Hip Osteoarthritis (OA)

WHAT IS HIP ARTHRITIS?

• While there are several types of arthritis that can affect the hip, osteoarthritis (OA) is degenerative and occurs when the protective cartilage that cushions the end of the bones wears down with time.

• Hip osteoarthritis, is one of the most common joint disorders in the United States. Based on population studies, 19.6% of people over the age of 50 have radiographic evidence of hip OA and 4.2% have symptomatic disease (Kim et al, 2014).

• Several risk factors may contribute to the development of hip OA, including:

  • Systemic risk factors (e.g. age, gender, genetics)

  • Intrinsic joint risk factors (e.g. anatomic variants and joint laxity)

  • Extrinsic risk factors (e.g. repetitive physical activities and obesity)

  • Population studies suggest that hip OA is twice as common in women as in men, and there is evidence to suggest a strong genetic component (Aresti et al, 2016), however, to date the exact primary hip OA etiology remains unknown (Lespasio et al, 2018).

  • The degenerative process in osteoarthritis effects the entire joint, and involves a progressive loss of articular cartilage, subchondral cystic formation, osteophyte or bone spur formation, periarticular ligamentous laxity, muscle weakness, and possible synovial inflammation (Hutton et al, 1989).

HOW DO YOU KNOW IF YOU HAVE HIP OSTEOARTHRITIS?

• The main symptom of hip osteoarthritis is pain. Most commonly the pain develops slowly and worsens over time, and patients will experience joint pain, stiffness and swelling. In some cases, the pain can have a sudden onset. (Aresti et al, 2016; Morvan et al, 2009; O'Neill and Felson, 2018).

• As the cartilage cushion wears down the cartilage becomes rough, and patients may experience clicking and decreased range of motion.
  

• Osteoarthritis can have a profound effect on daily activities and lead to difficulty walking, stair climbing, and rising from a seated position. Long-standing hip arthritis can also lead to pain in the knees and lumbar spine (Stief et al, 2018; Warashina et al, 2019).
  

HOW IS HIP ARTHRITIS DIAGNOSED?

• The diagnosis of hip osteoarthritis is based on a detailed history, physical examination, and imaging.
  

Hip pain from osteoarthritis can be confused with other common hip conditions, including greater trochanteric pain syndrome, piriformis syndrome, adductor tendon pain, stress fracture, inflammatory arthropathies (e.g. rheumatoid arthritis), lumbar radiculopathy, pelvis bone tumors, osteonecrosis, pelvic insufficiency fractures, and meralgia parasthetica. Non-musculoskeletal conditions (e.g. groin hernia, intrapelvic pathology, and leaking abdominal aortic aneurysms) may also present with hip and/or groin pain.

HOW IS HIP OSTEOARTHRITIS TREATED?

• How is hip osteoarthritis treated surgically?
  
  • Despite evidence that nonoperative treatment strategies can be effective in treating symptoms of hip OA, the American Academy of Orthopaedic Surgeons’ recent practice guidelines reported that there is no conclusive recommendation for any of the above commonly used conventional therapies because of the effect of these treatments is "short-lived" (AAOS, 2017).
  • In severe arthritis, joint replacement surgery removes the damaged joint and replaces it with an artificial joint.
  • The total number of hip replacements has been increasing, with a 30% increase in the number of hip replacements between 2000 and 2010 (Wolford et al, 2015).
    
• What non-surgical options are available to treat hip osteoarthritis?

  • Maintaining a healthy body weight, avoiding overuse or repetitive activities, and strength training around the joint can help manage pain. It is important to stay as active as possible, and keep the muscles from getting weak. Braces, medications and injections can also help control pain (Quinn et al, 2018; Zhang et al, 2008).

• What injections are effective for hip osteoarthritis? What is the Evidence?
  • Steroid Injections
    • Corticosteroid injections can be effective in temporarily reducing pain and increasing range of motion, but the improvement is short-lived with most studies showing the improvement lasts less than 3 to 6-months (Kruse et al, 2008).
    • Recent evidence suggests that caution should be exercised when using multiple intra-articular steroid hip injections before a total hip replacement as there may be a significantly higher risk for prosthetic joint infection when compared to a single injection (Chambers et al, 2017).
  • Hyaluronic Acid Injections (Learn more here)

    • Hyaluronic acid is a naturally occurring compound in the joint, and may help protect the cartilage and help control pain associated with hip osteoarthritis. Hyaluronic acid down-regulates pro-inflammatory cytokines, such as interleukin-1 (IL-1), impacting pain relief and immune modulation. Some studies conducted in vitro and in vivo on humans, shows hyaluronic acid also seems to have a chondroprotective effect (Takahashi et al, 2000).
      

    • At this time, the US Food and Drug Administration (FDA) has approved viscosupplementation injections for knee osteoarthritis only. The FDA has not approved viscosupplementation for the hip and guidelines from the European and international scientific societies for the management of hip osteoarthritis differ regarding recommendations of intra-articular hyaluronic acid for hip osteoarthritis (Ronconi et al, 2023). In the US, the use in hip osteoarthritis is considered off-label.
      

