Hip Osteoarthritis

Definition/Description

Hip OA.jpg

Osteoarthritis is a degenerative condition as a result of mechanical overload in a weight bearing joint.[1] Current thought is that hip OA results from a number of distinct conditions, each associated with unique etiologic factors and possible treatments that share a common final pathway. The most common symptom of hip OA is pain around the hip joint (generally located in the groin area). Most of the time, the pain develops slowly and worsens over time, or pain can have a sudden onset. Aging and genetic factors are important contributing causes of hip OA[2].

Hip osteoarthritis mainly affects the articular cartilage, as well as causing changes to the subcondral bone, synovium, ligaments and capsule.[3] This degeneration lead to loss of joint space, which can potentially be symptomatic.[3] It is one of the top 15 contributors of global disability.[4] Hip osteoarthritis is prevalent in 10% of people above 65, where 50% of these cases are symptomatic.[5] The hip is defined as the second most painful joint (after the knee) as a result of osteoarthritis according to a Italian study.[6] The xray image, on right, shows advanced OA of a hip.

Clinically relevant anatomy

For detailed information, see the hip anatomy page.

Hip-joint-acetabulum-femur-head-caput-femoris-greater-trochanter-lesser-minor-major-ilum-front-skin-names.png
Muscles2.png

Epidemiology & etiology

Prevalence

According to the Centers for Disease Control and Prevention, lifetime risk for symptomatic hip OA is 18.5% for men and 28.6% for women[2].

Hip osteoarthritis is prevalent in 10% of people above 65, where 50% of these cases are symptomatic.[5] Research suggest that there are a 25% risk of developing hip osteoarthritis for people who live to the age of 85,[1]

Primary osteoarthritis versus Secondary osteoarthritis

In primary OA, the disease is of idiopathic origin (no known cause) and usually affects multiple joints in a relatively elderly population. Secondary OA usually is a monoarticular condition and develops as a result of a defined disorder affecting the joint articular surface (eg, trauma). or from abnormalities of joint eg 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.[7]

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

[1][5][8][9]

Characteristics/Clinical Presentation

Signs & symptoms:[9][10][11][12]

  • 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[13]

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:.[1][14]

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.[15] 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:[9][10][11] (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

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. The video below explains the xray changes seen in hip OA

[16]
  • X-rays: Findings include joint space narrowing, marginal osteophytes, subchondral sclerosis, and bone cysts.[17] 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.[14]
  • CT scan
  • Bone scan: Aids in assessing the condition of soft tissue and bone of the hip

[9]

Outcome measures

Medical management

Medical management of hip osteoarthritis focuses on treating the symptoms. Effective disease-modifying interventions have not been established yet, thus a major focus should be on primary prevention strategies.[1] 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

[1][9]

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)

[1][18]

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

[1][18]

Physiotherapy management

Physiotherapy plays in major role in the management of patients with hip osteoarthritis. The goal is to  improve strength, mobility and increase range of motion. Physiotherapy also helps relieve pain and restores normal movement in the hip and legs and also addresses pain management and functional adaptions. Patient-specific exercise programmes has shown to decrease pain and improve function in hip osteoarthritis.[1][14]

Techniques include;

  • manual techniques eg passive movement to increase joint flexibility.
  • exercises,
  • ice and heat,
  • taping,
  • stretching
  • improve their stance and balance
  • aid ability to peform ADL's.

A biopsychosocial approach to the management of hip osteoarthritis leads to patients experiencing less anxiety, even though the condition may not always improve.[14] It is important to consider the rest of the multidisciplinary team as well. Dietitians, occupational therapists and psychologists can play an important part in the management of hip osteoarthritis.

The video below gives a brief overview of physiotherapy exercise management.

[19]

Education

  • Pathology and disease process
  • Role of physiotherapy and expected outcomes of physiotherapy interventions
  • Importance of weight reduction (combination of diet and exercise)
  • Self-management of pain:
    • Use of modalities such as heat and ice
    • Relaxation techniques
    • Coping strategies
    • Exercise

[1][9][18]

The RACPG 20188 guidelines recommend as per below

Weight management – Knee and/or hip OA[20]

We strongly recommend weight management for people with knee and/or hip OA. For those who are overweight (body mass index [BMI] ≥25 kg/m2 ) or obese (BMI ≥30 kg/m2 ), a minimum weight loss target of 5–7.5% of body weight is recommended. It is beneficial to achieve a greater amount of weight loss given that a relationship exists between the amount of weight loss and symptomatic benefits. Weight loss should be combined with exercise for greater benefits. For people of healthy body weight, education about the importance of maintaining healthy body weight is essential.

