Hip Osteoarthritis

Original Editor - Eric Robertson, Kim Presiaux

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Definition/Description

Osteoarthritis is a degenerative condition as a result of mechanical overload in a weight bearing joint. Hip osteoarthritis mainly affects the articular cartilage, as well as causing changes to the subcondral bone, synovium, ligaments and capsule. This degeneration lead to loss of joint space, which can potentially be symptomatic. It is one of the top 15 contributors of global disability. Hip osteoarthritis is prevalent in 10% of people above 65, where 50% of these cases are symptomatic. The hip is defined as the second most painful joint (after the knee) as a result of osteoarthritis according to a Italian study.

Clinically relevant anatomy

For detailed information, see the hip anatomy page.

Epidemiology & etiology

Prevalence

Hip osteoarthritis is prevalent in 10% of people above 65, where 50% of these cases are symptomatic. Research suggest that there are a 25% risk of developing hip osteoarthritis for people who live to the age of 85,

Primary osteoarthritis

Mostly caused by abnormality of the articular cartilage, but can also be a secondary result of developmental changes and abnormalities such as femeroacetbular impingement. Abnormalities normally include acetabular displasia. Pistol grip deformities are seen in some cases, mostly linked with slipped upper femoral epiphysis. Although seen as a specific condition, it is often linked with metabolic abnormalities.

Secondary osteoarthritis

Secondary osteoarthritis is caused by predisposing anatomic abnormalities such as developmental or congenital deformities.

Risk factors

• Previous hip trauma (causing injury or fracture) - mostly resulting in unilateral hip osteoarthritis
• Primary inflammatory arthritis (e.g. rheumatoid arthritis, ankylosing spondylitis)
• Joint morphology
• Genetics
• Congenital and developmental hip disease (e.g. congenital hip dislocation, Perthe's disease, slipped upper femoral epiphysis, developmental hip dysplasia)
• Subchondral bone defects
• Obesity - mostly resulting in bilateral hip osteoarthritis
• Occupation causing excessive strain on hips (e.g. manual labor causing repeated loading)
• Increase in age
• Gender (female > male)
• Sport (higher impact sport at a younger age can cause increase in articular cartilage strength, where low impact sport do not change the composition of the cartilage)
• Menopause
• Metabolic diseases and acromegaly
• Sedentary lifestyle
• Femoroacetabular impingement
• Avascular necrosis
• Ethnicity - 80-90% less prevalent in the Asian population when compared to the Caucasian population in the USA
• Diet - low Vitamin D, C and K levels

Characteristics/Clinical Presentation

Signs & symptoms:

• Pain:
  • Progressively increasing
  • Aggravated - movement; when hip is loaded wrong or too long; cold weather
  • Eased with continuous movement
  • Commonly in groin/thigh, radiating to buttocks or knee
  • End-stage: Constant pain, night pain
• Stiffness:
  • Morning stiffness with end-stage osteoarthritis, usually eased with movement (<1 hour)
• "Locking" of hip movement
• Decreased range of motion - leading to joint contractures and muscle atrophy
• Crepitis with movement
• Gait abnormalities - short limb gait, antalgic gait, trendelenburg gait, stiff hip gait
• Leg length discrepancy
• Local inflammation

Differential diagnosis

• Muscle contusion
• Muscle strains - gluteus and adductors
• Athletic pubalgia
• Piriformis syndrome
• Hamstring syndrome
• Inflammatory disorders
• Snapping hip syndrome
• Hip bursitis
• Arthritis
• Septic arthritis of the hip
• Avascular necrosis
• Labral tears
• Hip fractures
• Hip dislocations
• Tumors
• Chondral defect
• Ligamentus teres injury
• Sciatica
• Nerve irritation (especially obturator & lateral femoral cutaneous)
• Joint capsule disorders
• Inguinal ligament strain

Diagnostic procedures

Hip osteoarthritis can be diagnosed by a combination of the findings from a history and physical examination. The most used criteria in the diagnosis of hip osteoarthritis are those from the
American College of Rheumatology:.

