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Indications for total hip replacement: comparison of assessments of orthopaedic surgeons and referring physicians
  1. K E Dreinhöfer1,
  2. P Dieppe2,
  3. T Stürmer3,4,
  4. D Gröber-Grätz1,
  5. M Flören1,
  6. K-P Günther1,
  7. W Puhl1,
  8. H Brenner3
  1. 1Department of Orthopaedic Surgery, University of Ulm, Ulm, Germany
  2. 2Department of Social Medicine, Medical Research Council, Health Services Research Collaboration, University of Bristol, Bristol, UK
  3. 3Department of Epidemiology, German Centre for Research on Ageing, Heidelberg, Germany
  4. 4Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to:
    P Dieppe
    Department of Social Medicine, Medical Research Council, Health Services Research Collaboration, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2 PR, UK;P.Dieppe{at}


Objectives: To analyse differences of opinions on indications for primary total hip replacements (THRs) within and between groups of orthopaedic surgeons and the physicians who refer patients to them.

Methods: 22 orthopaedic centres in 12 European countries took part, resulting in a postal survey of 304 orthopaedic surgeons and 314 referring physicians. Each participant was asked to state what importance different domains (pain, functional impairment, physical examination and radiographs) have on their decision to recommend THR and to select the most appropriate level of severity of each symptom or sign for recommending THR. In addition, the participants were asked to prioritise other personal or environmental factors that affect their decision to undertake a THR.

Results: Rest pain, pain with activity and functional limitations were the most important criteria for THR, although range of motion and radiographic changes were of least importance. Both similarities and differences were observed within and between groups of surgeons and referring physicians in the overall approach to indications and the most appropriate level of severity of disease for recommending THR. Most surgeons agreed on severity levels in only 4 of 11 items and most referring physicians in only one. Between the groups, major differences occurred with regard to the importance of activities of daily living and the appropriate level of symptoms for THR. In general, compared with surgeons, referring physicians reported that the disease needed to be more advanced to warrant surgery.

Conclusion: Currently, no consensus exists on objective indication criteria for THR. The observed differences between the gatekeepers (referring physicians) and surgeons can lead to variations and perhaps inequities in the provision of care.

  • EUROHIP, The European collaborative database of cost and practice patterns of THR
  • THR, total hip replacement

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  • Published Online First 26 January 2006

  • TS and PD are partially funded by unrestricted research grants from Merck and the UK Medical Research Council, respectively. The funding agencies had no role in the preparation of the manuscript or in the decision with respect to publication.

  • Competing interests: None declared.

  • The European collaborative database of cost and practice patterns of THR (EUROHIP) study group consists of the following members: Martin Krismer and Bernd Stöckl, University of Orthopedic Surgery, Innsbruck, Austria; Karl Knahr and Oswald Pinggera, Orthopedic Spital Wien–Speising, Austria; Pekka Ylinen, Orton Orthopaedic Hospitala, Helsinki, Finland; Moussa Hammadouche, Groupe Hospitalier Cochin, Paris, France; Christian Delaunay, Clinique De L’yette, Longjumeau, France; Philippe Chiron, Centre Hospitalier Ranguell, Toulouse, France; Wolfhart Puhl, Karsten Dreinhöfer, Markus Flören, Sabrina Baumann and Dagmar Gröber-Grätz, University of Ulm (RKU), Ulm, Germany; Klaus-Peter Günther and Stefan Fickert, Carl-Gustav Carus University, Dresden, Germany; Joachim Löhr, Alexander Katzer and Dietrich Klüber, ENDO-Clinic, Hamburg, Germany; Volker Ewerbeck, Peter Aldinger and Dominik Parsch, University of Heidelberg, Heidelberg, Germany; Wolfram Neumann, Ingmar Meinecke and Olof Bittner, Otto von Guericke University, Magdeburg, Germany; Wilfried von Eiff and Conrad Middendorf, Center for Hospital Management (CKM), Münster, Germany; Hanns-Peter Scharf, Peter Schräder and Sabine Schmitt, University Clinic Mannheim, Mannheim, Germany; David Rowley, Ninewells Hospital and Medical School, Dundee, UK; Ian Learmonth, Avon Orthopaedic Centre, Bristol, UK; Paul Dieppe, Victoria Cavendish and Susan Williams, HSRC, University of Bristol, Bristol, UK; Peter Kellermann and Ildiko Fistzer, University of Szeged, Szeged, Hungary; Thorvaldur Ingvarsson, Akureyri University Hospital, Iceland; Paolo Gallinaro and Alessandro Massè, Universita degli Studi di Torino, Torino, Italia; Andrzej Górecki and Maciek Ambroziak, Medical University of Warsaw, Warsaw, Poland; Eduardo Garcia-Cimbrelo, Hospital La Paz, Madrid, Spain; Anna Nilsdotter and Urban Benger, Helsingborg Hospital, Skåne, Sweden; Christian Hellerfelt and Christer Olson, Lasarett Karlshamm, Sweden; Jörg Huber and Ivan Broger, Kantonalspital Aarau, Switzerland; Robert Theiler, Kurt Uehlinger and Angela Hett, Stadtspital Triemli, Zurich, Switzerland; and Til Stürmer, Harvard Medical School, Boston, USA.