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, which will helps to avoid movements that may cause pain.

The RACPG 20188 guidelines recommend as per below

Assistive walking device – Hip OA[20]

It may be appropriate to offer an assistive walking device (eg cane) for some people with knee and/or hip OA, depending on a person’s preference and capability.

Exercise therapy

Exercise therapy is an effective treatment modality for hip osteoarthrosis.[14] Specific exercises can increase range of motion and flexibility, as well as strengthen the muscles 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.[14][18] The benefits of exercise can assist the patients in their self-management of hip osteoarthritis.

Hydrotherapy is effective in the management of hip osteoarthritis. The combination of buoyancy and the reduction of gravity greatly assists patients that are struggling to weight-bear as a result of the pain from the hip osteoarthritis.[18]

A 2016 study of 210 people with hip OA found that those who participated in a 12-week exercise program had less pain and more mobility than the placebo or no-treatment groups.[21]

A study on a 6 week education and exercise programme has shown significant and sustained improvements in pain and disability on patients wait-listed for joint replacement surgery. Further positive results included improvements in function, knowledge and psycho-social aspects.[22] Clinical trials further suggest that it can postpone the need of total hip replacement surgery.[18]

The RACPG 20188 guidelines recommend as per below

Land-based exercise – Hip OA [20]

Hip Theraband.png

We strongly recommend offering land-based exercise for all people with hip OA to improve pain and function, regardless of their age, structural disease severity, functional status or pain levels. Exercise has also been found to be beneficial for other comorbidities and overall health. However, we are unable to specifically recommend either for or against different types of land-based exercise at this stage. Clinicians should prescribe an individualised progressive exercise program, taking into account the person’s preference, capability and the availability of local facilities. Realistic goals should be set. Dosage should be progressed with full consideration given to the frequency, duration and intensity of exercise sessions, number of sessions, and the period over which sessions should occur. The clinician should monitor the person’s response to the exercise program and could try a different form of land-based exercise if improvements are not evident. Attention should be paid to strategies to optimise adherence. Strong for recommendation (when combining all studies of land-based exercise) Conditional (neutral) for recommending one type of land-based exercise over another (eg walking, muscle strengthening, stationary cycling, Tai Chi, Hatha yoga) Moderate (land-based) Very low (walking, muscle strengthening, stationary cycling, Tai Chi, Hatha yoga)

The RACPG 20188 guidelines recommend as per below

Aquatic exercise/ hydrotherapy – Knee and/or hip OA[20]

It may be appropriate to offer aquatic exercise/hydrotherapy for some people with knee and/or hip OA. This will depend upon personal preference and the availability of local facilities.

Manual therapy

A range of manual therapies is used in the treatment of hip osteoarthritis:[14]

  • Soft tissue techniques and stretches
  • Mobilization of accessory and physiological movements
  • Manipulation

Research is inconclusive on the effect of manual therapy in the treatment of hip osteoarthritis.[1] The immediate effect of a manual therapy, specifically joint mobilization decrease pain and improve hip range of motion, especially in the elderly population. Joint 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.[23] 

The RACPG 20188 guidelines recommend as per below

Massage therapy – Knee and/or hip OA[20]

It may be appropriate to offer a short course of massage therapy for some people with knee and/or hip osteoarthritis (OA). This should be considered only as an adjunctive treatment to enable engagement with active management strategies, and only for short term, cognisant of issues related to cost and access.

Manual therapy (stretching, soft tissue and/or joint mobilisation and/ or manipulation) – Knee and/or hip OA

It may be appropriate to offer a short course of manual therapy (stretching, soft tissue and/or joint mobilisation and/ or manipulation) for some people with knee and/or hip OA. This should be considered only as an adjunctive treatment to enable engagement with active management strategies and only for short term, cognisant of issues related to cost and access.

Clinical bottom line

Management of hip osteoarthritis varies according to the severity of the condition. A combination of pharmaceutical and non-pharmaceutical modalities is recommended for the optimal management of the condition. Physiotherapy plays an important role in customized exercise programmes for patients living with hip osteoarthritis.

