The Operating Theatre Journal April 2022

Multiple long-term conditions should not be a
barrier to hip replacement surgery
Having multiple long-term
conditions should not prevent
people with osteoarthritis
having hip replacements. New
research found that the surgery
improved their quality of life and
complication rates were generally
low. Despite this, the study found
that fewer than half of those
with hip osteoarthritis had hip
replacement surgery.
Osteoarthritis is a common
type of arthritis that causes
pain and stiffness. In severe
cases, hip replacement surgery
is recommended. However,
surgery might be delayed, or
even ruled out, if the person has
other existing health conditions.
Such decisions are not based on
evidence; the researchers say no
previous research has explored
whether people with multiple
long-term conditions have worse
outcomes than others after this
procedure.
This study analysed the health
records of 27,560 people aged 65
and over, who all had a diagnosis
of hip osteoarthritis. Decisions on
surgery were influenced by longterm
conditions, the study found;
the more long-term conditions
people had, the less likely they
were to have a hip replacement.
Yet these people generally had
good outcomes and benefitted
from surgery.
The research highlights the
importance of an evidencebased
approach. The researchers
hope their work will help inform
doctors and patients about the
relative risks and benefits of hip
replacement surgery.
What’s the issue?
People with osteoarthritis have
joints that are painful, stiff, and
sometimes swollen. This happens
when the protective cartilage on
the ends of bones breaks down.
It most often affects the knees,
hips and small joints of the hands
and is the most common type of
arthritis in the UK.
When symptoms are mild, they
can be managed with regular
exercise, weight management or
with special devices to reduce the
strain on joints during everyday
activities. If symptoms get worse,
people may need painkillers or a
structured exercise plan with a
physiotherapist.
In severe osteoarthritis, people
can have surgery to completely
replace the hip or other affected
joint. Hip replacement surgery
generally gives people a greater
range of movement and reduces
their pain.
People having hip replacements
are 70 years old, on average. By
this age, many have other longterm
conditions, such as high
blood pressure or diabetes, which
might increase the risk of any
surgery. Doctors may therefore be
concerned about recommending
hip replacement surgery for older
people who have such conditions.
Researchers explored how
multiple long-term conditions
influence the likelihood and timing
of hip-replacement surgery. They
also looked at the impact of
multiple long-term conditions on
the outcomes of hip replacement
surgery.
What’s new?
The researchers analysed GP
health records from across the UK.
They included data from 27,560
people aged 65 years and older.
Participants had an average age
of 75 years and most (62%) were
women. All had a diagnosis of hip
osteoarthritis in their records.
The team assessed participants’
general health through the
number of other conditions,
and medications mentioned in
their records, and the number
of primary care consultations in
the preceding 12 months. There
is no single way to measure
other conditions; the researchers
assessed conditions using
different approaches, including a
measure of frailty.
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Hospital records showed that
fewer than half (40%) the
participants underwent hip
replacement surgery.
In the whole group, which
included people with and without
multiple long-term conditions,
the study found:
People with more long-term
conditions were less likely to have
hip replacement surgery, even if
they had moderate poor health,
and the benefits of surgery
outweighed the risks
Neither age nor gender affected
the rate of surgery, which
suggested that surgery was
withheld because of the longterm
conditions the people had,
and not these other factors
Even people who were ‘mildly
frail’ were less likely to have the
surgery
Most surgery took place 10 months
after a diagnosis was added to GP
records, but the more pre-existing
long-term conditions a person
had, the longer they waited.
In a group of 6682 people with hip
osteoarthritis and multiple longterm
conditions, the researchers
looked at the outcomes of hip
replacement surgery.
They found that:
Regardless of pre-existing
conditions, patients reported
improved quality of life 6 months
after surgery
Other conditions weakly predicted
risk of complications (such as a
heart attack or wound infection)
but the increases in risk were
small
People with worse health before
surgery were more likely to have
complications afterwards, though
the complication rates (3%) and
death rates (1%) were low
People’s health before surgery
did not influence how long they
stayed in hospital; but those with
worse health before surgery were
twice as likely to be readmitted
to hospital afterwards than the
healthiest people in the study
group.
The researchers concluded that,
for most people, having multiple
long-term conditions should
not be a barrier to having hipreplacement
surgery.
Why is this important?
Professionals and patients
both raise concerns about hipreplacement
surgery when people
have other long-term conditions.
This research provides evidence
about the risks and benefits of
hip-replacement surgery for this
group of people.
It found that hip-replacement
surgery improves quality of life
regardless of someone’s other
conditions. The surgery could
improve some other conditions,
such as depression, because of
the improvement in pain. The
team would like to follow people
up for longer, to understand the
longer-term impact of surgery in
people with multiple long-term
conditions.
The findings from this study show
that healthcare professionals and
patients should decide together
on the benefits of surgery to
them. They should discuss the
risks, including of anaesthesia,
and jointly come to a decision
based on evidence.
The researchers say that, as long
as the risk of having a general
anaesthetic is not too high, having
multiple long-term conditions
should not be a barrier to hip
surgery.
What’s next?
These results depend on the
accuracy of primary care
health records. If a diagnosis
was included in the medical
records some time after the first
symptoms appeared, people may
have been suffering with pain for
longer than the records suggest.
People with multiple long-term
conditions did not stay in hospital
any longer than other people after
surgery. It is possible that the
length of stay could be influenced
more by type of procedure.
Surgery carried out under local
anaesthetic might have shorter
hospital stays than those carried
out under general anaesthetic.
You may be interested to read
One of the papers this NIHR Alert
is based on: Ferguson R, and
others. Influence of pre-existing
multimorbidity on receiving a hip
arthroplasty: cohort study of 28 025
elderly subjects from UK primary
care. BMJ Open 2021;11:e046713
Another paper this NIHR Alert is
based on: Ferguson R, and others.
Does pre-existing morbidity
influences risks and benefits of total
hip replacement for osteoarthritis:
a prospective study of 6682 patients
from linked national datasets in
England. BMJ Open 2021;11:e046712
Published on 11 March 2022doi:
10.3310/alert_49302
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