Total Hip Replacement

Number: 0287


Aetna considers an Food and Drug Administration-approved metal-on-metal, metal-on-plastic, ceramic-on-plastic, or ceramic-on-ceramic total hip arthroplasty (THA) prosthesis medically necessary for adult members when the following criteria are met:

  1. Member has advanced joint disease demonstrated by:
    1. Pain and functional disability that interferes with activities of daily living (ADLs) from injury due to osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis of the hip joint; and
    2. Limited range of motion (ROM), antalgic gait, and pain in hip joint with passive ROM on physical examination: and
    3. Radiographic evidence of severe osteoarthritis (as evidence by 2 or more of the following: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, bone on bone articulation or joint space narrowing) of hip joint, or avascular necrosis (osteonecrosis) with stage III collapse of the femoral head, or rheumatoid arthritis (joint space narrowing); and
    4. History of of unsuccessful conservative therapy (non-surgical medical management) that is clearly addressed in the medical record (see Note). If conservative therapy is not appropriate, the medical record must clearly document why such approach is not reasonable; or
  2. Fracture of the femoral neck by imaging with pain interfering with ADLs; or
  3. Malunion of acetabular, femoral head or proximal femur fracture with pain interfering with ADLs; or
  4. Nonunion by imaging or failure of previous hip fracture surgery with pain interfering with ADLs; or
  5. Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur by imaging.

    Note: Members with osteoarthritis, traumatic arthritis, rheumatoid arthritis, or avascular necrosis should have at least 12 weeks of non-surgical treatment documented in the medical record (at least 24 weeks for persons with a relative contraindicationFootnotes for Relative contraindicaitons* -- see below), including all of the following, unless contraindicated:

    1. Anti-inflammatory medications or analgesics; and
    2. Flexibility and muscle strengthening exercises, and
    3. Activity modification; and
    4. Supervised physical therapy (ADLs diminished despite completing a plan of care); and
    5. Assistive device use (required for persons with relative contraindicationsFootnotes for Relative contraindicaitons* to joint replacement, optional for others); and
    6. Therapeutic injections into the hip (required for persons with relative contraindications Footnotes for Relative contraindicaitons * to joint replacement, optional for others).

      Footnotes* Relative contraindicaitons to joint replacement include the following: morbid obesity (body mass index (BMI) greater than 40), age less than 50 years).  Persons with relative contraindications should exhaust all non-surgical treatment options.

  6. Total joint replacement is considered not medically necessary in persons with any of the following absolute contraindications:
    1. Active infection of the joint or active systemic bacteremia that has not been totally eradicated; or
    2. Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned surgical site of the hip; or
    3. Allergy to components of the implant (e.g., cobalt, chromium or alumina); or
    4. Paraplegia or quadriplegia; or
    5. Permanent or irreversible muscle weakness in the absence of pain that prevents ambulation; or
    6. Rapidly progressive neurological disease except in the clinical situation of a concomitant displaced femoral neck fracture; or
    7. Skeletal immaturity.
  7. For persons with significant conditions or co-morbidities, the risk/benefit of THA should be appropriately addressed in the medical record.

  8. Aetna considers THA experimental and investigational for all other indications because of insufficient evidence of effectiveness.

Aetna considers a revision or replacement of a THA or hip resurfacing arthroplasty medically necessary for the following indications when accompanied by pain and functional disability (interference with ADLs):

  1. Aseptic loosening of one or more prosthetic components confirmed by imaging, or
  2. Fracture or mechanical failure of 1 or more components of the prosthesis confirmed by imaging, or
  3. Confirmed periprosthetic infection confirmed by gram stain and culture, or
  4. Displaced periprosthetic fracture confirmed by imaging, or
  5. Progressive or substantial periprosthetic bone loss confirmed by imaging, or
  6. Bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reactionFootnotes for removal and revision surgery*, or
  7. Recurrent (2 or more) dislocations confirmed by imaging not responsive to a reasonable course of conservative management or irreducible dislocation confirmed by imaging; or
  8. Clinically significant leg length discrepancy; or
  9. Upon individual case review, persistent hip pain of unknown etiology not responsive to a period of non-surgical care for six (6) months.

    And the member does not have any of the following contraindications to total hip revision or replacement:
    1. Loss of musculature (in particular hip abductor musculature), neuromuscular compromise or vascular deficiency in the affected limb, rendering the procedure unjustifiable; or 
    2. Osteoporosis or other osseous abnormalities which would make the likelihood of a poor outcome more probable; or
    3. Poor skin coverage; or
    4. Severe instability due to anatomic causes that would make the likelihood of a poor surgical outcome more probable.

Aetna considers a revision or replacement of a THA or hip resurfacing experimental and investigational when criteria are not met.

Aetna considers minimal incision or minimally invasive THA a medically necessary acceptable alternative to conventional THA.

Aetna considers measurement of synovial C-reactive protein, and the alpha-defensin test (Synovasure) experimental and investigational as a marker for peri-prosthetic infection in THA because the effectiveness of this approach has not been established.

Aetna considers MAKOplasty/MAKO Tactile Guidance System for total hip replacement experimental and investigational because its effectiveness has not been established.

Aetna considers the prophylactic use of tranexamic acid medically necessary in total hip arthroplasty to decrease blood loss.

Aetna considers obturator nerve blocks for management of post-operative pain following THA experimental and investigational because the effectiveness of this approach has not been established.

Footnotes* Aetna considers removal and revision surgery due to post total hip replacement (THR) metallosis alone, without evidence of loosening or malposition, experimental and investigational because there is insufficient clinical evidence in the published peer-reviewed medical literature.

See also CPB 0661 - Joint Resurfacing.


Previously, most total hip prostheses utilize an acetabular cup either lined with polyethylene or composed entirely of polyethylene articulating against a cobalt-chromium-molybdenum (CoCr) or ceramic femoral head.  Serious problems affecting the outcome of total joint replacement with these types of prostheses have been extensive and progressive peri-prosthetic osteolysis and aseptic loosening, which may result in revision, even though the components are still well fixed and functioning.  Polyethylene particulate debris generated from metal-on-polyethylene bearing surfaces and the resulting biologic response to this debris are thought to be largely responsible.

In recent years, there has been renewed interest in metal-on-metal bearing surfaces for total joint arthroplasty.  This is especially true in younger and more active patients who face the possibility of multiple revision procedures during their lifetime.  In the long-term, the second-generation all-metal prostheses have demonstrated lower friction and wear rates than metal-on-polyethylene bearing surfaces.  Recent studies reported that the second-generation metal-on-metal hip replacement prostheses exhibit a lower rate of acetabular revision and loosening than did those with previous metal-on-metal designs and that they had no more acetabular loosening or osteolysis than did those with metal-on-polyethylene articulations for follow-up periods of 5 to 10 years.

Another alternative to standard polyethylene is alumina-on-alumina ceramic.  When comparing hard-on-hard bearings, the ceramic-on-ceramic coupling has several theoretical advantages over metal-on-metal.  Because of the ceramic's extremely low coefficient of friction and its potential for superior wear resistance, these couples promise both wear rates that are appreciably less than polyethylene-on-metal and metal-on-metal couples.

Available literature indicates that alumina-on-alumina ceramic couplings are a viable alternative to metal-on-polyethylene designs.  The combination of new high quality ceramic acetabular and femoral bearing heads with hip systems that have achieved long-term stable fixation can result in a substantial increase in the longevity of fixation for implants especially in the younger and more active patients.

Available studies of metal-on-metal and ceramic-on-ceramic total hip implants primarily involve cohorts of younger, more active patients.  The chief advantage of these hip implants over standard metal-on-polyethylene hip implants is their greater longevity.  There is no adequate evidence that metal-on-metal or ceramic-on-ceramic total hip implants offer clinically significant benefits over standard metal-on-polyethylene hip implants for older patients.

Bhandari et al (2005) reported a meta-analysis of 6 randomized controlled studies suggested that bisphosphonates have a beneficial effect with regard to maintaining more peri-prosthetic bone mineral density than that in controls.  However, the limitations of the available studies and the lack of analyses of clinically relevant outcomes (e.g., functional outcomes, revision rates, and quality of life) necessitate the planning and conduct of a sufficiently sized, methodologically sound trial with clinically relevant end points.  Until this has been done, the current evidence regarding the beneficial effects of bisphosphonates on peri-prosthetic bone following total joint (e.g., knee and hip) arthroplasty should be interpreted with caution.

A technology assessment of hip implants by the Institute for Clinical Effectiveness and Health Policy (Augustovsky et al, 2006) found that the clinical trials comparing ceramic against conventional prostheses found no significant differences in the revision rate among the different types of prostheses.  In case series of patients with the ceramic prosthesis, reported revision rates at 10 years were less than 10 %, which is considered within acceptable limits and comparable to those reported for conventional prostheses.  Similar results have been reported for metal-on-metal hip prostheses, where randomized controlled trials with follow-up up to 5 years found no differences between metal-on-metal and conventional prostheses in effectiveness and complication rates (Augustovsky et al, 2006).  The assessment noted that, although there are some reports of an increase in cancer in persons with metal-on-metal hip prostheses, there are other reports evaluating metal-on-metal prostheses with follow-up up to 28 years that have found no increase in the incidence of any cancer.  The assessment stated that no study comparing ceramic prosthesis with metal-on metal prosthesis was found.  The assessment concluded that, although interim results with both the ceramic and metal-on-metal prostheses are promising, available studies have found no significant differences in revision rates during follow-up periods of 10 to 15 years.  The assessment stated that, because the advantages of these materials may be observed at longer terms, their potential benefits would be greatest for younger patients (under 50 years of age) (Augustovsky et al, 2006).

