA1c level below 8% should be targeted (EC).
- Patients with a BMI ≥30 kg/m2 should be advised to lose weight prior to THR surgery (↑, evidence-based and guideline adaptation).
- An asymptomatic bacteriuria should not be treated prior to a scheduled THA (↑↑, evidence-based).
- Patients with a suspected mental disorder should be advised to seek specialist consultation prior to THR surgery (EC).
- Prior to performing THA surgery, anemia diagnostics as well as therapy should be performed if the latter is required (↑↑, evidence-based and guideline adaptation).
- After intra-articular injection of corticosteroids, THA surgery should be performed at the earliest 6 weeks after injection; a three-months delay is recommended, however (↑, evidence-based).
The patient’s willingness to undergo joint replacement and the physician’s assessment of its necessity do not always match (37). During the shared decision-making process, the patient’s individual expectations and goals should be identified and documented (EC) and then their actual feasibility by means of THR should be discussed (EC). These include the expected benefits in terms of postoperative outcome (pain relief, improvement in function, activity and quality of life), the surgical risks in general as well as the individual risk profile and the likelihood of achieving individual goals. Patient-friendly information material should assist the informed consent process (EC). Finally, the consultation should conclude with a jointly reached decision for or against surgery. It should be agreed on that the expected benefits of surgery outweigh its potential risks (EC).
The recommendations were incorporated in a practical checklist (eTable 2) to support guideline implementation.
The literature research on which the guidelines are based was supported by project funds from the German Endoprosthetics Foundation.
The authors would like to thank the guideline group – including Prof. Jörg Lützner MD and Dr. Natascha Einhart MD – for their excellent collaboration during the guideline development process.
We would also like to thank all the representatives of professional societies and organizations involved in the consensus process, as well as Dr. Monika Nothacker MD for the support given on the part of the AWMF (eBox).
Conflict of interest statement
Prof. Günther was remunerated for an authorship by Orthopedics and Trauma Surgery Up2date. In writing the present manuscript, he was supported by the German Endoprosthetics Foundation. He was remunerated by Zimmer Biomet, AE, and OrthoTraumaUpdate for the preparation of scientific meetings. He received funding from Zimmer Biomet and the German Endoprosthetics Foundation to conduct contracted clinical studies and a research project which he initiated.
The other authors declare that they have no conflicts of interest.
Manuscript received on 1 June 2021, revised version accepted on 17 August 2021
Translated from the original German by Dr. Grahame Larkin, MD
As with many other professional journals, clinical guidelines in the German Medical Journal are not subject to the peer review process since S3 guidelines are already texts that have been assessed and discussed by experts (peers) and already have a broad consensus.
Prof. Klaus-Peter Günther MD, University Center of Orthopedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus University at the Technical University of Dresden, Fetscherstr. 74, 01307 Dresden, Germany
Cite this as:
Günther KP, Deckert S, Lützner C, Lange T, Schmitt J, Postler A: Total hip replacement for osteoarthritis—evidence-based and patient-oriented indications. Dtsch Arztebl Int 2021; 118: 730–6. DOI: 10.3238/arztebl.m2021.0323
eReferences, eTables, eBox:
Center for Evidence-Based Healthcare, University Medicine Carl Gustav Carus Dresden and the Medical Faculty Carl Gustav Carus of the Technical University Dresden: Stefanie Deckert, Toni Lange, Prof. Jochen Schmitt MD
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Indication Criteria for Total Hip Arthroplasty in Patients with Hip Osteoarthritis—Recommendations from a German Consensus InitiativeMedicina, 202210.3390/medicina58050574
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