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12 Articles in Volume 13, Issue #1
A Modest Proposal (Thanks to Jonathan Swift—1667-1745)
Chronic Pain: Study of Complementary and Alternative Treatments
Decompression Surgery to Reduce Diabetic Peripheral Neuropathy
Extracorporeal Shock Wave Therapy—Application for Trigger Points
Improving a Practice Model for Prescribing Opioids
Interpretations and Actions Following Cytochrome P450 Testing
Is It Safe to Restart an NSAID Following an Endoscopically Confirmed NSAID-Induced GI Bleed?
January/February 2013 Pain Research Updates
Massage Therapy in an Ambulatory Pain Clinic
Practical Tips in the Treatment of Osteoarthritis of the Hip
Quantum Theory Underpins Electromagnetic Therapies for Pain Management
When a Pain Patient Insists on Alternative Treatments Alone

Practical Tips in the Treatment of Osteoarthritis of the Hip

The American College of Rheumatology (ACR) recently revised its recommendations for treatment of osteoarthritis (OA) of the hand, hip, and knee.1 The newly revised recommendations add to the recommendations of three other organizations that have published arthritis treatment guidelines in the last 10 years. These include the European League Against Rheumatism (EULAR), Osteoarthritis Research Society International (OARSI), and the British National Institute for Health and Clinical Excellence (NICE).2-4 In a previous issue, we highlighted the treatment recommendations for OA of the knee.5 In this educational review, we will focus on the management of OA of the hip—the second most common form of OA—using the ACR guidelines as the standard, and then discuss other treatment options that are available to practitioners.

ACR Recommendations

Osteoarthritis is a common cause of pain and disability in adults. Approximately 14% of the population over age 25 suffer from OA and 1 out of 3 individuals over 65 years of age are affected.6 Hip OA affects between 3% to 7% of patients over age 55.7,8 There is a highly heritable component associated with OA; in fact, 60% of women have a genetic contribution.9 Among the genes that have been linked to OA are several that are involved in the development and maintenance of joint shape, including members of the Wingless (Wnt) and the bone morphogenetic protein families. Important genetic markers for the development and progression of the disease are currently under research.9

There is no cure or treatment to prevent the development of OA. Therefore, treatment is aimed at reducing pain and improving function. The ACR guidelines, which focused on pharmaceutical and non-pharmaceutical therapies, used the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach for classifying current recommendations.1,10-12 Using this approach, interventions received one of four designations: strongly recommend, conditionally recommend, conditionally not recommend, and no evidence/evidence lacking. The ACR did not make any recommendations regarding surgical interventions—these will be discussed later in this article. The current recommendations assume that the patient has already tried and failed intermittent over-the-counter (OTC) acetaminophen, OTC non-steroidal anti-inflammatory drugs (NSAIDs), and OTC nutritional aides (glucosamine, chondroitin).1

Table 1 ACR Recommnedations for Hip Osteoarthritis Medications

The ACR did not “strongly recommend” any medications for the management of hip OA. Acetaminophen, oral NSAIDs, tramadol, and intra-articular corticosteroid injections are conditionally recommended for arthritis treatment depending on the clinical scenario (Table 1). For example, patients who have a history of coronary artery or peptic ulcer disease may need to be selective about the type of NSAID that is used, avoiding those with higher risks.1

The ACR considers non-pharmacologic measures to be the foundation for hip OA treatment. Land-based or aquatic exercise and weight loss (for those who are overweight) are strongly recommended, and should be tailored to the individual’s abilities and comorbid conditions. Self-management programs to learn more about arthritis and how to manage the disease; manual therapy with supervised exercise; psychosocial interventions; and use of thermal agents (icepacks) and walking aids (such as a cane or walker when needed) are conditionally recommended. There is no recommendation made for exercises to improve balance (tai chi, yoga) or manual therapy alone (Table 2).1

Table 2.  ACR Recommendations:  Non-pharmacologic Management of Hipe Osteoarthritis

In patients who do not desire surgical treatment or have medical conditions that preclude surgery, the ACR guidelines recommend that physicians consider opioid treatment for patients who fail initial medical management or non-pharmacologic interventions.1,13 Duloxetine (Cymbalta), transcutaneous electrical nerve stimulation, and traditional Chinese acupuncture are not recommended, as there are no large comprehensive studies of their efficacy in hip OA.1

Authors’ Recommendations: Combining Therapies

As with OA of the knee, it is recommended to use multiple modalities in treating OA of the hip as no single modality provides complete relief of symptoms.2 Combining multiple modalities allows for synergy among the different treatments and often provides better pain relief for patients. Figure 1 illustrates the six types of interventions that should be considered for the treatment of hip OA.