In a meta-analysis, Smith and colleagues (2010) compared the clinical and radiological outcomes and complication rates of hip resurfacing (HRS) and total hip arthroplasty (THA).  A systematic review was undertaken of all published (Medline, CINAHL, AMED, EMBASE) and unpublished or gray literature research databases up to January 2010.  Clinical and radiological outcomes as well as complications of HRS were compared to those of THA using risk ratio, mean difference, and standardized mean difference statistics.  Studies were critically appraised using the CASP appraisal tool.  A total of 46 studies were identified from 1,124 citations.  These included 3,799 HRSs and 3,282 THAs.  On meta-analysis, functional outcomes for subjects following HRS were better than or the same as for subjects with a THA, but there were statistically significantly greater incidences of heterotopic ossification, aseptic loosening, and revision surgery with HRS compared to THA.  The evidence base showed a number of methodological inadequacies such as the limited use of power calculations and poor or absent blinding of both patients and assessors, possibly giving rise to assessor bias.  The authors concluded that on the basis of the current evidence base, HRS may have better functional outcomes than THA, but the increased risks of heterotopic ossification, aseptic loosening, and revision surgery following HRS indicate that THA is superior in terms of implant survival.

Garbuz and associates (2010) conducted a prospective randomized clinical trial to compare clinical outcomes of resurfacing versus large-head metal-on-metal THA.  These researchers randomized 107 patients deemed eligible for resurfacing arthroplasty to have either resurfacing or standard THA.  Patients were assessed for quality-of-life outcomes using the PAT-5D index, WOMAC, SF-36, and UCLA activity score.  The minimum follow-up was 0.8 years (mean of 1.1 years; range of 0.8 to 2.2 years).  Of the 73 patients followed at least 1 year, both groups reported improvement in quality of life on all outcome measures.  There was no difference in quality of life between the 2 arms in the study.  Serum levels of cobalt and chromium were measured in a subset of 30 patients.  In both groups cobalt and chromium was elevated compared to baseline.  Patients receiving a large-head metal-on-metal total hip had elevated ion levels compared to the resurfacing arm of the study.  At 1 year, the median serum cobalt increased 46-fold from baseline in patients in the large-head total hip group, while the median serum chromium increased 10-fold.  At 1 year, serum cobalt was 10-fold higher and serum chromium 2.6-fold higher than in the resurfacing arm.  Due to these excessively high metal ion levels, the authors recommended against further use of this particular large-head THA.

Kim and colleagues (2013) stated that the timing of total hip replacement (THR) in patients with active tuberculosis (TB) of the hip is controversial, because of the potential risk of re-activation of infection.  There is little information about the outcome of THR in these patients.  These investigators performed a systematic review of published studies that evaluated the outcome of THR in patients with active TB of the hip.  A review of multiple databases referenced articles published between 1950 and 2012 was carried out.  A total of 6 articles were identified, comprising 65 patients.  Tuberculosis was confirmed histologically in all patients.  The mean follow-up was 53.2 months (range of 24 to 108).  Anti-TB treatment continued post-operatively for between 6 and 15 months, after debridement and THR.  One non-compliant patient had re-activation of infection.  At the final follow-up the mean Harris hip score was 91.7 (range of 56 to 98).  The authors concluded that THR in patients with active TB of the hip is a safe procedure, providing symptomatic relief and functional improvement if undertaken in association with extensive debridement and appropriate anti-TB treatment.

In a multi-center randomized, controlled trial with a non-inferiority design based on a minimal clinically important difference of 2.0 %, Anderson et al (2013) compared extended prophylaxis with aspirin and dalteparin for prevention of symptomatic venous thrombo-embolism (VTE) after THA.  Randomization was electronically generated; patients were assigned to a treatment group through a Web-based program.  Patients, physicians, study coordinators, health care team members, outcome adjudicators, and data analysts were blinded to interventions.  The setting of this study was 12 tertiary care orthopedic referral centers in Canada; and a total of 778 patients who had elective unilateral THA between 2007 and 2010 were enrolled.  After an initial 10 days of dalteparin prophylaxis after elective THA, patients were randomly assigned to 28 days of dalteparin (n = 400) or aspirin (n = 386).  Main outcome measures were symptomatic VTE confirmed by objective testing (primary efficacy outcome) and bleeding.  Five of 398 patients (1.3 %) randomly assigned to dalteparin and 1 of 380 (0.3 %) randomly assigned to aspirin had VTE (absolute difference, 1.0 percentage point [95 % confidence interval [CI]: -0.5 to 2.5 percentage points]).  Aspirin was non-inferior (p < 0.001) but not superior (p = 0.22) to dalteparin.  Clinically significant bleeding occurred in 5 patients (1.3 %) receiving dalteparin and 2 (0.5 %) receiving aspirin.  The absolute between-group difference in a composite of all VTE and clinically significant bleeding events was 1.7 percentage points (CI: -0.3 to 3.8 percentage points; p = 0.091) in favor of aspirin.  The authors concluded that extended prophylaxis for 28 days with aspirin was non-inferior to and as safe as dalteparin for the prevention of VTE after THA in patients who initially received dalteparin for 10 days.  Given its low cost and greater convenience, aspirin may be considered a reasonable alternative for extended thrombo-prophylaxis following THA.

An UpToDate review on “Total hip arthroplasty” (Erens et al, 2014) states that: “Contraindications -- Total hip arthroplasty (THA) should not be undertaken in a number of clinical settings, including:

  • Active infection (local or systemic)
  • Preexisting significant medical problems (e.g., recent myocardial infarction, unstable angina, heart failure, or severe anemia)
  • Skeletal immaturity
  • Paraplegia or quadriplegia
  • Permanent or irreversible muscle weakness in the absence of pain

Relative contraindications include a neuropathic (Charcot) joint, inability to ambulate that is not related to the hip disorder per se, absence of hip abductor muscle mass, progressive neurologic loss, and morbid obesity.  However, the effects of obesity on outcome remain uncertain.  Most studies do show an increased risk of infection, particularly in the highly obese.  This must be weighed against the fact that some morbidly obese patients can have significant improvement postoperatively.  A 2011 study from Canada noted that patients with morbid obesity can experience substantial benefit, despite a very small but statistically significant increase in the need for revision due to septic complications.  Other studies have emphasized the increased risk of both superficial and deep infections and have described an increased risk of dislocation in such patients”.

Omar et al (2015) examined the role of synovial C-reactive protein (CRP) in the diagnosis of chronic peri-prosthetic hip infection.  These researchers prospectively collected synovial fluid from 89 patients undergoing revision hip arthroplasty and measured synovial CRP, serum CRP, erythrocyte sedimentation rate (ESR), synovial white blood cell (WBC) count and synovial percentages of polymorphonuclear neutrophils (PMN).  Patients were classified as septic or aseptic by means of clinical, microbiological, serum and synovial fluid findings.  The high viscosity of the synovial fluid precluded the analyses in 9 patients permitting the results in 80 patients to be studied.  There was a significant difference in synovial CRP levels between the septic (n = 21) and the aseptic (n = 59) cohort.  According to the receiver operating characteristic curve, a synovial CRP threshold of 2.5 mg/L had a sensitivity of 95.5 % and specificity of 93.3 %.  The area under the curve was 0.96.  Compared with serum CRP and ESR, synovial CRP showed a high diagnostic value.  The authors concluded that according to these preliminary results, synovial CRP may be a useful parameter in diagnosing chronic peri-prosthetic hip infection.

Furthermore, an UpToDate review on “Total hip arthroplasty” (Erens et al, 2014) does not mention the use of synovial CRP as a post-operative management tool.

MAKOplasty/MAKO Tactile Guidance System

Werner and colleagues (2014) stated that in comparison with standard surgical techniques robotic-assisted surgery has the advantages of increased surgical accuracy, reproducibility, optimization of component position, and improved patient outcomes in unicompartmental knee arthroplasty (UKA) and THA procedures.  The MAKO Tactile Guidance System (TGS; MAKO Surgical Corp, Fort Lauderdale, FL) facilitates robotic-assisted arthroplasty procedures currently implemented in many operating rooms.  The benefits of this technology are evident, but have not been shown to improve patient outcomes and justify the added financial burden imposed.  The authors concluded that further research is needed to determine if this technological advancement will translate into improvements in longevity and clinical outcomes.

