Updated: 6/9/2021

Hip Osteoarthritis

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https://upload.orthobullets.com/topic/5005/images/osteoarthritis.jpg
https://upload.orthobullets.com/topic/5005/images/osteophytes.jpg
https://upload.orthobullets.com/topic/5005/images/subchondral_cysts.jpg
https://upload.orthobullets.com/topic/5005/images/tonnis-1.jpg
https://upload.orthobullets.com/topic/5005/images/tonnis-3.jpg
https://upload.orthobullets.com/topic/5005/images/tonnis-4.jpg
  • summary
    • Hip Osteoarthritis is degenerative disease of the hip joint that causes progressive loss of articular cartilage of the femoral head and acetabulum. 
    • Diagnosis can be made with plain radiographs of the hip.
    • Treatment is observation, NSAIDs, and corticosteroids for minimally symptomatic patients. Hip arthroplasty is indicated for progressive symptoms with severe degenerative disease.
  • 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
  • Etiology
    • 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
  • Classification
    • 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
  • 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
          • use for short-term pain relief strongly supported in 2013 AAOS CPG
      • 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
          • increasing concern for metal-on-metal adverse events, procedure therefore decreasing in use
      • total hip arthroplasty (THA)
        • indications
          • end-stage, symptomatic or severe osteoarthritis arthritis
          • preferred treatment for older patients (>50) and those with advanced structural changes
          • recommendation is to wait at least 3 months after ipsilateral intaarticular hip injection to decrease risk of prosthetic joint infection

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(OBQ05.39) Which of the following is a characteristic change in cartilage involved in moderate osteoarthritis?

QID: 76
1

Decreased thickness of subchondral bone

3%

(107/3508)

2

Decreased chondrocyte activity

21%

(720/3508)

3

Increased proteoglycan quantity

7%

(240/3508)

4

Increased water content

66%

(2304/3508)

5

Increased collagen quantity

3%

(121/3508)

L 3 D

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