Osteoarthritis and the Optimal Time for Total Hip ReplacementFebruary 23, 2015
WHAT IS OSTEOARTHITIS?
Degenerative arthritis or Osteoarthritis (OA) is a common condition that affects approximately 27 million Americans and it is most commonly seen in people who are 65 years or older. OA can cause cartilage degeneration and eventually lead to joint destruction which can significantly affect an individual’s quality of life by reducing mobility, limiting lifestyle choices and ultimately leading to significant disability and pain.
Patients with OA of the hip typically complain of pain in the groin, buttock, back, knee or upper thigh. This pain is typically exacerbated by weight bearing activities or by simply walking, putting on shoes or socks, or by climbing stairs. In more advanced cases, patients can have pain at rest (even though rest used to provide relief) or pain at night. Hip pain from OA can be more pronounced in the morning when patients also typically mention “stiffness” of the hip when they wake up. On occasion, patients may complain of associated mechanical symptoms (“locking, catching, and clicking”).
CONSERVATIVE TREATMENT OPTIONS
Although there is no cure for OA, non-pharmacologic management remains the first line of treatment. It includes lifestyle modifications that would help protect the joint and slow the progression of the disease (e.g., minimize activities such as climbing stairs, eliminate high-impact activities and weight loss), participation in physical therapy to reduce functional deficit and to improve joint stability, mobility and strength, and incorporation of mechanical aids such as a walking cane to help decrease weight-bearing forces during ambulation.
Patients with advanced OA might require pharmacologic intervention to help manage persistent pain. Acetaminophen remains the first choice, but nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids can be considered as well for patients who don’t obtain adequate relief with acetaminophen.
WHEN TO RECOMMEND SURGERY, IS THERE A CONSENSUS AMONG PHYSICIANS?
It is generally agreed that patients need to be evaluated by an orthopedic surgeon for Total Hip Replacement when a conservative approach has failed to provide relief of symptoms for OA. However, the decision of when to refer a patient to the orthopedic surgeon or when to suggest surgery as the next step can be a complex one for the healthcare provider, since there are no universally accepted criteria by which to determine the optimal time for surgery.
Several studies surveying primary care providers and orthopedic surgeons in Europe and in the United States regarding timing for Total Hip Replacement have shown that although both groups of physicians agree on the factors to consider for surgery (pain, functional impairment, range of motion, etc.), they have different points of view regarding the importance and the severity of these factors in determining the optimal time to recommend surgery1,2. For instance, although activity limiting pain and functional limitations are considered key indicators for surgery, there is no consensus on the severity of pain and the severity of functional impairment that would warrant the surgical procedure.
The complexity of this decision is compounded by the current understanding that timing of surgery might be more important than previously realized, and that performing surgery earlier in the course of functional decline may be associated with a better outcome3.
Orthopedic surgeons at NEBH, who pioneered Total Joint Replacement and who perform the largest volume of Total Joint Replacements surgeries in New England each year, suggest that primary care providers use these questions as a guide when considering an orthopedic referral for their patients with OA:
- Has the pain become intractable?
- Does the patient complain of pain at night accompanied by extreme fatigue during the day?
- Has there been a significant reduction in activities of daily living and/or the ability to work?
- Does the patient complain of an increased difficulty with simple tasks such as putting on socks or shoes, or going upstairs?
- Has there been a significant decrease in muscle mass?
- Has there been any long-term benefit from decreased activity or from the use of non-steroid anti-inflammatory medicines or cortisone injections?
- Is fatigue a limiting factor?
Lastly, the decision to operate is also heavily influenced by the patient’s desire to proceed with surgery. According to NEBH physicians, a discussion with the patient about the overall quality of life that has been achieved with conservative treatment and whether the “bad days” outweigh the “good days” can provide guidance as to the right time to proceed with Total Hip Replacement surgery.
1-Dreinhöfer KE1, Dieppe P, Stürmer T, Gröber-Grätz D, Flören M, Günther KP, Puhl W, Brenner H. Indications for total hip replacement: comparison of assessments of orthopaedic surgeons and referring physicians. Ann Rheum Dis. 2006 Oct;65(10):1346-50. Epub 2006 Jan 26.
2-Mancuso CA1, Ranawat CS, Esdaile JM, Johanson NA, Charlson ME. Indications for total hip and total knee arthroplasties. Results of orthopaedic surveys. J Arthroplasty. 1996 Jan;11(1):34-46.
3-Fortin PR1, Penrod JR, Clarke AE, St-Pierre Y, Joseph L, Bélisle P, Liang MH, Ferland D, Phillips CB, Mahomed N, Tanzer M, Sledge C, Fossel AH, Katz JN. Timing of total joint replacement affects clinical outcomes among patients with osteoarthritis of the hip or knee. Arthritis Rheum.;46(12):3327-30, Dec, 2002