Domb et al (2014) compared THA with a robotic-assisted posterior approach with manual alignment techniques through a posterior approach, using a matched-pair controlled study design, to assess whether the use of the robot made it more likely for the acetabular cup to be positioned in the safe zones described by Lewinnek et al and Callanan et al.  Between September 2008 and September 2012, a total of 160 THAs were performed by the senior surgeon; 62 patients (38.8 %) underwent THA using a conventional posterior approach, 69 (43.1 %) underwent robotic-assisted THA using the posterior approach, and 29 (18.1 %) underwent radiographic-guided anterior-approach THAs.  From September 2008 to June 2011, all patients were offered anterior or posterior approaches regardless of bone mass index (BMI) and anatomy.  Since introduction of the robot in June 2011, all THAs were performed using the robotic technique through the posterior approach, unless a patient specifically requested otherwise.  The radiographic cup positioning of the robotic-assisted THAs was compared with a matched-pair control group of conventional THAs performed by the same surgeon through the same posterior approach.  The safe zone (inclination, 30° to 50°; ante-version, 5° to 25°) described by Lewinnek et al and the modified safe zone (inclination, 30° to 45°; ante-version, 5° to 25°) of Callanan et al were used for cup placement assessment.  Matching criteria were gender, age ± 5 years, and (BMI) ± 7 units.  After exclusions, a total of 50 THAs were included in each group.  Strong inter-observer and intra-observer correlations were found for all radiographic measurements (r > 0.82; p < 0.001).  One hundred percent (50/50) of the robotic-assisted THAs were within the safe zone described by Lewinnek et al compared with 80 % (40/50) of the conventional THAs (p = 0.001); 92 % (46/50) of robotic-assisted THAs were within the modified safe zone described by Callanan et al compared with 62 % (31/50) of conventional THAs (p = 0.001).  The odds ratios for an implanted cup out of the safe zones of Lewinnek et al and Callanan et al were zero and 0.142, respectively (95 % CI: 0.044 to 0.457).  The authors concluded that use of the robot allowed for improvement in placement of the cup in both safe zones, an important parameter that plays a significant role in long-term success of THA.  However, whether the radiographic improvements that were observed would translate into clinical benefits for patients (e.g., acetabular wear, prosthetic dislocations, reductions in component impingement, and improved longevity) remains unproven.

Elmallah and associates (2015) stated that complications following THA (e.g., dislocation, component loosening and wear) continue to be common indications for revision surgery.  Multiple studies have attributed some of these problems to poor acetabular cup alignment and placement outside of the purported radiographic safe zone.  In addition, it has been shown that conventional manually performed acetabular cup placement may not lead to optimal alignment, regardless of surgical experience.  Additionally, incorrect leg length and offset can lead to dissatisfaction and instability.  Therefore, robotic-arm assisted surgery has been introduced to improve accuracy of cup placement and leg length, and to offset with the aim of reducing the risk of hip instability and improving satisfaction after primary THA.  These investigators reviewed the use of robotic-arm assisted surgery in 224 patients and examined if pre-operatively determined radiographic targets were achieved post-operatively and the proportion of acetabular cups outside of the safe zone.  Pre-determined ante-version and inclination were 15 and 40 degrees, respectively.  Results have shown that the use of robotic-arm assisted surgery resulted in a post-operative mean inclination of 40 degrees (range of 34 to 51 degrees) and a mean ante-version of 16 degrees (range of 9 to 25 degrees); 99 % of the patients remained within the pre-designated safe zone.  Evidence has shown that robotic-arm assisted surgery may have improved accuracy in cup placement when compared to conventional surgery and possibly to computer-assisted surgery.  The authors concluded that when compared to the literature on robotic-arm assisted surgery, thee findings were comparable.  They believed that this surgical technique may aid in reducing post-operative THA complications (e.g., aseptic loosening and dislocations); but further prospective studies are needed to evaluate clinical outcomes and long-term results.

Banerjee et al (2016) stated that precise and accurate biomechanical reconstruction during THA is essential for durable long-term survivorship.  Accurate fit of cementless hip implants is also crucial to reduce micro-motion between the bone-implant interfaces to allow for stable osseointegration.  Robotic technology aims to minimize potential human errors and improve implant alignment and fit, and address persisting concerns with modern-day cementless THA.  Although robotic THA dated back to the early 1990s, concerns with increased operating times, costs, and complications led to its withdrawal.  However, semi-active systems have renewed interest in robot-assisted joint arthroplasty.  These researchers reviewed the current technology, its potential benefits, and the reported clinical and radiographic outcomes.  Early evidence suggested that robotic use may lead to more accurate reconstruction of radiographic parameters (e.g., implant positioning, fit, center-of-rotation, and leg-length discrepancy).  The authors concluded that further research is needed to determine if these will translate into better outcomes and improved implant longevity to justify increased costs.  (Keywords of this article included MAKO).

Furthermore, an UpToDate review on “Total hip arthroplasty” (Erens et al, 2016) does not mention “robotic-assisted arthroplasty/MAKOplasty” as a therapeutic option.

The Alpha-Defensin Test (Synovasure)

Patel and colleagues 92016) noted that synovial fluid biomarkers can be considerably helpful in the diagnosis of peri-prosthetic joint infection (PJI) and improve the accuracy of other tests such as serum biomarkers.  Synovial fluid white blood cell (WBC) count and differential are currently minor criteria in the definition of PJI as proposed by the International Consensus Group.  In recent years, however, numerous biomarkers have been investigated for patients with PJI, including inflammatory cytokines (e.g., interleukins 1, 6, 8,10, and 17, tumor necrosis factor-alpha [TNF-α], interferon-γ, resistin, and thrombospondin), inflammatory reactive proteins (such as CRP), bactericidal leukocyte enzymes (e.g., esterase, elastase, and bactericidal/permeability-increasing protein, gelatinase-associated lipocalin, and lactoferrin, all of which are present in polymorphonuclear leukocytes), markers of angiogenesis (e.g., vascular endothelial growth factor) and anti-microbial proteins (e.g., as  alpha- defensing [α-defensin], β-defensin, and cathelicidin LL-37).  Many of these synovial fluid biomarkers did not have any correlation with synovial WBC count, so these synovial fluid markers are not simply surrogate markers for an increase in local inflammation in the joint as a result of a PJI.  Additionally, it was found that the markers that had the highest specificity and sensitivity were proteins that have anti-microbial properties, which is likely the reason for their increased concentration in synovial fluid during PJI.  Since the mechanism of action for these biomarkers is different than that of currently used tests, these biomarkers hold great promise for a novel approach in diagnosing PJI.  The authors stated that the main disadvantage of synovial biomarkers is that these tests depend on the availability of synovial fluid, and synovial fluid cannot be aspirated from a joint in all PJI cases.  Moreover, some of the inflammatory biomarkers may represent any type of inflammatory process in the prosthetic joint (e.g., an adverse reaction to foreign material); thus, these tests may not be specific enough for PJI.

Kasparek and co-workers (2016) investigated the novel Synovasure PJI lateral flow test device for detection of alpha-defensin and determined its diagnostic accuracy for the intra-operative diagnosis of PJI and compared it to frozen section.  A total of 40 consecutive patients, who underwent revision surgery, between September 2014 and September 2015 were included.  Patients underwent 29 revision total knee arthroplasties (TKAs) and 11 revision THAs; 12 patients had a confirmed PJI based on Musculo-Skeletal Infection Society (MSIS) criteria, and 28 patients were considered aseptic.  The overall accuracy to detect PJI using the lateral flow assay was 85 % (95 % CI: 70 % to 93 %).  The device has a positive predictive value (PPV) of 80 % (95 % CI: 44 % to 96 %) and a negative predictive value (NPV) of 87 % (95 % CI: 68 % to 96 %) and showed a sensitivity of 67 % (95 % CI: 35 % to 89 %) and specificity of 93 % (95 % CI: 75 % to 99 %).  Frozen section had a lower sensitivity (58 % [95 % CI: 29 % to 84 %]) but a higher specificity (96 % [95 % CI: 80 % to 100 %]).  Receiver operator curve analysis demonstrated an area under the curve of the Synovasure PJI Lateral Flow Test Kit and frozen section of 0.80 and 0.77, respectively.  The authors concluded that the findings of the present study suggested that the intra-operative lateral flow test was at least equivalent to intra-operative frozen section and was a useful tool to confirm the absence of PJI.  Moreover, they stated that although the clinical results are promising, they are not as good as previous studies using alpha-defensin levels measured in a laboratory.

Pupaibool and colleagues (2016) reviewed the current evidence on the utility of serum and synovial fluid biomarkers to help aid in the diagnosis of PJI with focusing on synovial fluid alpha-defensin.  Articles and data for this review were identified by searches of PubMed and Ovid Medline up to June 1, 2016.  In addition, these investigators manually reviewed the bibliographies of the retrieved articles for additional citations for references from relevant articles on the diagnosis of PJI.  Serum biomarkers can be elevated in various inflammatory conditions.  Synovial fluid biomarkers are more accurate for the diagnosis of PJI compared to serum biomarkers.  Based on current available data, alpha-defensin is the most promising synovial fluid biomarker for the diagnosis of PJI and is commercially available.  The authors concluded that synovial fluid alpha-defensin could enhance the ability to identify PJI and incorporate into the diagnostic algorithm in the future.  Moreover, they stated that large-scale studies are needed to provide more data for its significance for the diagnosis of PJI.