Clinical criteria A

• Hip pain
• Hip internal rotation <15°
• Erythrocyte sedimentation rate (ESR) ≤45mm/h OR hip flexion ≤115° if ESR not available

Clinical criteria B

• Hip pain
• Pain with hip internal rotation
• Morning stiffness ≤1 hour
• >50 years

Clinical plus radiographic criteria

• Hip pain
• Two of the following:
  • ESR <20mm/h
  • Osteophytes on hip x-rays
  • Joint space narrowing on x-rays

Sutlive et al. published a list of variables for detecting hip osteoarthritis in patients with unilateral hip pain. If there are 3/5 variables present, the chance of having OA is 68%. With 4-5/5 the chance increases to 91%. The variables are positive when there’s pain or a limited range of motion in the tests.

The five variables are:

• Flexion
• Internal rotation
• Scour test: external and internal rotation in abduction and adduction of the hip.
• Patrick’s or FABER test: flexion,abduction and external rotation of the hip.
• Hip flexion test

Physical Examination

A consultation with an orthopaedic surgeon would include the following: (Also see the page for hip examination)

• Observation
• Subjective interview:
  • Complaints of pain, deformity, stiffness and/or limp
  • Previous history linked to hip pain (congenital or childhood problems, previous trauma)
• Physical examination:
  • Standing
  • Trendelenberg test
  • Gait
  • Supine (including leg length)
• Objective observation (posture, deformities, muscle atrophy)
• Palpation:
  • Tenderness at the hip
  • Pain and sensitivity over greater trochanter
• Range of motion:
  • Early signs of hip osteoarthritis is limited abduction and rotation. As the disease progresses, flexion, extension and adduction becomes more difficult.
  • Normally painful at end of available range of motion
• Crepitis with movement
  

Special investigations

X-ray: Hip osteoarthritis

Hip osteoarthritis can be diagnosed by clinical presentation only, but special investigation (e.g. x-rays) are vital to monitor the progression of the disease.

• X-rays: Findings include joint space narrowing, marginal osteophytes, subchondral sclerosis, and bone cysts. This is normally the first investigation done that aids in the diagnosis of hip osteoarthritis.
• MRI: More effective in detecting early change in the bone structure, such as focal cartilage defects and bone marrow lesions in the subchondral bone.
• CT scan
• Bone scan: Aids in assessing the condition of soft tissue and bone of the hip

Outcome measures

• Patient acceptable symptom state (PASS)
• Visual analogue scale (VAS)
• Hip disability and osteoarthritis outcome score (HOOS)
• Western Ontario and McMaster universities osteoarthritis index (WOMAC)
• Harris hip score
• Oxford hip score (OHS)
• Algofunctional index (AFI)
• Intermittent and constant osteoarthritis pain index (ICOAP)
• Lequesne index
• 6 Minute Walking Test
• Timed up and go test
• Patients specific complaints list (PSC)
• SF-36
• Fear Avoidance Belief Score
• International Hip Outcome Tool
• Ibadan Knee/Hip Osteoarthritis Outcome Measure

Medical management

Medical management of hip osteoarthritis focuses on treating the symptoms. Effective disease-modifying interventions have not been estabilished yet, thus a major focus should be on primary prevention strategies. The optimal management of hip osteoarthritis consists of a combination of pharmaceutical and non-pharmaceutical treatment modalities. It is also important to take the patient's wishes and expectations into consideration.

Primary prevention

• Patient education - especially in primary health care
• Muscle strengthening
• Joint preserving surgery prior to onset of hip osteoarthritis/early in disease process
• Modification of risk factors:
  • Weight control
  • Switching from high-impact to low-impact activities
  • Minimization of pain aggravating activities

Pharmacological management

• Symptom-relief drugs:
  • Treatment of choice: Paracetamol
  • NSAIDs:
    • Low doses and duration due to side effects
    • To be used for patients not responding well to paracetamol
    • Patients with high risk of developing gastrointestinal side effects: Non-selective NSAID together with a gastroprotective agent OR selective COX-r inhibitor
  • Duloxetine - works on central nervous system to inhibit pain
  • Opioids:
    • Tramadol (non-narcotic opioid)
    • Can be used in combination with paracetamol
    • Alternative if not NSAIDS and COX-2 inhibitors are not effective or contraindicated
  • Intra-articular injections:
    • Corticosteroids
      • Consider when patients are having flare-ups and is not responding to paracetamol and NSAIDs.
    • Platelet-rich plasma (evidence still lacking)
  • Hyaluronic acid - Evidence still lacking for effectiveness in the management of hip osteoarthritis
• Disease-modifying osteoarthritis drugs (research on this topic still ongoing)

Surgical intervention

Total hip replacement

Total hip replacement

90% of total hip replacements are done as a result of end-stage hip osteoarthritis. It is a successful orthopaedic procedure in the treatment of hip osteoarthritis, when conservative management has failed and is highly effective at relieving symptoms.