Most of these treatments have a small to moderate impact on OA pain; the use of multiple modalities is an intuitive strategy for improving patients’ symptoms. Most of the studies have been performed in knee OA or in a mixed group of both knee and hip OA; therefore, definitive studies on the effects of modalities specific to hip OA are lacking. In considering other treatment options, we have made recommendations based on the best evidence available to date (Table 3).

Pharmaceutical Medications

There is general consensus among all the guidelines supporting the use of acetaminophen, oral NSAIDs, and tramadol.1-4 The ACR cautions that if a patient is prescribed acetaminophen in the full dosage (up to 4,000 mg/d), that patient should be counseled to avoid all other products containing acetaminophen, including OTC cold remedies as well as combination products with opioid analgesics.1

Because of concerns about dose-dependent risk of gastrointestinal, cardiovascular, hematologic, hepatic, and renal adverse events associated with NSAIDs, many prescribers may be nervous about prescribing high doses of these agents to their patients.14 To overcome these concerns, oral NSAID formulations recently have been created that include nitric oxide links to inhibit cyclooxygenase—a class of medications called cyclooxygenase-inhibiting nitric oxide donating drugs. This class of medications may hold promise in the future by causing less gastric toxicity.15

Figure 1.  Modalities for treatment of hip osteoarthritis

Topical NSAIDs have not been well studied in hip OA; therefore, it is unknown whether they provide similar pain relief to that experienced in other joints.14

Tramadol has been shown to provide pain relief and improved function in patients with OA. It is conditionally recommended by the ACR because side effects are common.16 As noted previously, duloxetine was not recommended by the ACR as there are no large studies in hip OA.1

Injectables

Injectables provide a fairly convenient method for treatment of OA symptoms, although for hip OA, fluoroscopic or ultrasonic guidance is frequently required. Compliance is good and dosing is fairly convenient. Side effects of injectable medications are uncommon. As noted previously, intra-articular steroids were conditionally recommended by the ACR, whereas no recommendation was made for viscosupplementation.1

Viscosupplementation

Vicosupplementation is an intra-articular therapy that uses injections of hyaluronic acid (HA) in an attempt to restore the viscoelasticity of synovial fluid in the joint. In clinical studies examining OA of the knee, viscosupplementation has been shown to provide short- and moderate-term pain relief as well as improvement in function and global assessment of symptoms.17 There are only small randomized controlled trials involving patients with hip OA that show a modest effect of HA injections.18-20 Viscosupplements have minimal side effects, so they would be an ideal treatment. In the future, viscosupplementation may be an option for hip OA treatment, but no current recommendations can be made for its use. Viscosupplementation injection in the hip is currently an off-label use and may not be covered by a patient’s insurance.

Complementary/Alternative Remedies

Complementary and alternative remedies for hip OA are a quickly expanding group of treatments that are popular with many patients. Studies conducted on these compounds are typically not as strong as those involving drug treatments; therefore, it is difficult to give firm recommendations for the use of many of the remedies.

Table 3.  Other Potential Treatment Options for Hip Osteoarthritis

Avocado/Soybean Unsaponifiables

Avocado/soybean unsaponifiables (ASU) were found to improve function, pain, and global evaluation in patients with knee OA. However, there are no strong studies involving hip OA. The mechanism for action is thought to involve the inhibition of interleukin-1, which stimulates collagen synthesis. This potentially has a disease-modifying effect, but needs further study.21 Side effects are reported as very minimal. Dosing is 300 to 600 mg daily, and ASU is reasonably cheap.

Topical Capsaicin

Capsaicin (made from chili peppers) has been shown in smaller studies to provide mild to moderate relief of OA pain. The agent, however, requires frequent dosing (3-4 applications daily), which limits its efficacy.22 Because there is an initial burning quality to the product, it is recommended to start with a low strength and small amounts and then increase the strength and amount as tolerated by the side effects over time. It takes 2 to 3 weeks to fully get the effect of treatment. Capsaicin treatment is strongly recommended by EULAR and OARSI and weakly recommended by NICE.2-4 The ACR states there is no evidence to provide a recommendation for its use.1

Glucosamine

The use of glucosamine supplement, a natural compound found in healthy cartilage, has been controversial. There are 25 studies evaluating glucosamine in the treatment of OA (all types) with mixed results. However, 14 of the 25 studies used a preparation made by Rottapharm (not available in the United States), which showed improvement in pain and function. Funnel plots and Egger’s linear regression model evaluating these studies for bias showed no evidence of bias. Those studies using non-Rottapharm preparations showed no benefit of glucosamine supplementation in the treatment of OA.23 In all the studies, side effects were similar to placebo.