Sigmund and associates (2017) stated that the diagnosis of PJI remains demanding due to limitations of all the available diagnostic tests.  The synovial fluid marker, α-defensin, is a promising adjunct for the assessment of potential PJI.  These investigators examined the qualitative assessment of α-defensin, using Synovasure to detect or exclude peri-prosthetic infection in total joint arthroplasty.  In a prospective diagnostic study, these researchers studied 50 patients (28 women, 22 men, mean age of 65 years; range of 20 to 89) with a clinical indication for revision arthroplasty who met the inclusion criteria.  The presence of α-defensin was determined using the qualitative Synovasure test and compared with standard diagnostic methods for PJI.  Based on modified MSIS criteria, 13 cases were categorized as septic and 36 as aseptic revisions; 1 test was inconclusive.  The Synovasure test achieved a sensitivity of 69 % and a specificity of 94 %.  The positive and negative likelihood ratios were 12.46 and 0.33, respectively.  A good diagnostic accuracy for PJI, with an area under the curve of 0.82, was demonstrated.  Adjusted p-values using the method of Hochberg showed that Synovasure was as good at diagnosing PJI as histology (p = 0.0042) and bacteriology with 1 positive culture (p = 0.0327).  The authors concluded that with its ease of use and rapid results after approximately 10 minutes, Synovasure may be a useful adjunct in the diagnosis of PJI.

Suda and colleagues (2017) noted that diagnosing peri-prosthetic infection remains a challenge.  Multiplex-PCR and biomarkers such as alpha-defensin are potentially useful and fast methods for detecting peri-prosthetic infection.  These researchers  compared these new methods with clinical assessment, conventional microbiological methods and histo-pathological examination.  A total of 28 consecutive patients with 30 joints and a mean age of 67.7 years (range of 39 to 88) with removal of THA or TKA were included in this study.  Patients were classified according to the modified MSIS for infected joints.  Punction fluid and tissue specimens were taken for conventional microbiological examination, the alpha defensin test was performed, a synovial membrane specimen was used for multiplex-PCR and histopathological examination was carried out.  The alpha-defensin test and multiplex-PCR showed a sensitivity of 76.9 versus 30.8 % and a specificity of 82.4 versus 100 %, respectively.  These investigators found a significant difference between the positive and negative results (p = 0.0023).  The conventional microbiological methods were not significantly different from the alpha-defensin test (p = 0.244) with a sensitivity of 84.6 % and a specificity of 100 % but did differ significantly from the multiplex PCR (p = 0.0030).  There was a significant difference between modified MSIS classification and multiplex PCR (p = 0.0007).  The authors concluded that neither the alpha-defensin test nor multiplex-PCR could detect peri-prosthetic infection immediately and reliably.  They stated that the multiplex-PCR was suitable for detecting the non-infected but not the truly infected; and the alpha-defensin test was helpful but showed no satisfactory results.  These researchers stated that the conventional microbiological methods remain the most reliable for peri-prosthetic infection diagnosis.

Tranexamic Acid in Total Hip Replacement

Zhang and colleagues (2016) stated that as the prevalence of THA is increasing, it is usually associated with considerable blood loss.  Tranexamic acid (TXA) has been reported to reduce peri-operative blood loss in hip joint arthroplasty.  However, the best route of TXA administration continues to be controversial.  Ina meta-analysis, these investigators integrated all data from the 7 included trials to compare the safety and effectiveness of topical and intravenous TXA administration in primary THA.  The end-points assessed in this meta-analysis included the comparisons of total blood loss, post-operative hemoglobin (Hb) decline, transfusion rates, the incidence rate of deep vein thrombosis (DVT), pulmonary embolisms (PE), and wound infection.  Literature searches of PubMed, Embase, the Cochrane Library, the Chinese Biomedical Literature database, the CNKI database, and Wan Fang Data were performed up to August 30, 2016.  Randomized controlled trials (RCTs) were included in this meta-analysis if they compared the safety and effectiveness of intravenous versus topical administration of TXA in patients who underwent primary THA.  The meta-analysis was performed following the guidelines of the Cochrane Reviewer's Handbook and the PRISMA statement.  The pooling of data was carried out by using RevMan 5.3, Denmark.  A total of 7 RCTs involving 964 patients met the inclusion criteria.  the meta-analysis indicated that there were no significant differences in the 2 groups in terms of total blood loss ([mean difference (MD) = -14.74, 95 % CI: -89.21 to 59.74, p = 0.7], transfusion rates [RD = -0.02, 95 % CI: -0.05 to 0.02, p = 0.39]; no significant differences were found regarding the incidence of adverse effects (AEs) such as DVT [RD = 0.00, 95 % CI: -0.01 to 0.01, p = 1.00], PE [RD = 0.00, 95 % CI: -0.01 to 0.01, p = 0.71], or wound infection [RD = -0.01, 95 % CI: -0.06 to 0.04, p = 0.66]).  The pooled results showed that the intravenous groups had a lower post-operative Hb decline (MD = -0.47, 95 % CI: -0.74 to -0.20, p = 0.0006).  It was probably due to insufficient data and the varied reporting of outcomes.  There was some inherent heterogeneity due to the small sample size of each primary study.  The authors concluded that topical and intravenous administrations of TXA had a similar effect on the decrease of blood loss without an increased risk of complications (e.g., DVT, PE, and wound infection).  They noted that intravenous TXA administration may have a maximum efficacy; while topical TXA administration may be preferred in patients who with high risk of thrombo-embolic events.  However, they stated that larger, high-quality RCTs are needed to examine the optimal regimen, dosage, timing before recommending the widespread use of TXA in total joint arthroplasty.

Moskal and Capps (2016) stated that previous meta-analyses established that TXA confers benefits when used during THA.  However, 2 of these meta-analyses included a variety of routes of administration of TXA in THA (topical, intravenous, oral, and intra-articular), another meta-analysis included a variety of anti-fibrinolytic drugs (not restricted to a single drug), and the final meta-analysis included non-RCTs.  This meta-analysis focused on a single medication, TXA, administered in a specific way, intravenously in patients undergoing primary THA, using data reported only in RCTs.  Outcomes were restricted to blood loss, allogeneic transfusion rates, and complications.  Other outcomes, such as return to function or clinical scores, could not be evaluated because of lack of consistent reporting.  The authors stated that to better understand the effects of intravenous TXA in THA on clinical outcomes, such as recovery, return to function, and patient-reported outcome measures, it would be helpful to have more RCTs examining these measures in a standardized manner.  They noted that intravenous TXA was beneficial for blood loss intra-operatively, blood loss through drains, and total blood loss during hospitalization, in addition to reducing allogeneic transfusion rates.  However, no difference between intravenous TXA and placebo was found for most complications, except DVT, which showed favorable results with placebo.

In a meta-analysis, Shang and colleagues (2016) compared the safety and effectiveness of combined intravenous and topical TXA versus intravenous use alone in primary TKA and THA.  PubMed, Embase, Cochrane library and OVID were searched.  Eligible RCTs evaluating combined intravenous and topical TXA versus intravenous alone in primary TKA and THA were included.  The relative risk (RR) or the mean difference (MD) for dichotomous or continuous data was calculated respectively, and heterogeneity was analyzed by Chi-square and I2 tests.  A total of 5 RCTs met the inclusion criteria  and were included in the study.  The meta-analysis indicated that there was statistically significant difference favoring the combined group in total blood loss(MD = -160.90, 95 % CI: -201.26 to -120.54, p < 0.00001), Hb drop (MD = -0.41, 95 % CI:-0.73 to 0.08], p = 0.01), transfusion requirements(RR = 0.29, 95 % CI: 0.12 to 0.70], p = 0.006) and length of hospital stays (MD = -0.21, 95 %CI: -0.40 to -0.02], p = 0.03).  Both groups showed similar outcomes regarding thrombo-embolic complications(RR = 0.84, 95 % CI: 0.26 to 2.70], p = 0.76).  The authors concluded that based on the findings of this study, combined use of intravenous and topical TXA was more effective than intravenous TXA alone in primary TKA or THA without increasing the risk of thrombo-embolic complications.  Moreover, they stated that further high quality studies with more patients are needed in future studies.

In a meta-analysis, Li and associates (2017) evaluated the safety and effectiveness of combined intravenous and topical methods of application versus single intravenous of TXA in primary TKA and THA.  These researchers performed a systematic search in Medline(from 1966 to September 25, 2016), PubMed (from 1966 to September 25, 2016), Embase (from 1980 to September 25, 2016), ScienceDirect (from 1985 to September 25, 2016) and the Cochrane Library.  Only high-quality RCT were identified; 2 authors independently performed data extraction and quality assessment of included studies.  Meta-analysis was conducted using Review Manager 5.1 software.  A total of 6 RCTs that included 687 patients met the inclusion criteria.  The present meta-analysis indicated that there were significant differences in terms of total blood loss (MD = -193.59, 95 % CI -338.06 to -49.13, p = 0.009), transfusion rate (RD = -0.07, 95 % CI -0.12 to -0.03, p = 0.001), Hb decline (MD = -0.51, 95 % CI -0.83 to -0.18, p = 0.01) and length of stay (MD = -0.20, 95 % CI -0.38 to -0.02, p = 0.03) between groups.  The authors concluded that combined administration of TXA in patients with TKA and THA was associated with significantly reduced total blood loss, transfusion requirements, post-operative Hb decline and length of stay compared to single application alone, but was not associated with prolonged operation time.  Moreover, no AEs, such as superficial infection, DVT or PE, were associated with TXA.  These researchers suggested that combined administration of TXA demonstrated excellent clinical safety and effectiveness in patients with TKA and THA.  Moreover, they stated that well-designed studies with larger sample size are needed to provide further reliable evidence for the combined use of TXA.

