Hip Osteoarthritis

What is osteoarthritis…

Osteoarthritis is a degenerative joint disease which results in the breakdown of joint articular (hyaline) cartilage. The body’s ability to repair the damage that occurs as a result of wear and tear, and various other conditions, is very limited.  The end result is a complete wearing out of the cartilage with the joint losing its congruency and the bone underneath becoming exposed.  To learn more about the hip anatomy and how it works normally please refer to hip joint anatomy.

Primary hip osteoarthritis – is the most common and is age-related. Cartilage starts wearing gradually and results in osteoarthritis. This generally occurs around the age of 50 but may delvelop earlier.

Inflammatory arthritis – such as rheumatoid arthritis is a condition where the inflammatory reaction inside the joint affects the synovial tissue and joint cartilage. This reaction gradually damages and erodes the joint cartilage. Medical management of inflammatory joint conditions has drastically reduced the incidence of significant joint cartilage damage and delayed onset of symptoms due to wear of cartilage.

Secondary hip osteoarthritis – is a condition commonly resulting from trauma to the hip which might have directly damaged the joint cartilage or caused a fracture involving the joint surface which again can damage the cartilage. Developmental conditions like hip dysplasia (where the joint does not develop properly) can also result in early onset hip osteoarthritis. Less common or infrequent causes are avascular necrosis of the hip and bone growth disorders. Important high-risk factors include, but are not limited to: repetitive injury, persistent pathology or being overweight.

What are the symptoms…

Pain is the main presenting feature. It is typically felt in the groin but can be in the outer hip, gluteal region, or thigh. It is rarely felt only in the knee region. Pain is commonly felt during activities but may also present at rest. Sleep disturbance is a frequent problem. Limitation of activities is another major symptom; it limits walking, restricts movement and makes it difficult to pursue sports and fitness activities. Sometimes the affected leg requires assistance, for example to get into or out of a car or bed. Stiffness results in problems with day-to-day activities like putting on shoes or tying laces. Both these symptoms slow down walking speed and distance. Limping is commonly seen. There might also be other symptoms like joint clicking or a loud noise. In my practice I have often noticed patients with pre-existing low back problems presenting with flare up of back pain.

How is hip osteoarthritis diagnosed…

Osteoarthritis is typically diagnosed by history, physical examination, and investigation such as a plain radiograph (X-ray). History taking involves obtaining information from the patient about hip symptoms, how much it affects personal daily life, how rapidly or slowly it has evolved, other medical problems and treatment previously tried. This is followed by a physical examination to look for gait changes, tenderness around the hip, movements in the hip, pain and noise associated with movements, assessment of the spine and, if necessary, other joints. Investigation to confirm diagnosis is usually a plain radiograph (X-ray). Loss or wear of cartilage is seen as loss of joint space as shown in the X-ray image below.

In a few patients CT scan, MRI or bone scan is required to confirm diagnosis or to provide a more detailed assessment of the hip joint.

How hip osteoarthritis is managed…

Hip osteoarthritis is not curable. It gets worse over time.  The rate at which it progresses varies from person to person, but the usual trend is that symptoms become more severe as the osteoarthritis worsens.  The symptoms, however, might fluctuate from day-to-day – sometimes for no reason and unfortunately this is a common experience among patients.

Treatment options include non-operative and operative treatment.

Non-operative treatment

This includes pain killers, lifestyle modifications and maintain a healthy weight. Taking up low impact exercises instead of continuing high impact activities certainly eases the pain in many patients.

Physiotherapist or osteopath guided exercises should be regular and within pain tolerance limits.  This will help to maintain a range of movements, muscle strength and helps with nutrition of the remaining healthy cartilage in the joint.  All these measures help to ease pain and maintain good levels of physical activities especially in the early stages. Even if exercises do not relieve the pain and a patient ends up having a hip replacement, doing these exercises to strengthen the muscles and improve balance aids faster recovery after hip replacement. This is called ‘pre-habilitation’.

A walking aid used in the opposite hand helps to ease the pain, reduces the limp and aids improved walking and walking longer distances.

Hip injection can be an effective alternative to relieve pain. Mr Velayudham offers this only in a selected group of patients after careful assessment and discussion. In the earlier stages of hip osteoarthritis this might ease the pain for a finite period which varies from person to person and the extent to which pain is relieved is also variable. This procedure is done under image guidance (like x-ray or ultrasound): there is an extremely rare chance of hip infection following the injection. If a steroid is injected into the hip joint, it is better to avoid hip replacement surgery for at least three months (preferably six months) as there is some retrospective evidence that indicates the injection might increase the chance of hip infection after the hip replacement. Additionally, vaccinations are best avoided for two weeks both before and after a hip steroid injection.

Steroid absorption into the body is very minimal.

In advanced osteoarthritis the benefits of steroid injections are much less compared to mild to moderate osteoarthritis.

Operative treatment includes total hip replacement or resurfacing hip replacement. This option is indicated when all possible and appropriate non-operative treatment methods have been explored and are no longer improving symptoms which are now adversely affecting quality of life. Please refer to total hip replacement or resurfacing hip replacement to learn more.