The American Academy of Orthopaedic Surgeons (AAOS) has established new Appropriate Use Criteria (AUC) for the management of hip osteoarthritis (OA), strongly recommending nonsurgical treatments to alleviate pain and increase mobility. These AUCs are intended to help clinicians best manage the condition, with treatments being “ranked for appropriateness based on the latest research and clinical expertise and experience,” AAOS said in a press release.
The AUCs also support the academy’s clinical practice guideline, “Management of Osteoarthritis of the Hip,” which gave the highest ratings of “strong evidence” for the use of nonsteroidal anti-inflammatory drugs (NSAIDs), intra-articular corticosteroids, and physical therapy for treatment.
For NSAIDs, six high-quality placebo-controlled studies were identified by the guideline authors, showing that short-term use of these agents, including naproxen, celecoxib, and diclofenac, for no longer than 13 weeks, improved pain, function, or both. The percentage of patients responding to this treatment ranged from 30% to 67%.
For intra-articular corticosteroids, three high-quality studies compared the active treatment with placebo, showing statistically significant benefits on both pain and function scores, with effect duration ranging from 8 weeks to 3 months.
And for physical therapy, the guideline notes that there were nine high-quality studies and three of moderate quality, with conflicting evidence. So the authors conducted a meta-analysis, which found “a net positive benefit of physical therapy on functional outcomes at 6 to 12 month follow-up,” as well as pain reduction at 9 months.
The guideline also addresses a number of concerns about hip arthroplasty, such as the appropriateness of joint replacement for patients with modifiable risk factors such as obesity, mental health disorders, and smoking.
“Some patients who have worked closely with their medical team to best mitigate these risk factors might be considered on an individual basis for surgery,” said Robert H. Quinn, MD, who is the AAOS AUC section leader on the Committee on Evidence-Based Quality and Value.
“In these instances, the doctor and patient must weigh the benefits and risks of surgery. At the end of the day, it’s one surgeon and one patient, and hopefully both are considering the optimal treatment based on the patient’s particular condition and diagnosis,” Quinn said in the press release.
Approaches that the guideline does not support included the use of glucosamine for improving function, stiffness, and pain, with moderate evidence. Only one randomized trial of glucosamine in hip OA was of high quality, and found no benefit versus placebo.
Another treatment not supported was the use of intra-articular hyaluronic acid, which failed to provide improved pain and function comparable to what was seen with steroid injections in two trials. The evidence was considered strong.