Osteoarthritis of the Hip

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Osteoarthritis of the Hip

M O H A M M A D T R I A D I W I JAYA , M D

O R T H O PA E D I C S & T R A U M AT O L O G Y

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Overview

Osteoarthritis is a degenerative joint disease

that causes gradual damage to the joint, leading to pain, stiffness,

and limited mobility.

“ wear and tear”

condition of the hip joint

normal hip vs hip damaged by osteoarthrits

Hip osteoarthritis - orthoinfo - AAOS [Internet]. [cited 2024 Jan 23]. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/osteoarthritis-of-the-hip/

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Anatomy

• Ball and socket joint

• Connects the lower extremity with the axial skeleton, allowing for movement in three major axes:

• Transverse (flexion and extension)

• Longitudinal (internal and external rotation)

• Sagittal (abduction and adduction)

Hip anatomy [Internet]. [cited 2024 Jan 23]. Available from: https://www.orthobullets.com/recon/12769/hip-anatomy

Glenister R, Sharma S. Anatomy, Bony Pelvis and Lower Limb, Hip. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL):

StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526019/

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Risk Factors of Osteoarthritis of the Hip

1.Increasing age 2.Female gender 3.Genetics

4.Anatomical abnormalities

MODIFIABLE 5. Obesity

6. Heavy physical stress at work 7. Traumatic injuries

8. Repetitive stress on the joint 9. Previous injury to the hip joint UNMODIFIABLE

These factors increase the likelihood of developing hip osteoarthritis

Lespasio MJ, Sultan AA, Piuzzi NS, Khlopas A, Husni ME, Muschler GF, Mont MA. Hip Osteoarthritis: A Primer. Perm J. 2018;22:17-084. doi: 10.7812/TPP/17-084. PMID: 29309269; PMCID:

PMC5760056.

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Bennell, Kim. (2013). Physiotherapy management of hip osteoarthritis. Journal of Physiotherapy. 59. 145–157. 10.1016/S1836-9553(13)70179-6.

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Tom; I, Alves-Pimenta S, Sargo R, Pereira J, Colaço B, Brancal H, et al. Mechanical osteoarthritis of the hip in a one medicine concept: A narrative review - BMC veterinary research [Internet].

BioMed Central; 2023 [cited 2024 Jan 24]. Available from: https://bmcvetres.biomedcentral.com/articles/10.1186/s12917-023-03777-z

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Etiology

Primary

Usually in 6 th / 7 th decade

Multiple joints

Progress slowly

Secondary

Usually in 3 rd / 4 th decade

Single joint

Progress

rapidly

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Sign and Symptoms

1. Joint pain 2. Stiffness

3. Reduced Mobility 4. Grating Sensation 5. Swelling

6. Muscle Weakness 7. Limping

8. Radiating Pain

9. Worsening symptoms with Activity 10. Reduced Joint Function

Lespasio MJ, Sultan AA, Piuzzi NS, Khlopas A, Husni ME, Muschler GF, Mont MA. Hip Osteoarthritis: A Primer. Perm J. 2018;22:17-084. doi: 10.7812/TPP/17-084. PMID: 29309269; PMCID: PMC5760056.

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Diagnosis

Physical Examination

▪Tenderness around hip joint

▪ Antalgic gait, limping, muscle wasting, trendelenburg (+), lower limb shortening

▪ROM limitation

▪ Lack of full extension (>5 degrees flexion contracture)

▪ Lack of full flexion (flexion < 90-100 degrees)

▪ Limited internal rotation

Key point: Anterior or inguinal pain and tenderness Examine the knee and lumbar spine (reffered pain?)

Hip osteoarthritis [Internet]. [cited 2024 Jan 23]. Available from: https://www.orthobullets.com/recon/5005/hip-osteoarthritis

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Imaging Tests

X-ray:

• Standing AP pelvis

•AP + lateral hip

Findings:

•Joint space narrowing

• Osteophytes

•Subchondral sclerosis

• Subchondral cysts

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Tonnis Classification

Grade 0 Normal radiographs

Grade 1 Sclerosis of femoral head and acetabulum Slight joint space narrowing Slight lipping at joint margins

Grade 2 Small cysts in femoral head/acetabulum Moderate joint space narrowing Moderate loss of head sphericity

Grade 3 Large cysts in femoral head/acetabulum Joint space

obliteration/severe narrowing Severe femoral head deformity VS. AVN

Huang BK, Tan W, Scherer KF, Rennie W, Chung CB, Bancroft LW. Standard and Advanced Imaging of Hip OsteoarthritisWhat the Radiologist Should Know. Semin Musculoskelet Radiol. 2019;23(3):289–303.

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Management in OA hip

Principles / aim of treatment:

1. To help the patient understand the nature of the disease 2. To provide psychological support

3. To alleviate pain

4. To suppress the inflammatory reaction (in the synovial membrane)

5. To encourage the patient to remain as physically active as possible to maintain joint function and prevent deformity

6. To correct existing deformity 7. To improve function

8. To strengthen weak muscles

9. To rehabilitate the individual patient

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Non pharmacological

Weight reduction Physical therapy Occupational therapy

Walking stick

Non operative

Disease modifying therapies for Osteoarthritis (DMOADs)

Analgesics

Corticosteroid joint injections

Operative

Arthroscopy Osteotomy

Hip Joint Arthroplasty Arthrodesis

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Non Pharmacological

Treatment

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Occupational Therapy

Goal of treatment: improving the performance of activities of daily living (ADL)

1. Feeding

2. Personal Hygiene 3. Ambulation

Rees HW. Management of Osteoarthritis of the Hip. J Am Acad Orthop Surg. 2020;28(7):e288–91.

