What are the indications for hip arthroplasty in older adults with severe hip joint damage and comorbidities such as diabetes, heart disease, or obesity?

Indications for Hip Arthroplasty in Older Adults

Hip arthroplasty is strongly indicated for older adults with radiographically moderate-to-severe osteoarthritis (bone-on-bone articulation, subchondral sclerosis, cystic changes) who have severe pain or functional disability that interferes with daily activities and who have failed appropriate nonoperative therapy, regardless of comorbidities such as diabetes, heart disease, or obesity. 1, 2

Primary Clinical Indications

Radiographic Evidence Required:

• Moderate-to-severe osteoarthritis with bone-on-bone articulation, subchondral sclerosis, and cystic changes (equivalent to Kellgren-Lawrence Grade 3-4 or Tonnis Grade 2-3) 2
• Advanced symptomatic osteonecrosis with secondary arthritis 1

Symptomatic Criteria:

• Severe pain that limits daily activities, including nighttime pain 2
• Functional disability affecting occupation (inability to stand at work, walk long distances) 2
• Mobility limitations that compromise quality of life 3, 2
• Pain and functional impairment not adequately controlled by conservative measures 1

Failed Conservative Management:

• When bone-on-bone arthritis exists in the weight-bearing portion of the joint, prolonged conservative therapy may not be reasonable 2
• Patients should have attempted at least one appropriate nonoperative therapy (physical therapy, NSAIDs, weight optimization, ambulatory aids, or intraarticular injections) 1

Management of Comorbidities

Diabetes:

• Conditionally recommend delaying surgery to improve glycemic control, though no specific HbA1c threshold is mandated 1
• Educate patients about increased surgical risks with poor glycemic control 1
• The decision should balance the risk of delayed surgery (worsening pain, function, deconditioning) against perioperative complications 1

Obesity:

• Conditionally recommend proceeding to surgery without delay to meet rigid BMI thresholds, even for BMI ≥50 1
• Obesity alone is not a contraindication to hip arthroplasty 1
• Patients must be educated about increased medical and surgical complications associated with obesity 1
• Weight loss should be strongly encouraged, but surgery should not be indefinitely delayed 1

Heart Disease:

• Cardiac risk assessment should follow existing guidelines for perioperative evaluation 1
• Age and comorbidities increase perioperative mortality risk (2.6-2.9% for nonagenarians, 1.09-1.54% for octogenarians), but this must be weighed against continued disability 4
• Interdisciplinary care programs are strongly recommended to decrease complications and improve outcomes 1

Age Considerations

Advanced Age is NOT a Contraindication:

• Age alone should not be a barrier to total hip arthroplasty when functional impairment is severe 1, 2
• Elective THA is safe and effective in octogenarians and even patients aged 87+ years with appropriate patient selection 5, 6
• Patient selection should be based on symptomatology, overall health, functional status, and rehabilitation potential—not chronological age 7, 5
• Advanced age patients (80+ years) achieve 80% pain-free status and 70% walk without assistance at 4-year follow-up 5
• Median overall survival after THA in patients over 85 is 6.77 years, with no difference based on comorbidity index 6

Critical Decision Points

Proceed Without Delay When:

• Bone-on-bone arthritis with severe symptoms exists 2
• Severe bone loss with deformity or ligamentous instability is present (delaying increases technical difficulty and failure risk) 1
• Neuropathic joint with progressive destruction exists (early surgery prevents worsening bone loss) 1
• Patient has completed appropriate conservative trials and symptoms persist 1

Do NOT Mandate Delay For:

• Arbitrary 3-month "cool-down" periods 1
• Additional physical therapy trials once indicated for surgery 1
• Further trials of NSAIDs, braces, ambulatory aids, or intraarticular injections 1
• Achieving specific BMI thresholds 1

Consider Delay Only For:

• Active nicotine use (conditionally recommend reduction/cessation, but complete cessation is not required) 1
• Poorly controlled diabetes (for glycemic optimization) 1
• Life-threatening medical conditions requiring stabilization 1

Special Populations

Ankylosing Spondylitis with Advanced Hip Arthritis:

• Strongly recommend total hip arthroplasty over no surgery 1
• Surgery should be performed by orthopedic surgeons highly experienced in joint replacement for AS patients 1
• Observational studies demonstrate postoperative improvements in pain, functioning, and hip range of motion 1

Hip Fracture in Older Adults:

• For displaced femoral neck fractures, total hip arthroplasty provides functional benefit over hemiarthroplasty, though with increased complication risk (moderate strength recommendation) 1
• Surgery should occur within 24-48 hours when safely possible 1
• Cemented femoral stems are strongly recommended in older adults to reduce periprosthetic fracture risk 1

Common Pitfalls to Avoid

• Do not delay surgery indefinitely for weight loss—obesity increases risk but is not an absolute contraindication 1
• Do not exclude elderly patients based solely on age—functional status and rehabilitation potential matter more 5, 6, 4
• Do not mandate complete nicotine cessation—reduction is preferred, but surgery should not be contingent on complete cessation 1
• Do not require additional conservative therapy once bone-on-bone arthritis with severe symptoms exists—further delay worsens outcomes 2
• Do not assume high comorbidity precludes surgery—careful patient selection and interdisciplinary care optimize outcomes 1, 6

Outcomes and Expectations

• THA achieves excellent pain relief and functional improvement in properly selected elderly patients 3, 5, 6
• Complications occur more frequently in elderly patients (15-27.5%), but most are treatable and not life-threatening 5, 4
• Hospital stay increases by 0.6-3.1 days in the most elderly groups 4
• Despite increased adverse events, elderly patients report high satisfaction and gains in activities of daily living 4
• Mortality risk must be balanced against continued disability from untreated arthritis 7, 4