A Veteran's Health Administration assessment (VHA, 2014) found evidence for use of TXA in patients undergoing total knee arthroplasty and total hip arthroplasty. They found, however, that "[e]vidence is lacking for the safe and effective use of TXA in joint revision surgery or use in hip fracture surgery, therefore the risk/benefit of TXA in these settings is unknown."

An assessment by the Canadian Agency for Drugs and Techologies in Health (CADTH, 2015) found that, overall, the conclusions of published reviews supported the use of TXA to decrease intraoperative and postoperative blood loss in primary hip and knee arthroplasty. An evidence-based guideline from Health Quality Ontario (2014) recommends the use of TXA for knee and hip replacement.

Guidelines on perioperative blood loss from the American Society of Anesthesiologists (2015) found: "Meta-analysis of placebo-controlled RCTs indicate that tranexamic acid for prophylaxis of excessive bleeding administered before and/or during a procedure is effective in reducing perioperative blood loss, the number of patients transfused, and the volume of blood products transfused (CategoryA1-B evidence). Randomized trials comparing tranexamic acid with placebo or no tranexamic acid controls report no differences for stroke, myocardial infarction, renal failure, reoperation for bleeding, or mortality (Category A2-B evidence). Meta-analysis of placebo-controlled RCTs indicate that tranexamic acid for prophylaxis of excessive bleeding initiated after a knee and hip arthroplasty and before tourniquet deflation compared with placebo also reported lower blood loss volumes (Category A1-B evidence). . . . The literature is insufficient to evaluate the postoperative administration of tranexamic acid for treatment of excessive blood loss."

Preoperative Intravenous Glucocorticoids for Reduction of Acute Pain and Post-Operative Nausea and Vomiting Following Total Hip Arthroplasty

Yang and colleagues (2017) performed a systematic review and meta-analysis of published RCTs to evaluate the safety and efficacy of pre-operative intravenous glucocorticoids versus controls for the prevention of post-operative acute pain and post-operative nausea and vomiting (PONV) after primary THA.  A computer literature search of electronic databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, China National Knowledge Infrastructure (CNKI), and China Wanfang database, was conducted to identify the relevant RCTs comparing pre-operative intravenous glucocorticoids versus placebos for reducing acute pain and PONV in THA patients.  The primary outcomes included the use of the visual analog scale (VAS) with rest or mobilization at 6, 24, 48, and 72 hours and the occurrence of PONV.  The secondary outcome was total morphine consumption.  These researchers calculated the RR with a 95 % CI for dichotomous outcomes, and the weighted mean difference (WMD) with a 95 % CI for continuous outcomes.  Pooled data from 7 RCTs (411 THAs) favored pre-operative intravenous glucocorticoids against acute pain intensity at 4, 24, and 48 hours (p < 0.05).  There was no significant difference between the VAS with rest or mobilization at 72 hours (p > 0.05).  Subsequently, pre-operative intravenous glucocorticoids provided a total morphine-sparing effect of 9.36 mg (WMD = -9.36, 95 % CI: -12.33 to -6.38, p = 0.000).  In addition, pre-operative intravenous glucocorticoids were associated with a significant reduction of the occurrence of PONV (RR = 0.41, 95 % CI: 0.30 to 0.57, p = 0.000).  The authors concluded that intravenous glucocorticoids could decrease early pain intensity and PONV following THA.  However, they stated that the low number of studies and variation in dosing regimens limited the evidence for its use.  Thus, more high-quality RCTs are needed to identify the optimal drug and the safety of intravenous glucocorticoids.

These investigators stated that this meta-analysis had several potential limitations.  Their analysis comprised only 7 RCTs, and the sample size of the included studies was limited.  The potential risk of publication bias may exist due to the limited number of included studies; and the follow-up in the included studies ranged from 24 hours to 1 year after THA.  Thus, AEs may have been under-estimated.  Finally, the different dose and type of glucocorticoids also influenced the final conclusion.

Intra-Wound Vancomycin for Reduction of Peri-Prosthetic Joint Infection Following Total Hip Arthroplasty

Patel and colleagues (2018) noted that peri-prosthetic joint infection (PJI) is a devastating complication after hip and knee arthroplasty.  Intra-wound vancomycin has been described extensively in the spine literature; however, information regarding use in arthroplasty is limited.  These investigators examined the safety and efficacy of intra-wound vancomycin in arthroplasty surgery.  All primary THA and total knee arthroplasty (TKA) cases (n = 460) performed by a single surgeon from April 2016 to October 2017 were reviewed.  Starting in October 2016, intra-wound vancomycin was used in all total joints.  Baseline characteristics, infection rates, 90-day re-admission, and other complications were compared between untreated subjects and those who received intra-wound vancomycin.  In addition, cost data were considered.  Mean follow-up durations for the control and vancomycin groups were 11.3 and 7.7 months, respectively.  Baseline characteristics and co-morbidities were similar for the control (n = 112) and vancomycin groups (n = 348).  The vancomycin cohort demonstrated decreased both overall infection rate (0.57 % versus 2.7 %; p = 0.031) and PJI rate (0.29 % versus 2.7 %; p = 0.009) compared with the untreated group.  There was no statistical difference in incidence of ototoxicity or acute kidney injury (AKI).  Although there was no difference in overall 90-day re-admission rate, the vancomycin subset demonstrated lower re-admission rate due to infection (0.57 % versus 2.7 %; p = 0.031).  Based on the cost of vancomycin powder and calculated number needed to treat (NNT = 47.5), the cost to prevent 1 infection with the addition of intra-wound vancomycin was $816.  The authors concluded that these findings suggested that intra-wound vancomycin may be a safe, cost-effective approach that showed promise in reducing PJI in early follow-up.  They stated that future prospective and randomized research is needed before any formal recommendations for its routine use in total joint arthroplasty can be made.

The authors stated that the non-randomized and retrospective nature of the study was a drawback.  The relatively short-term and variable follow-up observed in the control and treatment groups was another drawback.  Although these investigators strived to capture all infections, there was the possibility that more indolent infections may have presented past the recorded follow-up period.  Similarly, these researchers acknowledged that the difference in post-operative follow-up between the control and vancomycin groups may introduce confounding variables.  Other limitations included the low effect size with regard to number of surgical site infections.  A sample size of 3,416 patients would be needed to adequately detect a 50 % reduction in infection rate from 2.7 % to 1.35 % with power of 0.80 and alpha of 0.05.  To obtain this number of control-group patients, a historical control infection rate would have to be used, or information from more than 1 surgeon should be used, which would introduce other confounding variables and protocol changes.  Furthermore, several consecutive years of clinical practice would be needed to identify enough vancomycin-group patients to gain appropriate power which would delay the reporting of a potentially safe and beneficial strategy in decreasing overall infection rate.  Consideration was given to including data from other surgeons and institutions, but the authors believed this would have introduced numerous confounding variables in an effort to increase sample size.  Future research on increasing the sample size to allow for appropriate power without introducing confounders is a worthy endeavor.  The allotted sample size of 460 was, however, sufficient in detecting the significantly decreased early infection rate noted in this investigation.  In addition, future higher powered investigations may consider potential variable effects on infection rate associated with THA versus TKA.

Dial and associates (2018) examined the safety profile of using vancomycin powder (VP) to reduce infection rates by reviewing acute post-operative complications.  These researchers carried out a retrospective review of 265 consecutive patients undergoing THA.  The first 128 patients, the control group, did not receive VP, and the subsequent 137 patients, the VP group, received VP at the time of wound closure.  Patient demographic data, medical co-morbidities, and peri-operative information were compared.  The primary outcome was a post-operative surgical complication within 90 days from surgery.  The control and VP group's demographic, medical co-morbidities and peri-operative information data were statistically similar.  Deep infection rate in the control group was 5.5 %, whereas the deep infection rate in the VP group was 0.7 % (p = 0.031).  Sterile wound complication rate was 4.4 % in the VP group, and 0 % in the control group (p = 0.030).  Remaining complications were not statistically different between the groups.  The authors concluded that VP was associated with an increase rate of sterile wound complications compared to the control group; however, the rate of PJI was decreased with the use of VP.  These investigators stated that they do not recommend for or against the use of VP at time of wound closure to prevent PJI, and higher powered studies are needed to demonstrate the efficacy of VP.

