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Introduction
  • Definition
    • degenerative disease of synovial joints that causes progressive loss of articular cartilage
  • Epidemiology
    • incidence
      • hip OA (symptomatic)
        • 88 per 100,000 per year
      • knee OA (symptomatic)
        • 240 per 100,000 per year
  • Risk factors 
    • modifiable
      • articular trauma
      • muscle weakness
      • heavy physical stress at work
      • high impact sporting activities 
    • non-modifiable
      • gender
        • females >males
      • increased age
      • genetics
      • developmental or acquired deformities
        • hip dysplasia
        • slipped capital femoral epiphysis
        • Legg-Calvé-Perthes disease
  • Pathophysiology
    • pathoanatomy 
      • articular cartilage 
        • increased water content 
        • alterations in proteoglycans 
          • eventual decrease in amount of proteoglycans
        • collagen abnormalities 
          • organization and orientation are lost
          • binding of proteoglycans to hyaluronic acid
      • synovium and capsule
        • early phase of OA
          • mild inflammatory changes in synovium
        • middle phase of OA
          • moderate inflammatory changes of synovium
          • synovium becomes hypervascular
        • late phases of OA
          • synovium becomes increasingly thick and vascular
          • bone
          • subchondral bone attempts to remodel 
          • forming lytic lesion with sclerotic edges (different than bone cysts in RA)
          • bone cysts form in late stages
  • Cell biology
    • proteolytic enzymes 
      • matrix metalloproteases (MMPs)
        • responsible for cartilage matrix digestion
        • examples
          • stromelysin 
          • plasmin
          • aggrecanase-1 (ADAMTS-4)
      • tissue inhibitors of MMPS (TIMPs)
        • control MMP activity preventing excessive degradation
        • imbalance between MMPs and TIMPs has been demonstrated in OA tissues
      • inflammatory cytokines
        • secreted by synoviocytes and increase MMP synthesis
          • examples
            • IL-1
            • IL-6
            • TNF-alpha
  • Genetics
    • inheritance
      • non-mendilian
    • genes potentially linked to OA
      • vitamin D receptor
      • estrogen receptor 1
      • inflammatory cytokines
        • IL-1
          • leads to catabolic effect
        • IL-4
        • matrilin-3
        • BMP-2, BMP-5
Presentation
  • History
    • identify age, functional activity, pattern of arthritic involvement, overall health and duration of symptoms
  • Symptoms
    • function-limiting hip pain 
      • effect on walking distances
    • pain at night or rest
    • hip stiffness
    • mechanical 
      • instability, locking, catching sensation
  • Physical exam
    • inspection
      • body habitus
      • gait
      • leg length discrepancy 
      • skin (e.g. scars)
    • range of motion
      • lack of full extension (>5 degrees flexion contracture)
      • lack of full flexion (flexion < 90-100 degrees) 
      • limited internal rotation
  • Neurovascular exam
    • straight leg test negative
Imaging
  • Radiographs
    • recommended views
      • standing AP pelvis
      • AP + lateral hip
    • optional views
      • false profile view (e.g. hip dysplasia)  
    • findings
      • osteoarthritis
        • joint space narrowing 
        • osteophytes 
        • subchondral sclerosis 
        • subchondral cysts 
      • pelvic obliquity
        • may be secondary to spinal deformity
        • may cause leg-length issues
      • acetabular retroversion  
        • makes appropriate positioning of acetabular component more difficult intraoperatively
Studies
  • Histology
    • loss of superficial chondrocytes
    • replication and breakdown of the tidemark
    • fissuring
    • cartilage destruction with eburnation of subchondral bone
Treatment
  • Nonoperative 
    • NSAIDs and/or tramadol
      • indications
        • first line treatment for all patients with symptomatic arthritis
      • technique
        • NSAID selection should be based on physician preference, patient acceptability and cost
    • walking stick
      • decreases the joint reaction force on the affected hip when used in the contralateral upper extremity
    • weight loss, activity modification and exercise program/physical therapy
      • indications
        • first line treatment for all patients with symptomatic arthritis
        • BMI > 25
      • technique
        • exercise aimed at increasing flexibility and aerobic capacity
    • corticosteroid joint injections
      • indications
        • can be therapeutic and/or diagnostic of symptomatic hip osteoarthritis
    • controversial treatments
      • acupuncture
      • viscoelastic joint injections
      • glucosamine and chondroitin
  • Operative
    • arthroscopic debridement 
      • indications
        • controversial 
        • degenerative labral tears
    • periacetabular osteotomy +/-  femoral osteotomy
      • indications
        • symptomatic dysplasia in an adolescent or young adult with concentrically reduced hip and mild-to-moderate arthritis
      • outcomes
        • mixed results
        • literature suggest this can delay need for arthroplasty
    • femoral head resection
      • indications
        • pathological hip lesions 
        • painful head subluxation
    • hip resurfacing
      • indications
        • young active, male, patients with hip osteoarthritis
    • total hip arthroplasty (THA)
      • indications
        • end-stage, symptomatic or severe osteoarthritis arthritis
        • preferred treatment for older patients (>50) and those with advanced structural changes
 
 

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