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



Expected practice


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


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 preoperative, 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


  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. Conservave treatment, managed by the PCP or Specialist, for a minimum of 3 months (Bree, 2013; AAOS, 2022). Treatment opons include:
      1. NSAIDS
      2. Assistive device for ambulation (e.g., cane, walker)
      3. Weight reduction program
      4. Therapeutic intra-arcular corsone injecon (maximum 2-3 injecons/year)
      5. 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 parcipated in an approved weight loss program for 90 days and a provider recommends proceeding with TKR surgery for a Patient who does not meet the appropriatenessstandards(Bree, 2015)
    2. Hgb A1c lessthan 7 within last 12 weeks prior to surgery. If Patient issupervised by endocrinologist, they may proceed if A1C is greater than 7
    3. Staged arthroplasty must be performed a minimum 31 daysfrom the index procedure in order to not be considered a readmission by CMS guidelines
  4. Patients parcipate in a total joint educaon class and shared decision making. Caregivers are included in educaon, so they understand expectaons.
  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 aer surgery (Bree, 2013). The Veterans Rand 12-Item Health Survey (VR-12) and the Hip Osteoarthris 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 me, 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


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)


  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)
  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 by 10am for discharge by 1pm to facilitate throughput.
  3. Transition to PO antibiotics after initial IV dose for 7 days postop.
  4. Routine discharge medications:
    1. ASA for 4 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. PO ASA for minimum of 4 weeks for standard risk patients with first dose at 20 hours post-op during hospital stay
    2. Direct Oral Ancoagulant for minimum of 4 weeks for high-risk patients with first dose at 20 hours post-op during hospital stay (or equivalent medicaon)
    3. TED hose bilaterally on during the day, off at night for 4 weeks(optional) or unl ambulatory – 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.


  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. After a primary THA, formal physical therapy is not typically necessary as it does not impact long term outcome
    1. Patients who may benefit from formal therapy include:
      1. Patients who have a pre-operave high risk for falls
      2. Patients who have a funconal issue that limits the ability to fully parcipate in a physician directed home exercise program
      3. Patients who have need for formal therapy other than physical therapy (Speech/ Occupaonal Therapy)
    2. Non-opioid pain medicaons (i.e. mul-modal)
      1. Benefits include superior pain control, improved paent sasfacon, minimize opioid related morbidity


  1. All educaonal and community promoonal materials will align with these guidelines.
  2. Avoid transfusions unl the paents Hgb is <7, the paent is clinically symptomac or considered high risk. Transfusions are ordered by the surgeon or if ordered by another provider, will be cleared by the surgeon


  1. Barbieri, A., Vanhaecht, K., Van Herck, P., Sermeus, W., Faggiano, F., Marchisio, S., & Panella, M. (2009). Effects of clinical pathwaysin the joint replacement: a meta-analysis. BMC medicine, 7(1), 1.
  2. Bree Collaborave. (2013). Bundle: Clinical Components of Total Knee or Total Hip Replacement
  3. Brown, N. M., Cipriano, C. A., Moric, M., Sporer, S. M., & Della Valle, C. J. (2012). Dilute betadine lavage before closure for the prevenon of acute postoperave deep periprosthec joint infecon. The Journal of arthroplasty, 27(1), 27-30.
  4. Cai, J., Karam, J. A., Parvizi, J., Smith, E. B., & Sharkey, P. F. (2014). Aquacelsurgical dressing reducesthe rate of acute PJI following total joint arthroplasty: a case–controlstudy. 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 Periprosthec Joint Infecon Aer Total Joint Arthroplasty. The Journal of Arthroplasty.
  6. Harari, D., Hopper, A., Dhesi, J., Babic-Illman, G., Lockwood, L., & Marn, F. (2007). Proacve care of older people undergoing surgery (‘POPS’): designing, embedding, evaluang and funding a comprehensive geriatric assessment service for older elecve surgical paents. 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 Pracce Guideline Workgroup. Periarcular Injecon in Total Joint Arthroplasty: The Clinical Pracce Guidelines of the American Associaon 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. Effecveness of diluted povidone-iodine lavage for prevenng periprosthec joint infecon: an updated systemac 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 Anbiocsfor Surgical Site Infecon Prevenon Aer Total Joint Arthroplasty Among Paents With a Beta-lactam Allergy, Open Forum Infecous 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 Mobilizaon Reducesthe Length of Stay Aer Elecve Hip Arthroplasty. The Journal of arthroplasty.
  11. Pérez-Serna, A. G., Negrete-Corona, J., Chávez-Hinojosa, E., & López-Mariscal, C. (2011). Effecveness ofsodium hyaluronate in paents with gonarthrosis: randomized comparave 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. Consensusstatement for perioperave care in total hip replacement and total knee replacementsurgery: Enhanced Recovery Aer Surgery (ERAS®) Society recommendaons. 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. Yakkan RR, Vanden Berge D, Summers SH, Mansour KL, Lavin AC, Hernandez VH. Extended Postoperave Prophylacc Anbiocsfor Primary and Asepc Revision Total Joint Arthroplasty: A Systemac Review. J Am Acad Orthop Surg. 2022;30(11):e822-e832. doi:10.5435/JAAOS-D-21-00977
  14. Yayac M, Moltz R, Pivec R, Lonner JH, Courtney PM, Ausn MS. Formal Physical Therapy Following Total Hip and Knee Arthroplasty Incurs Addional 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.