The authors stated that while the statistically significant decreased rate of PJI in the VP group may be explained by VP use, it is unclear why the control group PJI rate of 5.4 % was much higher than the 1 % to 2 % PJI rate reported in the literature, and this was a major limitation of this study.  While the cause was unclear, during this period the hospital had an increase in infection rates and a thorough evaluation by infectious disease experts was performed with no clear cause identified.  One consideration was that 6 of the 7 patients with PJI had a BMI greater than 30 kg/m2, which has been shown to be a risk factor for PJI in patients having THA through an anterior approach.  As mentioned, the higher rate of chronic obstructive pulmonary disease (COPD) in the control group could also have contributed to a higher infection rate.  Lastly, one of the PJI in the control group received clindamycin for pre-operative prophylaxis, a bacteriostatic antibiotic, which could be associated with higher rates of PJI.

Obturator Nerve Blocks for management of Post-Operative Pain Following Total Hip Arthroplasty

Nielsen and colleagues (2019) noted that a substantial group of patients suffer from moderate-to-severe pain following elective total hip arthroplasty THA.  Due to the complex innervation of the hip, peripheral nerve block techniques can be challenging and are not widely used.  Since the obturator nerve innervates both the antero-medial part of the joint capsule as well as intra-articular nociceptors, these researchers hypothesized that an obturator nerve block (ONB) would decrease the opioid consumption following THA.  Sixty-two patients were randomized to receive ONB or placebo (PCB) after primary THA in spinal anesthesia. Primary outcome measure was opioid consumption during the first 12 postoperative hours. Secondary outcome measures included postoperative pain score, nausea score and ability to ambulate.  In a randomized clinical trial, a total of 60 patients were included in the analysis.  Mean (SD) opioid consumption during the first 12 post-operative hours was 39.9 (22.3) mg peroral morphine equivalents (PME) in the ONB group and 40.5 (30.5) mg PME in the PCB group (p = 0.93).  No difference in level of pain or nausea was found between the groups.  Paralysis of the hip adductor muscles in the ONB group reduced the control of the operated lower extremity compared with the PCB group (p = 0.026); however, his did not affect the subjects' ability to ambulate.  The authors concluded that a significant reduction in post-operative opioid consumption was not observed for active versus placebo ONB following THA.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

Total hip replacement (THA):

CPT codes covered if selection criteria are met:

27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft [minimally invasive or conventional approach]
27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft [minimally invasive or conventional approach]

CPT codes not covered for indications listed in the CPB:

0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure) [MAKOplasty/MAKO Tactile Guidance System]
86140 - 86141 C-reactive protein [as a marker for peri-prosthetic infection]

HCPCS codes covered if selection criteria are met:

C1776 Joint device (implantable)

ICD-10 codes covered if selection criteria are met:

C40.20 - C40.22 Malignant neoplasm of long bones of lower limb [proximal femur]
C79.51 Secondary malignant neoplasm of bone [proximal femur]
M05.00 - M14.89 Rheumatoid arthritis
M12.551 - M12.559 Traumatic arthropathy, hip
M16.0 - M16.9 Osteoarthritis of hip
M16.2 - M16.7 Osteoarthritis, secondary, hip
M16.9 Osteoarthritis of hip unspecified
M80.051+ - M80.059+, M80.851+ - M80.859+, M84.451+ - M84.453+, M84.459+, M84.551+ - M84.559+, M84.651+ - M84.659+ Pathologic fracture of neck of femur (hip)
M84.750+ - M84.759+ Atypical femoral fracture
M87.00, M87.10, M87.20, M87.30, M87.80, M87.9, M90.50 Osteonecrosis of bone, site unspecified
M87.051 - M87.059, M87.151 - M87.159, M87.251 - M87.255, M87.351 - M87.353, M87.851 - M87.859, M90.551 - M90.559 Osteonecrosis of femur
M97.01x+ - M97.02x+ Periprosthetic fracture around internal prosthetic hip joint
S32.411+ - S32.9xx+ Fracture of acetabulum, closed and open
S72.001+ - S72.26x+ Fracture of head and neck of femur
T84.010 - T84.011, T84.020 - T84.021, T84.030 - T84.031, T84.050 - T84.051, T84.060 - T84.061, T84.090 - T84.091 Mechanical complication of internal orthopedic device, implant, and graft
Z96.641 - Z96.649 Presence of artificial hip joint

ICD-10 codes contraindicated for this CPB :

A00.0 - B99 Infectious and parasitic diseases [active infection of the joint, active systemic bacteremia or active skin infection]
G82.20 - G82.54 Paraplegia (paraparesis) and quadriplegia (quadriparesis)
M00.051 - M00.059, M00.151 - M00.159, M00.251 - M00.259, M00.851 - M00.859, M00.9 Pyogenic arthritis involving pelvic region and thigh
M01.X51 - M01.X59 Direct infection of hip in infection and parasitic diseases classified elsewhere
M62.81 Muscle weakness (generalized) [permanent or irreversible muscle weakness preventing ambulation in the absence of pain
R62.50, R62.59 Lack of expected normal physiological development in childhood [skeletal immaturity]
S71.001+ - S71.159 Open wound of hip and thigh
T56.2x1+ - T56.2x4+ Toxic effect of chromium and its compounds [not covered for metallosis alone without evidence of loosening or malposition]
T56.811+ - T56.894 Toxic effect of other metals [not covered for metallosis alone without evidence of loosening or malposition]
T78.40x+ Allergy, unspecified

Revision, replacement of total hip arthroplasty, or revision hip resurfacing arthroplasty:

No specific code

CPT codes covered if selection criteria are met:

27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) [Revision of resurfacing arthroplasty]
27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft [revision of resurfacing arthroplasty]
27134 - 27138 Revision of total hip arthroplasty; with or without autograft or allograft

HCPCS codes covered if selection criteria are met:

C1776 Joint device (implantable)
S2118 Metal-on-metal total hip resurfacing, including acetabular and femoral components

ICD-10 codes covered if selection criteria are met:

T84.010+ - T84.099 Mechanical complication of internal joint prosthesis
T84.50x+ - T84.59x+ Infection and inflammatory reaction due to intenal joint prosthesis


CPT codes not covered for indications listed in the CPB:

Alpha-defensin test (Synovasure) - no specific code:

ICD-10 codes not covered for indications listed in the CPB:

T84.51xA - T84.52xS Infection and inflammatory reaction due to internal hip prosthesis

Obturator nerve blocks:

CPT codes not covered for indications listed in the CPB:

64450 Injection, anesthetic agent; other peripheral nerve or branch [obturator nerve blocks]

ICD-10 codes not covered for indications listed in the CPB:

G89.18 Other acute postprocedural pain [following total hip arthroplasty]
G89.28 Other chronic postprocedural pain [following total hip arthroplasty]

The above policy is based on the following references:

