URAC
The Arizona HOPCo Specialty Care Network is the only
URAC-accredited MSK clinically integrated network in the country.

Management of Osteoarthritis of Hip Clinical Practice

Clinical Region

Florida

PRACTICE APPROACH

Expected practice

PRACTICE STATEMENT

All adult patients with hip osteoarthritis (OA) will be assessed and provided care throughout the continuum based on the Bree Collaborative. AAOS ,2017

Rationale

Standardizing the processes of care can improve quality and utilization outcomes, including length of stay, costs, complications and 30-day readmissions (Loftus, et. al., 2014; Barbieri, et. al., 2009).  In addition, Medicare is expected to mandate a bundled payment program, further incentivizing organizations to improve financial and clinical performance.  Although implementation of one of two interventions alone can improve quality and utilization outcomes (Loftus, et. al, 2014), a comprehensive approach is recommended (Bree, 2013).

The Bree Collaborative is a widely recognized comprehensive approach and “defines the expected components of pre-operative, intra-operative, and post-operative care needed for successful TKR/THR surgery” (Bree, 2013).  The Bree Collaborative is a partnership among many different stakeholders within the State of Washington that is working to identify and promote strategies to reduce variation in care while improving care, safety, and health with evidence-based recommendations.

In December of 2022 the AAOS published its evidence based clinical practice guideline to help guide provider decision making towards evidence-based treatments of OA of the hip.  The AAOS guideline is supported by the American society of Anesthesiologists, The Hip Society, The American College of Radiology, and American Association of Hip and Knee Surgeons.  The AAOS guideline contains 20 recommendations for the pre-operative, perioperative, and postoperative care of patients with OA of the hip who are considering surgical treatment.  The AAOS conducted an extensive literature review and analyzed evidence.  Recommendations were graded by the strength of methodology of the available evidence.  A strong recommendation means the quality of supporting evidence is high (two or more high strength studies with consistent findings for recommending for or against the intervention), a moderate recommendation means that the benefits exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a negative recommendation), and a limited recommendation means there is a lack of compelling evidence and an unclear balance between benefits and potential harm (AAOS, 2022).

Clinical Approach

The clinical approach is based on consensus guidelines and includes expected practices which will be designed and implemented for the patients with hip osteoarthritis. Recommended clinical care is also included.

Expected Clinical Care

PREOPERATIVE

  1. Providers are responsible for gathering all the necessary documentation to demonstrate that minimum requirements for surgery have been met.
  2. Patients should meet the following minimum requirements prior to surgery:
    1. Conservative treatment, managed by the PCP or Specialist, for a minimum of 3 months (Bree, 2013; AAOS, 2013). Treatment options include:
      1. NSAIDS
      2. Assistive device for ambulation (e.g., cane, walker)
      3. Weight reduction program
      4. Therapeutic intra-articular cortisone injection (maximum 2-3 injections/year)
      5. No intra-articular cortisone injection within 3 months of surgery
      6. Physical therapy: Strengthening, gait, training, ROM
    2. Advanced joint disease.
  3. BMI less than 40 (AAOS 2022).
    1. An appeal process will be in place for patients who have participated in an approved weight loss program for 90 days and a provider recommends proceeding with THR surgery for a patient who does not meet the appropriateness standards (Bree, 2015).
    2. Hgb A1c less than 7 within last 12 weeks prior to surgery. If patient is supervised by endocrinologist, they may proceed if A1C is greater than 7.
    3. Staged arthroplasty must be performed a minimum 31 days from the index procedure in order to not be considered a readmission by CMS guidelines.
  4. Patients will participate in a total joint education class and shared decision making. Caregivers are included in education, so they understand expectations.
  5. Patients will obtain DME:
    1. Front wheeled walker
    2. Seat riser
    3. TED hose
    4. Shoehorn extender (THA)-optional
    5. Reacher-optional
  6. A standardized Patient Reported Outcomes (PRO) tool will be administered prior to surgery and after surgery (Bree, 2013). The Veterans Rand 12-Item Health Survey (VR-12) and the Hip Osteoarthritis Outcome Score (HOOS) tool will be used.
  7. Antibiotics in pre-op holding:
    1. Cefazolin (Ancef) 2 gm (less than 120 kg) or 3 gm (120 kg or greater) IV within 1 hour of cut time, or
    2. Options for penicillin/cephalosporin allergic/intolerant patients:
      1. Vancomycin 1 gm (less than 90 kg) or 1.5 gm (90 kg or greater) IV within 2 hours of cut time

