Osteoarthritis of the Hip

Synonyms

ICD-9 Codes

Degenerative arthritis of the hip

Osteoarthrosis of the hip

715.05
Osteoarthritis of the hip,
generalized

Osteoarthritis of the hip is characterized by a loss of articular

cartilage in the hip joint. The osteoarthrosis may be primary
(idiopathic) or secondary to hip diseases during childhood,
trauma, osteonecrosis, previous joint infection, or other conditions.

Clinical Symptoms
The classic presentation is a gradual onset of anterior thigh or
groin pain. Some patients have pain in the buttock or the lateral
aspect of the thigh. The pain may be referred to the distal thigh
(knee) and may be perceived only in the knee. Initially, pain
occurs only with activity, but gradually the frequency and
intensity of the pain increase to the point that pain occurs at rest
and at night. As osteoarthritis progresses, patients develop
decreased range of motion, which may manifest as a limp and
difficulty putting on trousers or shoes. Ambulatory capacity
gradually decreases as pain increases. Occasionally, patients will
have a severe limp and stiffness but little pain.
Careful questioning may reveal a history of hip problems as
an infant or toddler (indicative of developmental dysplasia of the
hip), as a small child (indicative of Legg-Calv-Perthes disease),
or as an adolescent (suggestive of slipped capital femoral
epiphysis). Patients with osteoarthritis of the hip may have other
coexisting conditions, as listed in the differential diagnosis.

715.15
Primary (idiopathic)
osteoarthritis of the hip,
localized
715.25
Secondary osteoarthritis of the
hip (eg, Legg-Calv-Perthes
disease)
715.35
Primary or secondary
osteoarthritis of the hip,
localized
716.15
Traumatic arthritis of the hip

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Definition

Tests
Physical Examination
The earliest sign of osteoarthritis of the hip is a loss of internal
rotation as determined by range-of-motion testing. Gradually,
global decreases in range of motion occur, and many patients
develop a fixed external rotation and flexion contracture. Flexion
contractures are particularly problematic because they greatly
affect gait patterns, as the patient must compensate by increasing
lumbar spine extension to afford hip extension. In addition, an
antalgic gait (short stance on the painful leg) and an abductor
lurch (swaying the trunk far over the affected hip) develop as
the body tries to compensate for the pain and secondary
weakness in the hip abductor muscles.
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OSTEOARTHRITIS OF THE HIP

Diagnostic Tests
AP and lateral radiographs of the hip are indicated for patients
with pain and limited internal rotation of the hip. The classic
radiographic features of osteoarthritis of the hip are joint space
narrowing, osteophyte formation, subchondral cyst formation,
and subchondral sclerosis (Figure 1).

Differential Diagnosis

Figure 1 AP radiograph showing

SECTION 5 HIP

degenerative joint
disease of the hip with
joint space narrowing
(black arrow), osteophyte formation (white
arrow), subchondral cyst
formation (black arrowhead), and subchondral
sclerosis (white
arrowhead).

Degenerative lumbar disk disease (normal hip motion)

Femoral cutaneous nerve entrapment (sensory changes,
burning, normal motion)
Herniated lumbar disk (diminished knee reflex, sensory
changes)
Inflammatory arthritis of the hip (rheumatoid arthritis,
systemic lupus erythematosus, ankylosing spondylitis)
Osteonecrosis of the femoral head (evident on radiographs)
Trochanteric bursitis (local tenderness, normal motion)
Tumor of the pelvis or spine (back pain, night pain, normal
motion)

Adverse Outcomes of the Disease

Osteoarthritis of the hip is a progressive condition with a natural
history of increasing pain and a subsequent decrease in function
associated with progressive gait abnormality. In the end stages
of the disease, pain is severe, occurring at night and at rest and
severely limiting ambulation, and large fixed contractures of the
hip develop secondarily. Progressive bone loss of the femoral
head or the acetabulum may occur but is uncommon.

Treatment
Initial treatment of all patients is nonsurgical and consists of a
combination of acetaminophen, NSAIDs, activity modification,
and the use of an assistive device held in the hand contralateral
to the affected hip. Nonweight-bearing exercise (such as the
use of a stationary bicycle or swimming) and hip strengthening
are occasionally helpful but may exacerbate symptoms. Intraarticular injections with corticosteroids are used occasionally;
they generally require fluoroscopic guidance for accurate
placement.
Vigorous, young patients in whom nonsurgical treatment fails
and who have a biomechanical derangement of the hip may be
candidates for a realignment osteotomy of the proximal femur or
the acetabulum. Hip fusion is a potential surgical option for a
young patient who either must return to work as a manual
laborer or who leads a vigorous lifestyle. The vast majority of

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OSTEOARTHRITIS OF THE HIP

patients in whom nonsurgical treatment fails, however, are most

appropriately treated with total hip replacement surgery
(Figure 2). Total hip replacement is associated with dramatic
decreases in pain as well as increases in function and is among
the most cost-effective medical interventions available when
quality-adjusted years of life are considered. Metal-on-metal hip
resurfacing (Figure 3), which uses a cap on the femoral head as
opposed to the stemmed femoral component used in a
conventional total hip arthroplasty, may be an appropriate
alternative for young, active patients. It has the potential benefits
of preserving proximal femoral bone stock (should revision
surgery be required in the future) and allowing the return to
higher level activities, such as running sports, that are not
typically recommended following conventional total hip
arthroplasty with a stemmed femoral component.

Adverse outcomes of nonsurgical treatment include

complications related to the chronic use of NSAIDs, such as
gastric, renal, or hepatic problems. Extended treatment with
acetaminophen in large doses can lead to hepatic toxicity. The
most common short-term complications related to total hip
arthroplasty include neurovascular injury, thromboembolic
events, infection, leg-length inequality, and prosthetic
dislocation. Long-term complications of total hip arthroplasty
are more common in young, active patients and relate primarily
to wear of the bearing surface and loosening of the components
that may require revision surgery. Patients who are treated with
osteotomy or hip fusion may require further surgical intervention
in the form of total hip arthroplasty if the surgery is
unsuccessful, subsequent arthritis develops, or pain relief is
incomplete.

Figure 2 AP radiograph of the

hip of a patient with

osteoarthritis
following total hip
arthroplasty.

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Adverse Outcomes of Treatment

Referral Decisions/Red Flags

Patients who have persistent pain despite nonsurgical treatment
including acetaminophen, multiple different NSAIDs, activity
modification, and/or the use of an assistive device require
appropriate referral for further evaluation of potential surgical
intervention. Young patients may be referred earlier to determine
if an alternative to conventional total hip arthroplasty (such as
redirectional osteotomy, hip fusion, or hip resurfacing) is
appropriate.

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Figure 3 AP radiograph of

a hip following
metal-on-metal hip
resurfacing.

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