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Physical Therapy

Exercise therapy is an effective treatment modality for hip osteoarthritis. Aim of

treatment: improve range of motion, reduce pain, and improve function

1. Walking

2. Balance / Gait training

3. Muscle strengthening: 4. Stationary cycling hip abductors, adductors, flexors, and extensors

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Pharmacological

Treatment

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NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) play a role in the management of hip osteoarthritis by → cyclooxygenases (COX) inhibitor

1. Pain relief

2. Anti-inflammatory effects

3. Improved functionality :By reducing pain and inflammation, NSAIDs can enhance joint function and mobility in individuals

4. Short time relief

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Intraarticular Hyaluronic Acid

HA is a natural component of synovial fluid, providing lubrication and cushioning within joints. The injections aim to alleviate pain and improve joint function by restoring the viscoelastic properties of synovial fluid

Intraarticular hyaluronic acid should not be considered for treatment of symptomatic

osteoarthritis of the hip as it does not improve function or reduce pain better than placebo.

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Operative

Treatment

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Hip Arthroscopy

Minimally invasive surgical procedures used to diagnose and treat a variety of hip conditions. An arthroscope is inserted into the hip joint through small incisions. This allows the surgeon to view inside the joint and guide miniature surgical instruments to address issues such as removing loose bodies and repairing damage

Indication :

Labral tears, capsular laxity, chondral injury, ligamentum teres avulsions, and removal of loose bodies

Not recommended for Tönnis grade 2 radiographic arthrosis

Includes:

• Joint irrigation

• Debridement

• Removing loose cartilaginous,

osteochondral fragments

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Labral tear

Hip arthroscopy - orthoinfo - AAOS [Internet]. [cited 2024 Jan 23]. Available from: https://orthoinfo.aaos.org/en/treatment/hip-arthroscopy/

Labral tear

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Osteotomies

• Cutting the bone adjacent to the involved joint and stabilizing the cut bone surfaces into a new position

• Aim of treatment: Improve the stability of the hip joint and alleviate pain.

• Improving the biomechanics of the joint, specifically alignment.

• Indication: Young patients with secondary OA

The goal → to relieve pain by redirecting the distribution of load and changing the stress

gradients

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varus derotation osteotomy (VDRO)

Periacetabular osteotomy (PAO)

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Hip Arthroplasty remains the standard of care in the

treatment of end-stage OA.

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Arthroplasty:

Hemiarthroplaty & Total Hip Arthroplasty

Feature Hemiarthroplasty (HA) Total Hip Arthroplasty (THA)

Definition Surgical procedure replacing one half

of the hip joint (either the femoral head or neck)

Surgical procedure replacing the entire hip joint, including the femoral head and acetabulum

Implant Components - Bipolar or unipolar prosthesis - Femoral stem - Head and neck of the femur - Femoral head

- Acetabular cup

Advantages - Less invasive - Provides full joint functionality

- Quicker recovery - Shorter surgery time

- Effective for advanced arthritis

Disadvantages - May not provide a long-term

solution for arthritis

- More invasive - Risk of acetabular arthritis

development

- Longer recovery time - Higher risk of dislocation

Li X, Luo J. Hemiarthroplasty compared to total hip arthroplasty for the treatment of femoral neck fractures: a systematic review and meta-analysis. J Orthop Surg Res. 2021 Mar 3;16(1):172. doi:

10.1186/s13018-020-02186-4. PMID: 33658055; PMCID: PMC7931515.

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Total Hip Arthroplasty:

Implant components

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•Cemented stem in THA → femoral component is fixed in the prepared femoral canal using

polymethylmethacrylate (PMMA) bone cement

(functions as a grout, producing an

interlocking fit between cancellous bone and prosthesis.)

•Cemented cup in THA → acetabular component of the prosthesis is fixed in place using bone cement.

•The load of an implant is carried to the bone through shearing forces in the cement

•The cement is mixed in a cartridge and the injected and pressurized using a cement gun

Cemented fixation

Satalich JR, Lombardo DJ, Newman S, Golladay GJ, Patel NK. Cementation in total hip arthroplasty: history, principles, and technique. EFORT Open Rev. 2022 Dec 7;7(11):747-757.

doi: 10.1530/EOR-22-0002. PMID: 36475555; PMCID: PMC9780613.

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 The goals of cementless fixation → to provide stable, reliable fixation of the implant into the bony surfaces (osseointegration) and achieve biologic fixation

 Coated or porous surface on the implant → promotes bone ingrowth and osteointegration.

 Technique: The implant is designed to achieve stability through a press-fit fixation, allowing for biological fixation and potential long-term

integration with the patient's bone.

Cementless fixation

Ni SH, Guo L, Jiang TL, Zhao J, Zhao YG. Press-fit cementless acetabular fixation with and without screws. Int Orthop. 2014 Jan;38(1):7-12.

doi: 10.1007/s00264-013-2075-2. Epub 2013 Aug 28. PMID: 23982638; PMCID: PMC3890122.

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