Hip resurfacing

This is normally done for the younger, more active population with painful dysplasia and deformities.

Hip osteotomy

An osteotomy is preformed to realign the hip joint to lessen pressure. This is not a common in the treatment of osteoarthritis.

Joint preserving surgery

• Arthroscopic debridement
• Surgical dislocation with offset reconstruction

Physiotherapy management

Physiotherapy plays in big role in the management of patient with hip osteoarthritis. Specific exercises can help increase range of motion and flexibility, as well as strengthen the muscles in of the hip and leg. Physiotherapists work together with the patient to develop an individualized, customized exercise program that meets the needs and lifestyle of the patient. Physiotherapy also plays a role in pain management and functional adaptions for the patient. A biopsychosocial approach to the management of hip osteoarthritis leads to patients experiencing less anxiety to handle the symptoms, even though the condition may not always improve. Evidence shows that exercises has a mild to moderated effect in reducing pain and improving function in hip osteoarthritis. Ex

The following physiotherapy modalities can be used in the management of patients with hip osteoarthritis:

• Patient education
• Weight management (combination of diet and exercise)
• Exercise therapy:
  • Land and water-based exercises
  • Strength training

Assistive devices

Mobility assistive devices like walking sticks/canes, crutches, or walking frames can improve mobility and independence of the patient. Occupational therapy also plays a role here, as they often also assists the patients with functional assistive devices like a long-handled reacher to pick up low-lying things will help you avoid movements that may cause pain.

Small clinical trials have recently suggested exercise therapy may postpone the need for THA [151] and may reduce medical expenditure for people with hip OA [152]. There are various activities included under the banner of exercise therapy, including strengthening, aerobic, and flexibility activities, many of which can be carried out on land or in the water. No particular activity type has been shown to produce superior results, and thus it is recommended that exercise programs be personalized to reflect the unique needs of each patient [153].

Physiotherapy for hip OA usually includes physiotherapist-led exercise therapies in conjunction with manual therapy. The value of physiotherapy in the management of hip OA is a hotly contested issue, with recent evidence suggesting it offers little benefit beyond what could be expected from a self-guided exercise program [149]. Systematic reviews on the topic have reported no benefit from the use of manual therapy in treating hip OA, nor any additional benefit when manual therapy is combined with an exercise program than is obtained from exercise alone [154, 155]. A recent clinical trial comparing physiotherapy-led management to sham therapy found no benefit of physiotherapy on pain or function [156]. More high-quality research is needed in this area, but the limited evidence currently available does not establish physiotherapy as effective in treating hip OA. A novel strategy being investigated for a potential role in modifying biomechanics to treat hip OA is bracing, although this research is still very much in its infancy [157, 158, 159, 160].