    • Hyaluronic acid injections have been studied in the hip and seem to help with pain and help delay joint replacement in patients with hip osteoarthritis (OA).
      • In one retrospective study, 90% of patients were able to avoid a total hip replacement 24-months after starting injections and 82% at 48-months (Migliore et al, 2012).
      • Hyaluronic acid injections have shown a promising effect in moderate-grade hip osteoarthritis. In one study of 226 patients treated with a single high-weight hyaluronic acid injection, patients showed improvements in pain and function up to 12 months following the injection (Pogliacomi et al, 2019).
        
      • A number of randomized controlled trials comparing PRP to hyaluronic acid demonstrated hyaluronic acid helped with pain, but either underperformed or had comparable results to the PRP injection (Doria et al, 2017; Dallari et al, 2016; Nouri et al, 2022; Villanova-Lopez et al, 2020). In one study, hyaluronic acid outperformed PRP at the longer term-follow-up (Di Sante et al, 2016). See summary of the studies below in the PRP treatment section.
    • Intra-articular hyaluronic acid injections also seem to increase the risk for a periprosthetic joint infection if within 6-months of surgery (Colen et al, 2021).
      
  • Platelet Rich Plasma (PRP) Injections (Learn more here)

    • PRP therapy concentrates the growth factors in your own blood. A recent systematic review of 5 randomized controlled studies found PRP for hip osteoarthritis significantly reduced pain and improved function without any major adverse events (Almutairi and Alazzeh, 2024).

      • In a randomized controlled study comparing the efficacy of autologous PRP, hyaluronic acid, or a combination of both PRP and hyaluronic acid in 111 patients at all follow-up intervals up to 12-month the PRP group showed a significant improvement when compared to the other groups. The combination of PRP and hyaluronic acid did not offer any greater improvement in pain (Dallari et al, 2016).

      • In a randomized controlled study of 43 patients with severe hip osteoarthritis treated with either PRP or hyaluronic acid, the PRP injection had short term benefit, but the hyaluronic acid had greater longer term improvement in pain and function at the 16-week follow up (Di Sante et al, 2016).
        

      • In a prospective randomized controlled trial, 80 patients were treated with either 3 PRP injections or 3 hyaluronic acid injections. Both groups showed improvement in pain at 6- and 12-month follow ups with similar improvement in pain (Doria et al, 2017).

      • In a randomized controlled trial comparing PRP and hyaluronic acid 74 patients were included and PRP showed improved function and reduced pain up to 12-months after the injection (Villanova-Lopez et al, 2020).
        

      • In another randomized controlled study comparing PRP, hyaluronic acid, or a combination of both injections in 105 patients followed for 6-months, the PRP and combination group showed greater improvement in pain than the hyaluronic acid group. The combination of PRP and hyaluronic acid also did not offer any greater improvement in pain than the PRP alone group (Nouri et al, 2022).

      • Not all randomized controlled studies show benefit. In a recent study, comparing PRP to a saline placebo injection, 60 patients received weekly injections for 3 weeks and there was no significant difference over a period of 6 months on pain, function or quality of life (Topaloglu et al, 2024).
        
  • Bone Marrow Concentrate "Stem Cell" Injection (Learn more here)

    • Bone marrow concentrate injections use mesenchymal stem cells (MSCs), a cell type found in bone marrow, to improve pain and function in hip osteoarthritis. Mesenchymal stem cells have been shown to be capable of cartilage and bone repair in animal models and early human clinical trials (Pittenger et al, 1999; Lang et al, 2013; Centeno et al, 2008). Contemporary literature suggests that the "regenerative effects" of MSCs are mediated by secreted factors, however, the role of mesenchymal stem cells and their role in musculoskeletal repair is still unclear (Diekman et al, 2010; Indrawattana et al, 2004).
      

    • Case studies and registry data have demonstrated encouraging results in hip osteoarthritis with no significant complications reported (Centeno et al, 2014; Whitney et al, 2020).

      • In a case study, a 64-year-old with severe hip osteoarthritis was treated with a hyaluronic acid, activated PRP and bone marrrow concentrate injection reported subjective improvement and partial articular surface regeneration on MRI 8-weeks after the procedure (Centeno et al, 2006).
      • In a review of registry data for 216 hips (196 patients) who underwent a bone marrow concentrate stem cell procedure, there was a statistically significant improvement in pain and function. Overall the mean reported percentage of improvement was 30% with patients under 55-years-old more likely to report improvement (Centeno et al, 2014).
        
      • In a case series, 16 patients (18 hips) diagnosed with symptomatic hip osteoarthritis who underwent a single bone marrow concentrate injection reported significant improvement in pain and function. Up to 6-months out from the injection patients still had a significant improvement in pain and function (Whitney et al, 2020).
        

References

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• American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Hip: Evidence-Based Clinical Practice Guideline. Published March 13, 2017.
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• Chambers AW, Lacy KW, Liow MHL, Manalo JPM, Freiberg AA, Kwon YM. Multiple hip intra articular steroid injections increase risk of periprosthetic joint infection compared with single injections. J Arthroplasty. 2017 Jun;32(6):1980–3.
• Colen S, Hoorntje A, Maeckelbergh L, van Diemen M, Dalemans A, van den Bekerom MPJ, Mulier M. Intra-Articular Hyaluronic Acid Injections Less Than 6 Months Before Total Hip Arthroplasty: Is It Safe? A Retrospective Cohort Study in 565 Patients. J Arthroplasty. 2021 Mar;36(3):1003-1008
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OTHER HIP CONDITIONS

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