The Future

Highly prevalent among the elderly, Hip osteoarthritis (OA) is highly prevalent among the elderly and carries a heavy burden of disease. Guidelines for the management of hip OA are often extrapolated from knee OA research, despite clear differences in the etiopathogenesis and response to treatments of OA at these sites. True inroads in reducing the burden of hip OA are most likely to be seen with an increased focus on risk factor modification prior to or in the early stages of the condition’s pathogenesis. Risk calculators such as those that currently exist for heart disease could be developed, incorporating imaging and even genetic biomarkers to enable stratification of people into varying risk levels for appropriate monitoring and management. With improved understanding of the etiopathogenesis of hip OA, intervention prior to or early in the disease course in a disease-modifying manner is likely to become feasible in the future. The management of hip OA has the potential to be an area of medicine undergoing substantial advancement in the decades to come.[24]

Resources

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Murphy NJ, Eyles JP, Hunter DJ. Hip osteoarthritis: Etiopathogenesis and implications for management. Advances in therapy 2016;33(11):1921-46.
  2. 2.0 2.1 Lespasio MJ, Sultan AA, Piuzzi NS, Khlopas A, Husni ME, Muschler GF, Mont MA. Hip osteoarthritis: a primer. The Permanente Journal. 2018;22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5760056/ (last accessed 19.11.2019)
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  6. Cimmino MA, Sarzi-Puttini P, Scarpa R, Caporali R, Parazzini F, Zaninelli A, Marcolongo R. Clinical presentation of osteoarthritis in general practice: determinants of pain in Italian patients in the AMICA study. Seminars in arthritis and rheumatism 2005;35(1):17-23).
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  12. Kim C, Nevitt MC, Niu J, Clancy MM, Lane NE, Link TM, Vlad S, Tolstykh I, Jungmann PM, Felson DT, Guermazi A.. Association of hip pain with radiographic evidence of hip osteoarthritis: Diagnostic test study. BMJ. 2015;351:5983.
  13. Fernandez M, Wall P, O’Donnell J, Griffin D. Hip pain in young adults. Aust Fam Physician. 2014;43(4):205–9.
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  15. Sutlive TG, Lopez HP, Schnitker DE, Yawn SE, Halle RJ, Mansfield LT et al. Development of a clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip pain. J Orthop Sports Phys Ther. 2008;38(9):542-50.
  16. Holy Cross Hospital Diagnosing an Arthritic Hip Joint Available from: https://www.youtube.com/watch?v=d_MJyedEz4o&app=desktop (last accessed 19.11.2019)
  17. Brandt CD. Diagnosis and non-surgical management of osteoarthritis. USA: Professional Communications, Inc. 2010.
  18. 18.0 18.1 18.2 18.3 18.4 18.5 Zhang W, Doherty M, Arden N, Bannwarth B, Bijlsma J, Gunther KP, Hauselmann HJ, Herrero-Beaumont G, Jordan K, Kaklamanis P, Leeb B. EULAR evidence based recommendations for the management of hip osteoarthritis: Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Annals of the rheumatic diseases 2005;64(5):669-81.
  19. Bob abd Brad Bone on Bone Hip Arthritis? 4 Things You Need to Try (ABSOLUTELY) Available from: https://www.youtube.com/watch?v=B1M6sJ_5kus&app=desktop (last accessed 19.11.2019)
  20. 20.0 20.1 20.2 20.3 20.4 2018 RACGP Guidelines for hip and knee arthritis Available from: https://www.racgp.org.au/download/Documents/Guidelines/Musculoskeletal/guideline-for-the-management-of-knee-and-hip-oa-2nd-edition.pdf (last accessed 19.11.2019)
  21. Arthritis Foundation Exercise Benefits for Hip Osteoarthritis Available from: https://www.arthritis.org/about-arthritis/types/osteoarthritis/articles/hip-oa-exercises.php (last accessed 19.11.2019)
  22. Saw MM. The effects of a six-week physiotherapist-led exercise and education intervention in patients with osteoarthritis, awaiting an arthroplasty in the South Africa [dissertation]. Cape Town: University of Cape Town. 2015.
  23. Beselga C, Neto F, Alburquerque-Sendín F, Hall T, Oliveira-Campelo N. Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: A randomised controlled trial. Man Ther. 2016;22:80-5.
  24. Murphy NJ, Eyles JP, Hunter DJ. Hip osteoarthritis: etiopathogenesis and implications for management. Advances in therapy. 2016 Nov 1;33(11):1921-46. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5083776/ (last accessed 19.11.2019)