3. Non-pharmacological treatment of hip OA should include regular education, exercise, appliances (stick, insoles) and weight reduction if obese or overweight Two systematic reviews have been undertaken for education,25 26 but neither of them contains subgroup data for hip OA. Both show non-statistically significant effects for an education programme compared with control. The ES from the one covering more trials was 0.15 (95% CI 20.43 to 1.18) and 20.02 (95% CI 20.51 to 0.47) for pain relief and functional improvement, respectively.25 One 24 month open RCT was undertaken in patients with hip OA awaiting THR. All patients were given the usual information and an information leaflet before randomisation. They were then assigned randomly to two groups: group 1 attended a collective multidisciplinary information session 2–6 weeks before surgery and group 2 did not and acted as a control. The results showed that the patients receiving education had less pain than the control group.27 Five systematic reviews have been undertaken for exercise,28–32 but again none of them are specific for the hip. The latest one with the most RCTs provided an ES of 0.39 (95% CI 0.30 to 0.47) for pain relief and an ES of 0.31 (95% CI 0.23 to 0.39) for functional improvement. There is no RCT evidence for the benefits of weight loss. However, one systematic review of observational studies (1 cohort and 11 case-control studies) on obesity and risk of hip OA demonstrated that there was a positive relationship between obesity and hip OA in the case-control studies (odds ratio (OR) = 2.3, 95% CI 1.2 to 4.4) but not in the cohort study (RR = 1.03, 95% CI 0.40 to 2.60).33 To determine whether exercise has an effect on weight reduction, which in turn might improve clinical outcome for patients with hip OA, further evidence is needed. There is no research evidence for appliances such as stick and insoles for hip OA, although they may help to reduce the adverse forces across the joint. In summary, only one RCT (category Ib) has been undertaken for education in hip OA alone and it suggests that education reduces pain. However, evidence (category Ia) for OA at any joint showed that education may have very little value and may not reach statistical significance. In contrast, although direct evidence for hip OA is lacking, exercise appears to be beneficial for OA of any kind (category Ia). There is some evidence to support the benefit of weight reduction for hip OA (category III), but no evidence for appliances (stick and insoles) (table 3). Nevertheless, despite the absence of trial data, interventions that reduce adverse mechanical forces across a compromised hip joint have obvious face validity. uelar

Exercise Therapy

Currently the amount of research on exercise therapy for patients with hip osteoarthritis is limited and the effect of treatment is rather low. However, Bennel states that multiple trials and reviews suggest that exercise therapy might be an effective treatment strategy for hip osteoarthrosis.

Below you can see a link to a summarised table with relevant studies using exercise therapy on land or in water (aquatherapy) and what they researched.

Table (from Bennell, K., “Physiotherapy management of hip osteoarthritis Journal of Physiotherapy”, Volume 59, Issue 3, September 2013, Pages 145–157.)

Exercises could be done in water as well, in order to facilitate recovery of the motorfuntion. In this situation, gravity is greatly reduced thus the burdensome weight and tension at the height of the effected joint will be reduced as well.   Advice and education is important in treatment, tell the patient about their condition. Why does it occur? What's the treatment? What's the importance of exercise? This will make the patient have a clear understanding in his condition and will improve the healing process.However, it is unclear if aquatic exercises are more effective than exercises on land. There is also no clear evidence on balneotherapy. Currently, there doesn’t exist evidence that balneotherapy might be a beneficial therapy approach.

Ultrasound therapy has been used across the globe in clinical practice, but as there is little evidence surrounding its use in the management of hip osteoarthritis, it is not recommended to use. 

Manual Therapy

A range of manual therapies is used as manual therapy treatment. These therapies are:

• soft tissue techniques and stretches
• mobilisation of accessory and physiological movements
• manipulation/ mobilisation

The immediate effect of a mobilization intervention on elderly patients with osteoarthritis has been researched by Beselga et al (2016), they found that after an intervention pain decreased and that the range of motion in the hip joint improved. The study suggests that mobilization might reduce pain, might ‘provide a stretching effect on the joint capsules and muscles, thus restoring normal arthrokinematics or may induce pain inhibition and improved motor control’ and might reduce kinesiophobia. However, these effects are currently not proven as studies regarding long-term effects are lacking. Further research for these effects is needed.

“While there have been no reports of serious adverse events associated with the use of manual therapy in patients with hip osteoarthritis, therapists should advise patients about the possibility of self-limiting posttreatment soreness.”

Resources

http://www.guidelines.gov/content.aspx?id=36893

https://www.ncbi.nlm.nih.gov/pubmed?otool=vublib

http://apps.webofknowledge.com.ezproxy.vub.ac.be:2048/WOS_GeneralSearch_input.do?product=WOS&search_mode=GeneralSearch&SID=U2HYlXJGBQdVzdFFDhX&preferencesSave d=

https://scholar.google.be/?inst=vub.ac.be

Clinical Bottom Line

Depending on the severity of the condition, managment will vary from patient to patient. It is important that the clinician individualizes treatment to each of their patients in order to ensure optimal outcomes.