  1. Streicher RM. Metal-on-metal articulation in total hip arthroplasty: The case for using metal-on-metal. J Arthroplasty. 1998;13(3):343-345.
  2. Walker PS, Blunn GW. Metal-on-metal articulation in total hip arthroplasty: The case for improving metal- or ceramic-on-polyethylene. J Arthroplasty. 1998;13(3):339-343.
  3. Jazrawi LM, Kummer FJ, Di Cesare PE. Hard bearing surfaces in total hip arthroplasty. Am J Orthop. 1998;27(4):283-292.
  4. Faulkner A, Kennedy LG, Baxter K, et al. Effectiveness of hip prostheses in primary total hip replacement: A critical review of evidence and an economic model. Health Technol Assess. 1998;2(6):1-133.
  5. Randle R, Gordiev K. Metal-on-metal articulation in total hip arthroplasty: Preliminary results in 57 cases. Aust N Z J Surg. 1997;67(9):634-636.
  6. Tountas AA. The historical development and clinical results on metal on metal total hip systems. Clin Orthop. 1997;340:283-284.
  7. Visuri T, Pukkala E, Paavolainen P, et al. Cancer risk after metal on metal and polyethylene on metal total hip arthroplasty. Clin Orthop. 1996;329(Suppl):S280-S289.
  8. Black J. Metal on metal bearings. A practical alternative to metal on polyethylene total joints? Clin Orthop. 1996;329(Suppl):S244-S255.
  9. Hilton KR, Dorr LD, Wan Z, et al. Contemporary total hip replacement with metal on metal articulation. Clin Orthop. 1996;329(Suppl):S99-S105.
  10. Dorr LD, Hilton KR, Wan Z, et al. Modern metal on metal articulation for total hip replacements. Clin Orthop. 1996;333:108-117.
  11. Wagner H, Wagner M. Metal/metal articulating interfaces. Orthopedics. 1996;19(9):749-752.
  12. Amstutz HC, Campbell P, McKellop H, et al. Metal on metal total hip replacement workshop consensus document. Clin Orthop. 1996;329(Suppl):S297-S303.
  13. Schmalzried TP, Peters PC, Maurer BT, et al. Long-duration metal-on-metal total hip arthroplasties with low wear of the articulating surfaces. J Arthroplasty. 1996;11(3):322-331.
  14. Amstutz HC, Grigoris P. Metal on metal bearings in hip arthroplasty. Clin Orthop. 1996;329(Suppl):S11-S34.
  15. Muller ME. The benefits of metal-on-metal total hip replacements. Clin Orthop. 1995;311:54-59.
  16. Fraser J. Knee and hip joint replacements. Longer lasting prostheses. Aust Fam Physicians. 1999;28(11):1109-1111, 1114-1115.
  17. Sieber HP, Rieker CB, Kottig P. Analysis of 118 second-generation metal-on-metal retrieved hip implants. J Bone Joint Surg Br. 1999;81(1):46-50.
  18. Zahiri CA, Schmalzried TP, Ebramzadeh E, et al. Lessons learned from loosening of the McKee-Farrar metal-on-metal total hip replacement. J Arthroplasty. 1999;14(3):326-332.
  19. Dorr LD, Wan Z, Longjohn DB, et al. Total hip arthroplasty with use of the Metasul metal-on-metal articulation. Four to seven-year results. J Bone Joint Surg Am. 2000;82(6):789-798.
  20. Harkess JW. Arthroplasty of hip. In: Campbell's Operative Orthopaedics. Vol I. 9th ed. ST Canale, ed. St. Louis, MO: Mosby; 1998; Ch. 7: 296-471.
  21. Quintana JM, Azkarate J, Goenaga JI, et al. Evaluation of the appropriateness of the hip joint replacement techniques. Intl J Tech Assess Health Care. 2000;16(1):165-177.
  22. Lombardi AV Jr, Mallory TH, Alexiades MM, et al. Short-term results of the M2a-taper metal-on-metal articulation. J Arthroplasty. 2001;16(8 Suppl 1):122-128.
  23. Garino JP. Modern ceramic-on-ceramic total hip systems in the United States: Early results. Clin Orthop. 2000;(379):41-47.
  24. Clarke IC, Good V, Williams P, et al. Ultra-low wear rates for rigid-on-rigid bearings in total hip replacements. Proc Inst Mech Eng [H]. 2000;214(4):331-347.
  25. Bierbaum BE, Nairus J, Kuesis D, et al. Ceramic-on-ceramic bearings in total hip arthroplasty. Clin Orthop. 2002;(405):158-163.
  26. Canadian Coordinating Office for Health Technology Assessment (CCOHTA). Relative benefits of various types of hip prostheses. Pre-assessment No. 2. Ottawa, ON: CCOHTA; February 2002.  
  27. MacDonald SJ, McCalden RW, Chess DG, et al. Metal-on-metal versus polyethylene in hip arthroplasty: A randomized clinical trial. Clin Orthop. 2003;(406):282-296.
  28. U.S. Food and Drug Administration (FDA), Center for Devices and Radiologic Health (CDRH. Ceramic TRANSCEND Hip Articulation System - P010001. New Device Approval. CDRH Consumer Information. Rockville, MD: FDA; March 25, 2003. Available at: Accessed July 15, 2003.
  29. Augustovski F, Pichon Riviere A, Alcaraz A, et al. Usefulness of ceramic prosthesis in total hip replacement. Report IRR No. 53. Buenos Aires, Argentina: Institute for Clinical Effectiveness and Health Policy (IECS); 2005.
  30. Bhandari M, Bajammal S, Guyatt GH, et al. Effect of bisphosphonates on periprosthetic bone mineral density after total joint arthroplasty. A meta-analysis. J Bone Joint Surg Am. 2005;87(2):293-301.
  31. Dumbleton JH, Manley MT. Metal-on-Metal total hip replacement: What does the literature say? J Arthroplasty. 2005;20(2):174-188.
  32. Yoo JJ, Kim YM, Yoon KS, et al. Alumina-on-alumina total hip arthroplasty. A five-year minimum follow-up study. J Bone Joint Surg Am. 2005;87(3):530-535.
  33. Dorr LD, Wan Z, Shahrdar C, et al Clinical performance of a Durasul highly cross-linked polyethylene acetabular liner for total hip arthroplasty at five years. J Bone Joint Surg Am. 2005;87(8):1816-1821.
  34. Parker MJ, Gurusamy K. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev. 2006;(3):CD001706.
  35. Parker MJ, Gurusamy K. Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev. 2006;(4):CD001708.
  36. Augustovski F, Pichon Riviere A, Alcaraz A, et al. Usefulness of ceramic or metal on metal prostheses in total hip replacement [summary]. Report IRR No. 84. Buenos Aires, Argentina: Institute for Clinical Effectiveness and Health Policy (IECS); 2006.
  37. Khan M, Kuiper JH, Richardson JB. Can cobalt levels estimate in-vivo wear of metal-on-metal bearings used in hip arthroplasty? Proc Inst Mech Eng [H]. 2007;221(8):929-942.
  38. Morshed S, Bozic KJ, Ries MD, et al. Comparison of cemented and uncemented fixation in total hip replacement: A meta-analysis. Acta Orthop. 2007;78(3):315-326.
  39. Nowicki P, Chaudhary H. Total hip replacement in renal transplant patients. J Bone Joint Surg Br. 2007;89(12):1561-1566.
  40. Daras M, Macaulay W. Total hip arthroplasty in young patients with osteoarthritis. Am J Orthop (Belle Mead NJ). 2009;38(3):125-129.
  41. Garcia-Rey E, Cruz-Pardos A, Garcia-Cimbrelo E. Alumina-on-alumina total hip arthroplasty in young patients: Diagnosis is more important than age. Clin Orthop Relat Res. 2009;467(9):2281-2289.
  42. Hooper GJ, Rothwell AG, Stringer M, Frampton C. Revision following cemented and uncemented primary total hip replacement: A seven-year analysis from the New Zealand Joint Registry. J Bone Joint Surg Br. 2009;91(4):451-458.
  43. Pospischill M, Kranzl A, Attwenger B, Knahr K. Minimally invasive compared with traditional transgluteal approach for total hip arthroplasty: A comparative gait analysis. J Bone Joint Surg Am. 2010;92(2):328-337.
  44. Smith TO, Nichols R, Donell ST, Hing CB. The clinical and radiological outcomes of hip resurfacing versus total hip arthroplasty: A meta-analysis and systematic review. Acta Orthop. 2010;81(6):684-695.
  45. Garbuz DS, Tanzer M, Greidanus NV, et al. The John Charnley Award: Metal-on-metal hip resurfacing versus large-diameter head metal-on-metal total hip arthroplasty: A randomized clinical trial. Clin Orthop Relat Res. 2010;468(2):318-325.
  46. Walsh J. Metal-on-metal hip resurfacing as an alternative to total hip arthroplasty. Technology Assessment. San Francisco, CA: California Technology Assessment Forum (CTAF); October 19, 2011.
  47. Azegami S, Gurusamy KS, Parker MJ. Cemented versus uncemented hemiarthroplasty for hip fractures: A systematic review of randomised controlled trials. Hip Int. 2011;21(5):509-517.
  48. Qu X, Huang X, Dai K. Metal-on-metal or metal-on-polyethylene for total hip arthroplasty: A meta-analysis of prospective randomized studies. Arch Orthop Trauma Surg. 2011;131(11):1573-1583.
  49. U.S. Food and Drug Administration (FDA). Concerns about metal-on-metal hip implant systems. Silver Spring, MD: FDA; updated March 29, 2012.
  50. U.S. Food and Drug Administration (FDA). Information for orthopaedic surgeons on meta-on-metal hip implant surgery. Silver Spring, MD; FDA; updated March 29, 2012.
  51. Matta JM, Ferguson TA. Total hip replacement after acetabular fracture. Orthopedics. 2005;28(9):959-960.
  52. Rogmark C, Johnell O. Primary arthroplasty is better than internal fixation of displaced femoral neck fractures: A meta-analysis of 14 randomized studies with 2,289 patients. Acta Ortho. 2006;77(3):359-367.
  53. Blomfeldt R, Tornkvist H, Ponzer S, et al. Displaced femoral neck fracture: Comparison of primary total hip replacement with secondary replacement after failed internal fixation: A 2-year follow-up of 84 patients. Acta Orthop. 2006;77(4):638-643.
  54. Harkess JW, Crockarell JR Jr. Arthroplasty of the hip. In: Canale ST, Beaty JH (editors). Campbell's Operative Orthopaedics. 11th ed. Philadelphia, PA: Mosby Elsevier; 2008:312-482.