Glucosamine is a slow-acting agent; therefore, a 3- to 4-month trial is recommended before deciding on efficacy. Glucosamine sulfate 1,500 mg daily (marketed as Dona by Rottapharm) is recommended whereas glucosamine hydrochloride is not as it has not shown to be efficacious.23 EULAR and OARSI strongly recommend the use of glucosamine.2,3 The ACR states there is no evidence for its use and NICE recommends against the use of glucosamine.1,4

Lifestyle Interventions

Lifestyle interventions provide some of the most important treatments for hip OA—these interventions are often as efficacious as other modalities and potentially provide disease-modifying effects, especially in the case of weight loss and exercise. As noted previously, the ACR recommends exercise and weight loss (for those who are overweight).

Thermotherapy

Thermotherapy, such as ice massage, has been shown to improve range of motion and function in patients with OA, but there are only a few studies evaluating this modality.24 Thermotherapy is weakly recommended by NICE and OARSI.3,4

Balneotherapy

Balneotherapy, or mineral bath treatment, shows improved pain, quality of life, and reduced analgesic intake in several studies and meta-analyses.25 Use of mineral bath treatment is weakly recommended by OARSI.3

Assist Devices

Canes

The use of canes is common among patients with hip OA. The ACR conditionally recommends the use of canes to assist patients with hip OA during walking activities.1 Canes are thought to help with the distribution of weight and ease of ambulation. Patients need education on the proper use of the canes as use is not intuitive for all patients.26,27

Therapeutic Ultrasound

Therapeutic ultrasound has been shown to improve pain and function in patients with hip OA.28 Many of the ultrasound studies are of lower quality due to the multiple methods of treatment (pulsed, continuous). Therapeutic ultrasound receives a weak recommendation by EULAR.2

Gene Therapy

There are currently many studies underway looking at heritability and specific gene loci related to hip OA. Targeting these specific genes, theoretically, will create treatment options for OA. Specific therapies targeting the Wnt pathway have shown promise in the treatment of myeloma bone disease and osteoporosis and may prove to be a benefit in OA as well.29-31
However, specific studies regarding this treatment in OA must be done before any type of gene therapy may be recommended. Gene therapy may be a valuable future treatment option in OA, but more research is needed.

Surgical Treatments

Arthroscopic Debridement for Hip OA

The role of arthroscopy in the radiographically arthritic hip is limited. Select patients with symptomatic femoral acetabular impingement and mild/early degenerative disease (<50% joint space narrowing or >2 mm joint space remaining on preoperative radiographs) may benefit from arthroscopic intervention. However, there is no evidence indicating arthroscopy has any short- or long-term benefit for patients with advanced preoperative OA.32-35

Osteotomies

Congenital hip dysplasia is a common cause of secondary OA in the hip.36 Young patients with symptomatic hip dysplasia and a well-preserved joint space may benefit from a redirectional osteotomy, which involves freeing the acetabulum from the pelvic ring via bone cuts and changing its position in an effort to preserve the native hip joint. Outcomes are closely related to the level of preoperative OA. Trousdale et al reported mostly good to excellent outcomes at 4 years in patients with mild OA at the time of osteotomy, while those with more advanced OA had mostly poor results with >50% requiring additional major surgery (hip fusion, total hip arthroplasty [THA], etc).37

Table 4.  Surgical Options for Hip Osteoarthritis

Total Hip Arthroplasty

Total hip arthroplasty (THA) is the gold standard for surgical management of hip arthritis. Since its development in the 1960s, the modern THA has proven to be one of the most predictable and reliable surgical interventions available to the orthopedic surgeon.38 In 2009, more than 327,000 primary THAs were performed in the United States, with this number expected to increase to well over 527,000 by 2030.39,40 The total hip implant is a combination of an acetabular shell with or without an articular liner; a prosthetic femoral head and neck; and a femoral stem to anchor the head/neck to the skeleton.

