G.P. Guidelines – Osteoarthritis of the Hip

Osteoarthritis of the hip presents with pain, stiffness, a reduced range of movement and occasionally a feeling that the joint will give way. The pain, which is typically felt in the groin and also sometimes in the thigh and knee, may be sharp and brought on by particular movement or activity (climbing stairs, standing up). It may also present as a dull ache occurring particularly after activity, or during the night. Pain may be exacerbated by minor trauma such as a knock or a fall. Stiffness tends to be worse after periods of immobility, and usually improves for a while with use. Findings on examination will include a painful restriction of hip movement. Osteoarthritis is not associated with systemic illness.

Osteoarthritis is common and its prevalence increases with age. In most patients with radiological changes, symptoms are not sufficiently troublesome to prompt a general practice consultation. In some patients symptoms may be intermittent but in others they may be relentless and debilitating. The underlying joint changes of osteoarthritis are generally irreversible and management aims to relieve symptoms and reduce disability.

Primary Care

Initial management strategies for patients with osteoarthritis of the hip include assurance and patient education, weight reduction in patients who are obese, walking aids, help with patient-specific exercise programs, and assessment and advice on cushion-soled footwear.

Drug treatment typically includes courses of simple analgesic and non-steroidal anti inflammatory drugs.

The patient must have had a pelvic x-ray, and a copy of the report should be enclosed with any subsequent referral letter.

Specialist services

These are in a position to:

  • Confirm or establish the diagnosis
  • Provide management advice coupled with physical therapies
  • Assess the need for, and undertake, hip surgery and rehabilitation

Referral advice

The majority of the management of patients with osteoarthritis of the hip can be undertaken in primary care.

However, referral to a specialist service is advised if:

  • There is evidence of infection in the joint
  • Symptoms rapidly deteriorate and are causing severe disability
  • The symptoms impair quality of life. Referral criteria should take into account the extent to which the condition is causing pain, disability, sleeplessness, loss of independence, inability to undertake normal activities, reduced functional capacity or psychiatric illness.

When not to refer

General medical condition. If co-existing medical problems would preclude an anaesthetic then the patient cannot be considered for surgery.

  • Excessive weight. Early failure of prosthesis is almost inevitable in the obese.
  • General sepsis.
  • Open ulcers on the leg, etc.

Aims and type of treatment

The aim of treatment is to relieve pain and restore the patient to a previous level of mobility.

The most common procedure performed is a total hip replacement, which may be cemented in the elderly, uncemented or hybrid in the younger patient.

In early cases, an injection of the hip may be of benefit. Only rarely nowadays is an osteotomy considered.

Advice to patients

Patients should be advised that a total hip replacement involves inserting an artificial joint. This should relieve pain and increase mobility allowing the patient to return to normal everyday activities. One does not expect the patient to return to strenuous sporting activities.

They should expect an 80% survival of the prosthesis at 15 years but should be warned of the possibility of loosening and later revision surgery, especially in the younger patient.

Perioperative procedure

Prior to a patient being refered to secondary care the following points should be discussed:

The patient will be advised to see their dentist for a dental check-up prior to surgery to exclude any chronic sepsis.

Offer of attending a Hip Class.

  • Patient will be called to a pre-admission clinic 2-4 weeks prior to admission for general assessment and preparation.
  • The patient will be admitted on the evening before or day of surgery.
  • The patient will be an Inpatient for approximately 4-7 days depending on social circumstances and a COPE assessment.
  • The patient should be independent on sticks or crutches prior to discharge.
  • The patient will be followed up in the clinic for approximately one year postoperatively.

Risks

  • The patient should be warned of the following risk:
  • Anaesthetic risk such as chest infection, etc.
  • Deep vein thrombosis and pulmonary embolus. Despite prophylaxis, pulmonary embolus occurs in up to 2% of patients undergoing total hip replacement, and deep vein thrombosis in 20%.
  • Dislocation. The dislocation rate following total hip replacement should be less than 2% and occurs mainly in the early post-operative period.
  • Wound infection in a major joint replacement is a potential disaster and should occur in less than 1% of patients.
  • Overall, 96% of total hip replacements obtain an excellent result.