  55. Williams D, Taylor A, McLardy-Smith P. Revision arthroplasty: An update. Skeletal Radiol. 2009;38(11):1031-1036.
  56. Kim YH, Kwon OR, Kim JS. Is one-stage bilateral sequential total hip replacement as safe as unilateral total hip replacement? J Bone Joint Surg Br. 2009;91(3):316-320.
  57. Wang J, Jiang B, Marshall RJ, Zhang P. Arthroplasty or internal fixation for displaced femoral neck fractures: Which is the optimal alternative for elderly patients? A meta-analysis. Int Orthop. 2009;33(5):1179-1187.
  58. Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: Part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis  Cartilage. 2010;18(4):476-499.
  59. Hopley C, Stengel D, Ekkernkamp A, Wich M. Primary total hip arthroplasty versus hemiarthroplasty for displaced intracapsular hip fractures in older patients: Systematic review. BMJ. 2010;340:c2332.
  60. Carroll EA, Huber FG, Goldman AT, et al. Treatment of acetabular fractures in an older population. J Orthop Trauma. 2010;24(10):637-644.
  61. Bozic KJ, Maselli J, Pekow PS, et al. The influence of procedure volumes and standardization of care on quality and efficiency in total joint replacement surgery. J Bone Joint Surg Am. 2010;92(16):2643-2652.
  62. Leonardsson O, Sernbo I, Carlsson A, et al. Long-term follow-up of replacement compared with internal fixation for displaced femoral neck fractures: Results at ten years in a randomised study of 450 patients. J Bone Joint Surg Br. 2010;92(3):406-412.
  63. Wingerter SA, Mehrle RK. Hip disease and hip arthroplasty. Orthop Clin of North Am. 2011;42(1):115-121.
  64. Senthi S, Munro JT, Pitto RP. Infection in total hip replacement: Meta-analysis. Int Orthop. 2011;35(2):253-260.
  65. Dai Z, Li Y, Jiang D. Meta-analysis comparing arthroplasty with internal fixation for displaced femoral neck fracture in the elderly. J Surg Res. 2011;165(1):68-74.
  66. Kim SJ, Postigo R, Koo S, Kim JH. Total hip replacement for patients with active tuberculosis of the hip: A systematic review and pooled analysis. Bone Joint J. 2013;95-B(5):578-582.
  67. Anderson DR, Dunbar MJ, Bohm ER, et al. Aspirin versus low-molecular-weight heparin for extended venous thromboembolism prophylaxis after total hip arthroplasty: A randomized trial. Ann Intern Med. 2013;158(11):800-806.
  68. Pennington M, Grieve R, Sekhon JS, et al. Cemented, cementless, and hybrid prostheses for total hip replacement: Cost effectiveness analysis. BMJ. 2013;346:f1026.
  69. Shi-Peng Y, Yun J, Cheng-Fu L. Meta-analysis of the role of two common prostheses in total hip replacement. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2013;35(6):672-676.
  70. Abdulkarim A, Ellanti P, Motterlini N, et al. Cemented versus uncemented fixation in total hip replacement: A systematic review and meta-analysis of randomized controlled trials. Orthop Rev (Pavia). 2013;5(1):e8.
  71. De Bellis UG, Legnani C, Calori GM. Acute total hip replacement for acetabular fractures: A systematic review of the literature. Injury. 2014;45(2):356-361.
  72. Erens GA, Thornhill TS, Katz JN. Total hip arthroplasty. UpToDate [online serial], Waltham, MA: UpToDate; reviewed December 2014.
  73. Omar M, Ettinger M, Reichling M, et al. Synovial C-reactive protein as a marker for chronic periprosthetic infection in total hip arthroplasty. Bone Joint J. 2015;97-B(2):173-176.
  74. Werner SD, Stonestreet M, Jacofsky DJ. Makoplasty and the accuracy and efficacy of robotic-assisted arthroplasty. Surg Technol Int. 2014;24:302-306.
  75. Domb BG, El Bitar YF, Sadik AY, et al. Comparison of robotic-assisted and conventional acetabular cup placement in THA: A matched-pair controlled study. Clin Orthop Relat Res. 2014;472(1):329-336.
  76. Elmallah RK, Cherian JJ, Jauregui JJ, et al. Robotic-arm assisted surgery in total hip arthroplasty. Surg Technol Int. 2015;26:283-288.
  77. Banerjee S, Cherian JJ, Elmallah RK, et al. Robot-assisted total hip arthroplasty. Expert Rev Med Devices. 2016;13(1):47-56.
  78. Erens GA, Thornhill TS, Katz JN. Total hip arthroplasty. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed January 2016.
  79. Zhang P, Liang Y, Chen P, et al. Intravenous versus topical tranexamic acid in primary total hip replacement: A meta-analysis. Medicine (Baltimore). 2016;95(50):e5573.
  80. Moskal JT, Capps SG. Meta-analysis of intravenous tranexamic acid in primary total hip arthroplasty. Orthopedics. 2016;39(5):e883-e892.
  81. Shang J, Wang H, Zheng B, et al. Combined intravenous and topical tranexamic acid versus intravenous use alone in primary total knee and hip arthroplasty: A meta-analysis of randomized controlled trials. Int J Surg. 2016;36(Pt A):324-329.
  82. Patel R, Alijanipour P, Parvizi J. Advancements in diagnosing periprostheticjJoint infections after total hip and knee arthroplasty. Open Orthop J. 2016;10:654-661.
  83. Kasparek MF, Kasparek M, Boettner F, et al. Intraoperative diagnosis of periprosthetic joint infection using a novel alpha-defensin lateral flow assay. J Arthroplasty. 2016;31(12):2871-2874.
  84. Pupaibool J, Fulnecky EJ, Swords RL Jr, et al. Alpha-defensin-novel synovial fluid biomarker for the diagnosis of periprosthetic joint infection. Int Orthop. 2016;40(12):2447-2452.
  85. Li JF, Li H, Zhao H, et al. Combined use of intravenous and topical versus intravenous tranexamic acid in primary total knee and hip arthroplasty: A meta-analysis of randomised controlled trials. J Orthop Surg Res. 2017;12(1):22.
  86. Sigmund IK, Holinka J, Gamper J, et al. Qualitative α-defensin test (Synovasure) for the diagnosis of periprosthetic infection in revision total joint arthroplasty. Bone Joint J. 2017;99-B(1):66-72.
  87. Suda AJ, Tinelli M, Beisemann ND, et al. Diagnosis of periprosthetic joint infection using alpha-defensin test or multiplex-PCR: Ideal diagnostic test still not found. Int Orthop. 2017;41(7):1307-1313.
  88. Veterans Health Administration (VHA), VHA Pharmacy Benefits Management Services, Medical Advisory Panel, VISN Pharmacist Executives and the National Surgery Office. Clinical Recommendations for Using TRANEXAMIC ACID for Reducing Blood Loss and Transfusion Requirements in Patients Undergoing Total Knee or Total Hip Arthroplasty. Washington, DC: VHA; December 2014.
  89. Canadian Agency for Drugs and Technologies in Health (CADTH). Prophylactic Tranexamic Acid Administration for Patients Undergoing Hip and Knee Replacement: Clinical Effectiveness, Cost-Effectiveness, and Guidelines. Rapid Response Report: Summary of Abstracts. Ottawa, ON: CADTH; June 16, 2015. 
  90. Health Quality Ontario; Ministry of Health and Long-Term Care. Quality-based procedures: Clinical handbook for primary hip and knee replacement [Internet]. Toronto, ON: Health Quality Ontario; February 2014.
  91. American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: An updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology. 2015;122(2):241-275.
  92. Yang Q, Zhang Z, Xin W, Li A. Preoperative intravenous glucocorticoids can decrease acute pain and postoperative nausea and vomiting after total hip arthroplasty: A PRISMA-compliant meta-analysis. Medicine (Baltimore). 2017;96(47):e8804.
  93. Huang P, Lyons M, O'Sullivan M. The infection rate of metal-on-metal total hip replacement is higher when compared to other bearing surfaces as documented by the Australian Orthopaedic Association National Joint Replacement Registry. HSS J. 2018;14(1):99-105.
  94. Laaksonen I, Lorimer M, Gromov K, et al. Trabecular metal acetabular components in primary total hip arthroplasty. Acta Orthop. 2018;89(3):259-264.
  95. Wagner H. Surface replacement arthroplasty of the hip. Clin Orthop Relat Res. 1978;(134):102-130.
  96. Patel NN, Guild GN 3rd, Kumar AR. Intrawound vancomycin in primary hip and knee arthroplasty: A safe and cost-effective means to decrease early periprosthetic joint infection. Arthroplast Today. 2018;4(4):479-483.
  97. Dial BL, Lampley AJ, Green CL, Hallows R. Intrawound vancomycin powder in primary total hip arthroplasty increases rate of sterile wound complications. Hip Pelvis. 2018;30(1):37-44.
  98. Chen X, Xiong J, Wang P, et al. Robotic-assisted compared with conventional total hip arthroplasty: Systematic review and meta-analysis. Postgrad Med J. 2018;94(1112):335-341.
  99. Stibolt RD Jr, Patel HA, Huntley SR, et al. Total hip arthroplasty for posttraumatic osteoarthritis following acetabular fracture: A systematic review of characteristics, outcomes, and complications. Chin J Traumatol. 2018;21(3):176-181.
  100. Shigemura T, Yamamoto Y, Murata Y, et al. Total hip arthroplasty after failed transtrochanteric rotational osteotomy for osteonecrosis of the femoral head: A systematic review and meta-analysis. Orthop Traumatol Surg Res. 2018;104(8):1163-1170.
  101. Nielsen ND, Runge C, Clemmesen L, et al. An obturator nerve block does not alleviate postoperative pain after total hip arthroplasty: A randomized clinical trial. Reg Anesth Pain Med. 2019 Jan 23 [Epub ahead of print].