INTRA-OPERATIVE CARE REQUIREMENTS

Patients will receive:

  1. Tranexamic acid, 1000mg IV at induction or topical intraoperatively(AAOS, 2022).
  2. 0.35% dilute povidone-iodine (Betadine) soak (using product for single patient use) (Kobayashi, 2021). Use in hemiarthroplasty is at the providers discretion.
  3. An intra-operative x-ray to assess for retained foreign object
  4. Silver-impregnated water-proof dressing (Mepilex) (Grosso, et. al., 2016; Cai, et. al., 2014)

CARE TO AVOID POST-OPERATIVELY

  1. Foley catheters for primary TJA
  2. PCAs for primary TJA
  3. Cold machines for primary TJA
  4. Femoral blocks for primary TJA
  5. Trapeze bed for primary TJA
  6. Abduction pillow for primary THA
  7. Transfusion if Hgb is above7 (unless clinically indicated)

POST-OPERATIVE CARE REQUIREMENTS

  1. The patient will be mobilized on the day of surgery (Bree, 2013; AAOS, 2015; Okamoto, 2016).
  2. Rounds and discharges are conducted in the morning and preferably completed as early as possible.
  3. Transition to PO antibiotics after initial IV dose for 7 days postop.
  4. Routine discharge medications:
    1. ASA 81 mg BID for 6 weeks
    2. Colace 100 mg PO BID
  5. Consider multi-modal approach to pain management to minimize need for prolonged opiates
    1. Opioid pain medications:
      1. Short-course Oxycodone Immediate-Release 5-10 mg PO Q6H PRN Moderate-Severe Pain
    2. Non-opioid pain medications (i.e. multi-modal)
      1. Benefits include superior pain control, improved patient satisfaction, minimize opioid related morbidity
    3. Medications such as acetaminophen, gabapentin, NSAIDS (e.g. ibuprofen, celecoxib) should be considered if not contraindicated
    4. Consider GI prophylaxis-as needed for aspirin or NSAID usage and patient risk factors.
  6. DVT prophylaxis:
    1. ASA 81mg BID for 6 weeks for standard risk patients
    2. For high risk patients chemoprophylaxis at providers discretion
    3. TED hose bilaterally on during the day, off at night for 4 weeks(optional)
    4. SCDs bilaterally to be on while in bed during hospital stay
      *High Risk: History of DVT/PE, active malignancy, females on hormone therapy or oral contraceptive that will not come off their medications, or any patient with multiple co-morbidities the physician feels puts the patient at increased risk.

THERAPY AND POST-ACUTE CARE

  1. Inpatient rehab admission is rarely indicated after primary THA
  2. Skilled Nursing Facility admission is infrequently indicated after THA
    1. When admitted to a skilled nursing facility, length of stay should be as efficient as clinically possible.
  3. When formal therapy is clinically indicated, outpatient physical therapy is preferred over home health therapy.
    1. The length of time the patient participates in formal therapy and the frequency of visits should be commensurate with clinical need.

GENERAL

All educational and community promotional materials will align with these guidelines.

