Total hip replacement or resistance training for severe hip osteoarthritis

Key Points

1. In patients with severe hip osteoarthritis and an indication for hip surgery, total hip replacement resulted in greater improvements in hip pain and function at six months than resistance training.
2. Surgery was just as safe as resistance training.

BACKGROUND & OBJECTIVE

Hip OA affects 33 million people worldwide and is a substantial contributor to disability (1). Total hip replacement is a common treatment for hip osteoarthritis, with more than one million surgeries performed each year (2). In Europe and Australia, the lifetime likelihood of undergoing total hip replacement is approximately 10% (3). However, there is little research comparing the effectiveness of total hip replacement to nonsurgical treatments.

This study is a randomized controlled trial comparing the effectiveness of total hip replacement to resistance training for severe hip osteoarthritis.

There is little research comparing the effectiveness of total hip replacement to nonsurgical treatments.

Clinicians should be aware that total hip replacement is a good option to consider for patients with severe hip osteoarthritis.

METHODS

• The study recruited 109 people over the age of 50 with severe hip osteoarthritis (OA) and a recommendation to undergo total hip replacement (THR). Half were assigned to surgery, and the other half received individual, supervised resistance training (RT) with a physiotherapist twice weekly for three months (see Video 1 for hip exercises).

• The primary outcome, assessed at baseline and 6 months, was patient-reported hip pain and function, as measured by the Oxford Hip Score.

• The secondary outcomes included: hip pain and function as assessed by the Hip Disability and Osteoarthritis Outcome Score; patient-reported physical activity level as assessed by the UCLA activity score; performance in a 40-m fast-paced walk test, and performance in a 30-second sit-to-stand test.

• There was also data collected on serious adverse health events occurring between baseline and six months.

HIP RESISTANCE EXERCISES

RESULTS

• The THR group had significantly more improvement on the Oxford Hip Score (15.9 points on a 48-point scale) than the RT group (4.5 points on a 48-point scale).

• The THR group also had significantly more improvement on the Hip Disability and OA Outcome Score, the UCLA activity scale score, and gait speed.

• The groups had similar outcomes in regard to the sit-to-stand functional test, and the number of serious adverse health effects.

LIMITATIONS

• Patients knew which treatment they received, and this could have affected their self-reported assessments.

• The percentage of patients with serious adverse events was similar in the two groups, although two of five events in the resistance-training group occurred after the patients had undergone THR.

• Only 14% of the eligible patients were enrolled, which may limit the generalizability of the findings.

• The benefits from the surgery might have been underestimated, because 9% of the patients in the THR group did not undergo surgery, and 21% of patients in the RT group had undergone THR at six months.

CLINICAL IMPLICATIONS

Although there is research showing that THR is effective for reducing pain and improving function, there is little data comparing it to non-surgical treatments such as RT, which has also been shown to be effective in treating severe hip OA (4).

This study compared THR to RT in patients over 50 years of age who had severe hip OA and an indication for surgery. It found that THR was superior in improving hip pain and function across a variety of measures. However, THR did not lead to clinically important improvements than resistance training with regard to physical activity level, gait speed, or sit-to-stand function at 6 months.

This study does not provide evidence that individuals with severe OA should avoid resistance training. Instead, it is about assessing the individual and identifying the best course of action as part of a shared decision-making process. Some individuals may still respond favourably to resistance training compared to others. Furthermore, those that eventually have a THR, there is the potential for faster recovery in the post-operative phase for individuals who have resistance training experience.

Clinicians should be aware that THR is a good option to consider for patients with severe hip OA.

+STUDY REFERENCE

Frydendal T, Christensen R, Mechlenburg I et al. (2024) Total Hip Replacement or Resistance Training for Severe Hip Osteoarthritis. N Engl J Med, Oct 31;391(17):1610-1620.

SUPPORTING REFERENCE

1. Fu M, Zhou H, Li Y, Jin H, Liu X. Global, regional, and national burdens of hip osteoarthritis from 1990 to 2019: estimates from the 2019 Global Burden of Disease Study. Arthritis Res Ther 2022;24:8-8
2. Ferguson RJ, Palmer AJ, Taylor A, Porter ML, Malchau H, Glyn-Jones S. Hip replacement. Lancet 2018;392:1662-1671.
3. Burn E, Murray DW, Hawker GA, Pinedo-Villanueva R, Prieto-Alhambra D. Lifetime risk of knee and hip replacement following a GP diagnosis of osteoarthritis: a real-world cohort study. Osteoarthritis Cartilage 2019;27:1627-1635.
4. Hansen S, Mikkelsen LR, Overgaard S, Mechlenburg I. Effectiveness of supervised resistance training for patients with hip osteoarthritis — a systematic review. Dan Med J 2020;67(6):A08190424-A08190424.