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Large Joints Feature

AAOS Issues New OA Clinical Practice Guidelines

Elizabeth Hofheinz, M.P.H., M.Ed. • Mon, May 1st, 2017

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The American Academy of Orthopaedic Surgeons (AAOS) has just released its new recommendations on the treatment of osteoarthritis (OA) of the hip.

AAOS: “strongly recommends the use of pre-surgical treatments to ease pain and improve mobility, including corticosteroid injections, physical therapy and non-narcotic medications. The new guidelines do not recommend the use of hyaluronic acid or glucosamine sulfate to minimize osteoarthritis symptoms, due to a lack of evidence supporting the efficacy of these treatments. In addition, there are no clinically significant differences in patient-oriented outcomes related to hip surgery approach—either anterior or posterior used during following total hip replacement (THR) surgery.”

“The CPG [clinical practice guidelines] also states that patients with moderate obesity (a body mass index greater than 30) and severe osteoarthritis of the hip may achieve lower outcome scores following THR when compared to non-obese patients; however, these patients have a similar level of satisfaction and relative improvement in pain and function after THR. In addition, there is limited existing evidence to support that patients who use tobacco products are at an increased risk for complications after THR. Age was moderately associated with lower function and quality of life outcomes; and mental health disorders (depression, anxiety and psychosis) with decreased function, pain relief and quality of life following surgery.”

With strong or moderate evidence, the CPG does recommend:

  • The use of risk assessment tools to assist in predicting patient complications, assessing surgical risks and educating osteoarthritis patients who are undergoing THR.
  • The use of corticosteroid injections to improve function and reduce pain “in the short-term” for patients with osteoarthritis of the hip.
  • Physical therapy as a conservative treatment to reduce pain in patients with mild to moderate osteoarthritis of the hip.
  • The use of non-narcotic medications and, specifically, non-steroidal anti-inflammatory drugs (NSAIDs) to improve short-term pain, function or both in patients with symptomatic osteoarthritis of the hip.
  • Postoperative physical therapy after THR to improve early function.
  • The use of tranexamic acid, injected or administered at the surgical site, for patients undergoing THR to minimize blood loss.

Robert H. Quinn, M.D. is the AAOS Appropriate Use Criteria (AUC) Section Leader on the Committee on Evidence-Based Quality and Value. He told OTW, “With all of our CPGs, developing the proper PICO [Patient/Problem, Intervention, Comparison, Outcome] questions is the biggest challenge as this process leads to collection of the best evidence. With this particular CPG, posing the correct questions and developing the best evidence around potential risk factors and mitigation was particularly challenging.”

“Hip replacement is a very effective procedure in relieving pain and increasing function in patients with osteoarthritis. Risk assessment tools can be very helpful in assigning risk and developing informed consent. As in prior guidelines, specifically knee arthritis, supplements and viscosupplementation were not shown to be helpful. Conservative modalities including non-narcotic medication, physical therapy, and corticosteroid injections are beneficial in pre-surgical treatment. Tranexemic acid appears to be effective in decreasing blood loss.”

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