Acetabular Component

For some patients, the acetabulum can be resurfaced. The vast majority of acetabular components used in the United States are “cementless devices” that use porous-coated titanium surfaces, allowing the patient’s bone to grow into the device, resulting in durable biological fixation. The track record with these devices has been excellent. One study, which includes a minimum of 20-year follow up, cites that 92% of the 124 hips available for study had retained the original acetabular metal shell. A total of 5 acetabular components had been revised for aseptic loosening or had radiographic evidence of definite loosening.41 Failure of these devices is largely due to the generation of wear particles and secondary osteolysis due to the immunologic response to these particles. Cemented acetabular components, more commonly used outside of the United States, remain an important option in elderly patients with poor bone quality—these products also have a strong long-term track record.42,43

Femoral Component

Similar to acetabular fixation, the large majority of femoral stems implanted today are cementless ingrowth components. Long-term follow up of modern ingrowth stems shows survivorship of 95% to 98% at 20 years.44,45 Cemented femoral stems, which also demonstrate strong long-term survivorship, remain an important option in the elderly population and in all patients with poor bone quality.

Bearing Surfaces

Several bearing options are available to replace the hip’s articular cartilage. The first successful bearing—a polyethylene acetabular liner mated with a metal femoral head—remains the most frequently used. Results of first-generation polyethylene show it has provided reliable service in >75% of patients at 35-year follow up.46 Second-generation polyethylene devices, used for the past decade, have a lower wear rate and are expected to improve upon these results.47 Polyethylene bearings fail over time due to the body’s reaction to polyethylene wear particles (osteolysis) causing the implants to loosen over time. Alternative bearings have been developed in an attempt to avoid this problem.

Ceramic-on-ceramic implants provide a bearing free of polyethylene, in exchange for the risk of ceramic fracture. Although rates of fracture are low, revision in the setting of ceramic debris can be unpredictable.48 Audible squeaking, affecting 2% to 20% of patients, has also affected patient satisfaction with this type of bearing.49,50

Metal-on-metal bearings have been successfully used in THA since the 1960s. Elevated serum levels of metal ions and the development of pseudotumors (periarticular soft-tissue masses felt to be related to metal wear particles) are also concerns with this type of bearing.51 Additionally, higher rates of early failure seen with the current generation of metal-on-metal total hips have recently curtailed its use.52 In fact, in January 2013, the FDA issued a safety communication to health care professionals outlining detailed recommendations for surgeons conducting metal-on-metal hip implants. The recommendations for surgeons include tips for before surgery and during patient follow up, for imaging the patient, monitoring and assessing metal ion levels, and considerations for device revision.53

Hip Resurfacing

Total hip resurfacing may be considered an alternative to THA, particularly in young active patients who might require multiple operations over their lifetimes. While a THA removes the native femoral head and neck, it preserves the femoral neck and much of the femoral head. Potential benefits of this approach include this preservation of proximal femoral bone stock as well as lowering risk of iatrogenic limb length inequality, and significantly decreasing the risk of dislocation of the implant from the femur. Because hip resurfacing requires a metal-on-metal bearing, concerns about metal hypersensitivity and the local effects of metal wear particles generated from the bearing surface remain. Resurfacing devices also carry an increased risk of femoral neck fracture, a significant concern in patient populations with poorer bone quality.54

The risk of early failure of these devices has been decreased with proper patient selection, with the ideal patient being a younger male with larger bone size and good bone quality.55,56 Survivorship of the implant in this population has been encouraging, with 95% survivorship reported at 10 years.57 Although many patients may inquire about the assumed benefits of hip resurfacing, prospective randomized trials have shown few differences between hip resurfacing and conventional, stemmed THA.58

Treatment algorithm for the management of patients with hip osteoarthritis

Summary

Hip OA is the second most common OA. While patients with advanced disease are difficult to treat nonoperatively, the operative options are well established and have been found to be predictable and reliable for the vast majority of appropriate patients. The recent ACR guidelines highlight the major pharmacologic and non-pharmacologic treatments available; other international guidelines supplement these recommendations. The ACR guidelines promote non-surgical treatment of hip OA before considering operative treatment. There is good evidence for the use of medications such as acetaminophen, tramadol, and NSAIDs; intra-articular steroid injections; lifestyle interventions such as education, exercise, weight loss, and mineral baths; and assistive devices such as canes and walkers. Ideally, treatment involves the use of multiple modalities to allow for synergy of interventions (see Treatment Algorithm). Future directions may include disease-modifying medications, gene therapy, or other biologics.

Last updated on: June 30, 2015
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Exercise recommendations for patients with osteoarthritis of the knee
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