References

  1. Barbieri, A., Vanhaecht, K., Van Herck, P., Sermeus, W., Faggiano, F., Marchisio, S., &Panella, M. (2009). Effects of clinical pathways in the joint replacement: a meta-analysis. BMC medicine, 7(1), 1.
  2. Bree Collaborative. (2013). Bundle: Clinical Components of Total Knee or Total Hip Replacement Surgery.
  3. Brown, N. M., Cipriano, C. A., Moric, M., Sporer, S. M., & Della Valle, C. J. (2012). Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. The Journal of arthroplasty, 27(1), 27-30.
  4. Cai, J., Karam, J. A., Parvizi, J., Smith, E. B., & Sharkey, P. F. (2014). Aquacel surgical dressing reduces the rate of acute PJI following total joint arthroplasty: a case–control study. The Journal of arthroplasty, 29(6), 1098-1100.
  5. Grosso, M. J., Berg, A., LaRussa, S., Murtaugh, T., Trofa, D. P., & Geller, J. A. (2016). Silver-Impregnated Occlusive Dressing Reduces Rates of Acute Periprosthetic Joint Infection After Total Joint Arthroplasty. The Journal of Arthroplasty.
  6. Harari, D., Hopper, A., Dhesi, J., Babic-Illman, G., Lockwood, L., & Martin, F. (2007). Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age and ageing, 36(2), 190-196.
  7. Hannon CP, Fillingham YA, Spangehl MJ, Karas V, Kamath AF, Hamilton WG, Della Valle CJ; AAHKS Anesthesia & Analgesia Clinical Practice Guideline Workgroup. Periarticular Injection in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty. 2022 Sep;37(9):1701-1707. doi: 10.1016/j.arth.2022.03.048. PMID: 35970572.
  8. Kobayashi, N., Kamono, E., Maeda, K. et al. Effectiveness of diluted povidone-iodine lavage for preventing periprosthetic joint infection: an updated systematic review and meta-analysis. J Orthop Surg Res 16, 569 (2021). https://doi.org/10.1186/s13018-021-02703-z
  9. Miranda R Norvell and others, Cefazolin vs Second-line Antibiotics for Surgical Site Infection Prevention After Total Joint Arthroplasty Among Patients With a Beta-lactam Allergy, Open Forum Infectious Diseases, Volume 10, Issue 6, June 2023, ofad224, https://doi.org/10.1093/ofid/ofad224
  10. Okamoto, T., Ridley, R. J., Edmondston, S. J., Visser, M., Headford, J., & Yates, P. J. (2016). Day-of-Surgery Mobilization Reduces the Length of Stay After Elective Hip Arthroplasty. The Journal of arthroplasty.
  11. Pérez-Serna, A. G., Negrete-Corona, J., Chávez-Hinojosa, E., & López-Mariscal, C. (2011). Effectiveness of sodium hyaluronate in patients with gonarthrosis: randomized comparative study. Acta Ortopédica Mexicana, 25(4), 208-215.
  12. Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, Yates P, Ljungqvist O. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthop. 2020 Feb;91(1):3-19. doi: 10.1080/17453674.2019.1683790. Epub 2019 Oct 30. Update in: Acta Orthop. 2020 Feb 14;:1. PMID: 31663402; PMCID: PMC7006728.
  13. Yakkanti RR, VandenBerge D, Summers SH, MansourKL, Lavin AC, HernandezVH.ExtendedPostoperative ProphylacticAntibiotics forPrimary and AsepticRevision Total Joint Arthroplasty: A Systematic Review. J Am AcadOrthop Surg. 2022;30(11):e822-e832. doi:10.5435/JAAOS-D-21-00977
  14. Yayac M, Moltz R, Pivec R, Lonner JH, Courtney PM, Austin MS. Formal Physical Therapy Following Total Hip and KneeArthroplasty Incurs Additional Cost Without Improving Outcomes. J Arthroplasty. 2020 Oct;35(10):2779-2785. doi: 10.1016/j.arth.2020.04.023. Epub 2020 Apr 18. PMID: 32674941.